Echocardiographic and Computed-tomographic Evaluation of the Fate of Bovine Pericardial Patch as a Pericardial Substitute in Bentall’s Procedure: Twenty-year’ Results

Objective: The study was designed to ascertain the influence of usage of bovine pericardial patch in patients undergoing Bentall’s procedure with respect to reexploration for bleeding, mediastinal infection, avoidance of conduit adhesions, late development of pericardial constriction and calcification. Materