Search Results (89)

Malignant mediastinal tumors are a group representing some of the most demanding oncological challenges for early, multi-level, and successful management. The timely identification of any suspicious clinical symptomatology is urgent in achieving an accurate, staged histological diagnosis, in order to follow up with an equally detailed medical therapeutic plan (interventional or not) and determine the principal goals regarding efficient overall treatment in these patients. We report a case of a 24-year-old male patient with an incident-free prior medical history. An initial chest X-ray was performed after the patient reported short-term, consistent moderate chest pain symptomatology, early work fatigue, and shortness of breath. The following imaging procedures (chest CT, PET-CT) indicated the presence of an anterior mediastinal mass (meas. ~11 cm × 10 cm × 13 cm, SUV: 8.7), applying additional pressure upon both right heart chambers. The Alpha-Fetoprotein (aFP) blood levels had exceeded at least 50 times their normal range. Two consecutive diagnostic attempts with non-specific histological results, a negative-for-malignancy fine-needle aspiration biopsy (FNA-biopsy), and an additional tumor biopsy, performed via mini anterior (R) thoracotomy with “suspicious” cellular gatherings, were performed elsewhere. After admission to our department, an (R) Video-Assisted Thoracic Surgery (VATS) was performed, along with multiple tumor biopsies and moderate pleural effusion drainage. The tumor’s measurements had increased to DMax: 16 cm × 9 cm × 13 cm, with a severe degree of atelectasis of the Right Lower Lobe parenchyma (RLL) and a pressure-displacement effect upon the Superior Vena Cava (SVC) and the (R) heart sinus, based on data from the preoperative chest MRA. The histological report indicated elements of a combined, non-seminomatous germ-cell mediastinal tumor, posthuberal-type teratoma, and embryonal carcinoma. The imminent chemotherapeutic plan included a “BEP” (Bleomycin^®/Cisplatin^®/Etoposide^®) scheme, which needed to be modified to a “VIP” (Cisplatin^®/Etoposide^®/Ifosfamide^®) scheme, due to an acute pulmonary embolism incident. While the aFP blood levels declined, even reaching normal measurements, the tumor’s size continued to increase significantly (DMax: 28 cm × 25 cm × 13 cm), with severe localized pressure effects, rapid weight loss, and a progressively worsening clinical status. Thus, an emergency surgical intervention took place via median sternotomy, extended with a complementary “T-Shaped” mini anterior (R) thoracotomy. A large, approx. 4 Kg mediastinal tumor was extracted, with additional RML and RUL “en-bloc” segmentectomy and partial mediastinal pleura decortication. The following histological results, apart from verifying the already-known posthuberal-type teratoma, indicated additional scattered small lesions of combined high-grade rabdomyosarcoma, chondrosarcoma, and osteosarcoma, as well as numerous high-grade glioblastoma cellular gatherings. No visible findings of the previously discovered non-seminomatous germ-cell and embryonal carcinoma elements were found. The patient’s postoperative status progressively improved, allowing therapeutic management to continue with six “TIP” (Cisplatin^®/Paclitaxel^®/Ifosfamide^®) sessions, currently under his regular “follow-up” from the oncological team. This report underlines the importance of early, accurate histological identification, combined with any necessary surgical intervention, diagnostic or therapeutic, as well as the appliance of any subsequent multimodality management plan. The diversity of mediastinal tumors, especially for young patients, leaves no place for complacency. Such rare examples may manifest, with equivalent, unpredictable evolution, obliging clinical physicians to stay constantly alert and not take anything for granted. Full article

Background/Objectives: Pulmonary vein isolation (PVI) is the standard treatment for atrial fibrillation (AF), but medium-term success rates remain suboptimal. Non-pulmonary vein triggers, particularly from the superior vena cava (SVC), contribute to AF recurrence. Empirical SVC isolation (SVCi) in addition to standard PVI may improve outcomes. This study evaluated the acute procedural efficacy and safety of PVI with adjunctive SVCi versus PVI alone in patients with paroxysmal AF (PAF). Methods: In this randomized, controlled, single-center study, 149 patients with PAF were assigned to either standard PVI (n = 74) or PVI with adjunctive empirical SVCi (n = 75) using a fourth-generation CB. Primary endpoints were acute procedural success and the incidence of procedure-related complications, particularly phrenic nerve injury (PNI) and sinus node dysfunction. Results: Acute PVI was achieved in all patients; SVCi was successful in 84.9% of the PVI + SVCi group. Major complication rates were low and comparable between groups (0% vs. 2.6%, p = 0.157). However, the overall complication rate was significantly higher in the PVI + SVCi group (50.6% vs. 6.8%, p < 0.001), driven primarily by transient or impending right PNI (38.6% vs. 6.8%, p < 0.001) and sinus node dysfunction. All PNI events resolved before the end of the procedure. Conclusions: Empirical SVCi using a fourth-generation CB is feasible and generally safe, but carries a higher risk of transient PNI and reversible sinus node dysfunction. Therefore, CB SVCi should be approached with caution. Further studies are needed to evaluate long-term outcomes and assess whether the potential benefits outweigh these procedural risks. Full article

The axillary and cephalic veins are commonly utilized for transvenous pacemaker lead access. They typically advance to the heart through the subclavian, brachiocephalic, and superior vena cava veins. Anatomical variations such as a persistent left superior vena cava (PLSVC) may pose a challenge, necessitating an alternative approach for lead placement. This anomaly can often be identified during venographic contrast imaging or by visualizing atypical venous courses during the procedure. Another challenge occurs when the venous pathway is tortuous. Careful monitoring during the procedure is crucial to ensure that the lead follows the intended path. If not, the lead may inadvertently enter a collateral, such as the inferior thyroid vein, which drains into the internal jugular or left brachiocephalic vein. Despite these deviations, the lead may eventually reach the heart, although via an unusual course. If such a lead is left in place, even in the absence of immediate complications, long-term outcomes are unpredictable and carry the risk of unforeseen complications. Full article

The azygos vein is a vessel that drains deoxygenated blood from the posterior wall of the thorax and upper abdomen into the superior vena cava. It can vary morphologically in both adults and fetuses in origin, termination, diameter, course, and tributaries, especially the hemiazygos vein and accessory hemiazygos vein, which, together with the azygos vein, form the azygos venous system. The main aim of this review is to summarize the current state of knowledge regarding the azygos vein. Another aim is to present the morphological variations of the azygos vein and their clinical significance. This information may be useful to clinicians, especially surgeons. This review also provides an overview of the embryological development of the azygos venous system and the consequences of its developmental errors, as well as their relationship to certain clinical cases and pathologies. Full article

Background/Objectives: Persistent Left Superior Vena Cava (PLSVC) is a condition that may complicate the ablation of Atrioventricular nodal reentry tachycardia (AVNRT). We aimed to report technical experience in ablation under scuh clinical setting. Methods: 3D guided electrophysiological procedure was conducted and PLSVC was confirmed. Slow-pathway ablation for the AVNRT was performed and typical junctional rhythm during the ablation was observed. Results: Exactly the same AVNRT remained inducible after 10 radiofrequency applications, which was very likely because of suboptimal temperature increase due to lacking sustained stability/contact of the catheter given the PLSVC anatomy and the patient’s deep respiration based on our observation during the RF applications. A non-steerable long sheath was introduced to achieve more firm contact of the ablation catheter, the slow-pathway was successfully ablated with just 1 application (seen immediately occurred, continuous typical junctional rhythms during ablation, and significantly better temperature during the ablation). Conclusions: PLSVC-related anatomical changes may destabilize ablation catheter making it difficult to establish sufficient energy delivery at the slow-pathway region and put forward the need for multiple ablations. Timely identifying such scenarios (e.g., insufficient stability, insufficient temperature) could help better plan/change the ablation technique or strategy to achieve better procedure outcomes. This technical report reminds us that typical junctional beats may not be the only determinant for successful ablation of the slow-pathway. The key to the solution often relies on basic ablation biophysics. Full article

Background: Ultrasonographic assessment of the diameters of various veins and their indices are among the most applied diagnostic tools for evaluating fluid responsiveness in clinical practice. Despite their widespread use, there is no definitive answer on which is preferable. Our study aimed to investigate the diagnostic accuracy of different venous diameters and their indices to assess fluid responsiveness. Methods: We conducted a systematic review and network meta-analysis, analyzing prospective studies evaluating the diagnostic accuracy of venous diameters (inferior vena cava [IVC], internal jugular vein [IJV], superior vena cava, and subclavian vena) and their indices for fluid responsiveness. Electronic databases were searched from inception until March 2024; this search was supplemented by snowballing methods. The risk of bias was evaluated with QUADAS-2, and evidence certainty was assessed using the GRADE approach. Nine prospective cohort studies (560 patients) were included. Results: The network meta-analysis revealed that the ΔCaval index exhibited a significant performance advantage over other “venous” test parameters. The caval index significantly outperformed IJV min/max and IVCmax. IJV index and IVCmin significantly outperformed IJVmin/max. The caval index was comparable to the IJV index. The caval index was comparable during mechanical ventilation and spontaneous breathing. Conclusions: In this meta-analysis, the ΔCaval index test showed higher diagnostic accuracy for fluid responsiveness compared with other venous tests. Caval and jugular indices displayed similar accuracy, and caval indices were consistent under mechanical ventilation and spontaneous breathing. Indices generally outperformed absolute values, except for IVCmin, which equaled the caval index in efficacy. This study was registered on the International Platform for Registered Protocols for Systematic Reviews and Meta-Analyses: INPLASY202430104. Full article

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis. Full article

The three-vessel view (3VV) is a standardized transverse scanning plane used in fetal cardiac ultrasound screening to measure the absolute and relative diameters of the pulmonary artery (PA), ascending aorta (Ao), and superior vena cava, as required. The PA/Ao ratio is used to support the diagnosis of congenital heart disease (CHD). However, vascular diameters are measured manually by examiners, which causes intra- and interobserver variability in clinical practice. In the present study, we aimed to develop an artificial intelligence-based method for the standardized and quantitative evaluation of 3VV. In total, 315 cases and 20 examiners were included in this study. We used the object-detection software YOLOv7 for the automated extraction of 3VV images and compared three segmentation algorithms: DeepLabv3+, UNet3+, and SegFormer. Using the PA/Ao ratios based on vascular segmentation, YOLOv7 plus UNet3+ yielded the most appropriate classification for normal fetuses and those with CHD. Furthermore, YOLOv7 plus UNet3+ achieved an arithmetic mean value of 0.883 for the area under the receiver operating characteristic curve, which was higher than 0.749 for residents and 0.808 for fellows. Our automated method may support unskilled examiners in performing quantitative and objective assessments of 3VV images during fetal cardiac ultrasound screening. Full article

Background: With the advent of effective chemotherapy, conversion surgery (CS) has been performed in patients who have responded to pretreatment, even for pancreatic cancer diagnosed as unresectable (UR) at the time of initial diagnosis. In CS, major arterial resection and reconstruction are necessary for complete radical resection. Methods: We discuss the key points for safely performing pancreatectomy with celiac axis (CA) resection combined with reconstruction, divided into resection and arterial reconstruction. The possibility of safe pancreatectomy concurrent with CA resection and reconstruction depends on the ability to create a “golden view” that provides an unimpaired view of the Abdominal Aorta, CA, Superior Mesenteric Artery, Inferior Vena Cava, and left renal vein from the ventral side. Pancreatectomy concurrent with CA resection requires arterial reconstruction. Postoperatively, arterial blood flow must be maintained. To achieve this, tension-free and short bypass should be observed. Results: From 2014 to 2024, sixteen URLA patients underwent CS, requiring major artery en bloc resection after pretreatment. We performed DP-CAR in eight patients, gastrectomy-distal pancreatectomy-splenectomy (Appleby procedure) procedure in one patient, PD-CHAR in two patients, PD-CAR in two patients, TP-CAR(spleen preserving) in one patient, and TP-CAR+TG in two patients. In total, five patients required surgery with CA reconstruction. Histopathologically, four of the five patients had T4 pancreatic cancer. The R0 surgical rate was 80%. Complication of Clavien–Dindo IIIa or higher was observed in one patient. There were no deaths. Conclusions: Parallel to the determination of pretreatment, surgeons must be prepared to safely and reliably perform pancreatectomies that require concurrent major arterial resection and reconstruction. Full article

The development of new organic nitrates is still relevant due to the clinical limitations of their use. Tetrahydrofurfuryl nitrate (NTHF) is a new organic nitrate obtained through a synthetic route of sugarcane. The aim of this research was to investigate the cardiovascular effects promoted by NTHF in rats. Isolated vascular smooth muscle cells (VSMC) were incubated with a specific probe and were analyzed in a flow cytometer to measure the NO concentration after NTHF treatment. Rat superior mesenteric rings were isolated and used for isometric tension recordings and the evaluation of the vasorelaxant activity induced by NTHF. For the in vivo study, polyethylene catheters were implanted into the abdominal aorta and inferior vena cava of the rats (weighing 250–300 g). NTHF increased NO levels in rat VSMCs. In anesthetized rats, NTHF induced hypotension and bradycardia after intravenous administration. These effects were attenuated after the administration of a sGC inhibitor, methylene blue. In the phenylephrine pre-contracted superior mesenteric artery of rats, NTHF (1 pM–10 μM) induced concentration-dependent vasodilatation in both the intact and removed endothelium. Furthermore, in the presence of NO° scavenging (C-PTIO and HDX) or ODQ, a sGC inhibitor, the vasorelaxation induced by NTHF was decreased. NTHF tolerance was evaluated in mesenteric artery rings previously exposed with isolated concentrations of the new organic nitrate. The vasorelaxant effect was not modified by exposure to nitrate. These results demonstrated that NTHF induced hypotension and bradycardia in vivo and a vasorelaxant effect with the participation of the NO-sGC-PKG pathway and triggering calcium-activated K⁺ channels without vascular tolerance induction. Full article

Background and Objectives: Coronary sinus oxygen saturation is a useful indicator of health and disease states. However, it is not routinely used in clinical practice. Cardiovascular magnetic resonance imaging (CMR) oximetry can accurately estimate oxygen saturation in the pulmonary artery. This research aimed to provide a method for calculating coronary sinus oxygen saturation (ScsO₂) from pulmonary artery oxygen saturation (SpaO₂) that could be applied to CMR. Materials and Methods: A systematic literature review was conducted to identify prior work that included invasive measures of ScsO₂ and either SpaO₂ or right ventricular oxygen saturation. This revealed one study with appropriate data (ScsO₂ and SpaO₂ measurements, n = 18). We then carried out agreement and correlation analyses. Results: Regression analysis demonstrated a statistically significant, positive relationship between ScsO₂ and SpaO₂, giving a regression equation of ScsO₂ = −31.198 + 1.062 × SpaO₂ (r = 0.76, p < 0.001). A multivariable regression analysis of all reported variables, excluding SpaO₂, independently identified superior vena cava oxygen saturation (SsvcO₂) and arterial oxygen saturation (SaO₂) as predictors of ScsO₂ (r = 0.78, p < 0.001), deriving the equation ScsO₂ = −452.8345 + 4.3579 × SaO₂ + 0.8537 × SsvcO₂. Conclusions: In this study, we demonstrated a correlation between coronary sinus oxygen saturation and pulmonary artery oxygen saturation, allowing the estimation of ScsO₂ from SpaO₂. This association enables the estimation of ScsO₂ from purely CMR-derived data. We have also described a second model using arterial and superior vena cava saturation measurements, providing an alternative method. Future validation in larger, independent cohorts is needed. Full article

Objective: To elucidate the pattern of the influence of the port angle of the superior vena cava supplying cannula (SVCS) on hemodynamics within the right atrium in VV-ECMO. Methods: A three-dimensional model of the right atrium was established based on CT images of a real patient. The 3D models of the SVCS and inferior vena cava draining cannula (IVCD) were established based on the Edwards 18Fr and Medos 22Fr real intubation models, respectively. Based on these models, three-dimensional models of the SVCS ports with bending angles of −90°, −60°, −30°, 0°, 30°, 60°, and 90° in the plane formed by the centerline of the SVCS and the center point of the tricuspid valve (TV) were established. Transient-state computational fluid dynamics (CFD) was performed to clarify the right atrium blood flow pattern and hemodynamic states at different SVCS port orientation angles. The velocity clouds, wall pressure, wall shear stress (WSS), relative residence time (RRT), and recirculation fraction (RF) were calculated to assess hemodynamic changes in the right atrium at different angles of the port of the SVCS. Results: As the angle of the port of the superior chamber cannula changed, the location of the high-velocity blood impingement from the SVCS changed, and the pattern of blood flow within the right atrium was dramatically altered. The results for the maximum right atrial wall pressure were 13,472 pa, 13,424 pa, 10,915 pa, 7680.2 pa, 5890.3 pa, 5597.6 pa, and 7883.5 pa (−90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the mean right atrial wall pressure were 6788.9 pa, 8615.1 pa, 8684.9 pa, 6717.2 pa, 5429.2 pa, 5455.6 pa, and 7117.8 pa ( −90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°). The results of the maximum right atrial wall WSS in the seven cases were 63.572 pa, 55.839 pa, 31.705 pa, 39.531 pa, 40.11 pa, 28.474 pa, and 35.424 (−90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively, and the results of the mean right atrial wall WSS results were 3.8589 pa, 3.6706 pa, 3.3013 pa, 3.2487 pa, 2.3995 pa, 1.3304 pa, and 2.0747 pa (−90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively. The results for the area percentage of high RRT in the seven cases were 3.44%, 2.23%, 4.24%, 1.83%, 3.69%, 7.73%, and 3.68% (−90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the RF were 21.57%, 23.24%, 19.78%, 12.57%, 10.24%, 5.07%, and 8.05% (−90° vs. −60° vs. −30° vs. 0° vs. 30° vs. 60° vs. 90°). Conclusions: The more the port of the SVCS is oriented toward the TV, the more favorable it is for reducing RF and the impingement of blood flow in the right atrial wall, but there may be an increased risk of RRT. The opposite orientation of the SVCS port to the TV is not conducive to reducing flow impingement on the right atrial wall and RF. Full article

Background/Objectives: Contrast-enhanced computed tomography (CT) is the standard radiologic examination for evaluating the extent of mediastinal tumors. If tumor infiltration into the large central thoracic vessels, the pericardium, or the myocardium is suspected, cine magnetic resonance imaging (cine-MRI) can provide additional valuable information. Methods: We conducted a retrospective study of patients with mediastinal tumors who were staged with CT, cine-MRI, and a T1-weighted turbo spin echo (T1TSE) prior to surgical resection. Imaging was re-evaluated regarding tumor infiltration into the pericardium, myocardium, superior vena cava, aorta, pulmonary arteries, and atria and compared with intraoperative findings and postoperative histopathological reports (gold standard). Unclear CT findings were further investigated. Results: Forty-seven patients (29 female and 18 male patients; median age: 58 years) met the inclusion criteria. Cine-MRI was able to predict infiltration of the aorta in 86%, pulmonary arteries in 85%, and atria in 80% of unclear CT cases. Aortic tumor infiltration in unclear CT cases was significantly more often correctly diagnosed with cine-MRI than with T1TSE sequence. Conclusions: Additional cine-MRI is of crucial benefit in unclear CT cases. We recommend performing cine-MRI if infiltration into the large central vessels and atria is suspected. T1TSE sequence is of very limited additional value. Full article

We present the case of a 49-year-old female of Caucasian European descent with chest tightness, fatigue, and palpitations, ultimately diagnosed with primary intracardiac angiosarcoma. Initial echocardiography revealed a significant mass within the right atrium, infiltrating the free wall. Surgical intervention included tumor excision and partial resection of the superior vena cava. Histopathological examination confirmed a high-grade angiosarcoma. Postoperative imaging identified a recurrent mass in the right atrium, suggestive of thrombus, alongside Takotsubo cardiomyopathy. Considering the elevated surgical risks and the presence of cardiomyopathy, management included anticoagulation therapy with Warfarin and adjuvant chemotherapy with Paclitaxel. Follow-up cardiac magnetic resonance imaging demonstrated a recurrent angiosarcoma with superimposed thrombus. This case presents the complex diagnostic and therapeutic landscape of angiosarcoma, highlighting the critical importance of early surgical intervention, advanced imaging techniques, and vigilant postoperative monitoring. Full article

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed minimally invasive procedure. Air embolism in a patient undergoing ERCP is relatively rare, accounting for approximately 2–3% of procedures performed, and a catastrophic air embolism is even rarer. Symptoms of air embolism can come from the cardiopulmonary and nervous system. It is important to remember this in the differential diagnosis of complications of ERCP, as early detection is crucial. In the case presented here, the diagnostic CT scan performed immediately after the incident brings awareness of how massive an air embolism can be. The CT results showed gas bubbles entering both the superior and inferior vena cava. The presence of air has been captured in the bile ducts, duodenum wall, heart, femoral veins and intracranially. Risk factors for this complication include previous biliary surgeries, the presence of prostheses and stents, cholangitis, liver tumors and anatomical anomalies such as hepatobiliary fistulas, as well as intrahepatic and extrahepatic anatomical leaks. As gas embolism is associated with serious health consequences, knowledge of the problem and adequate preparation may reduce the occurrence of the problem. Attention should be paid to basic and easily obtainable precautions when performing the procedure, such as the patient’s hemodynamic status, adequate hydration and positioning during the procedure. Full article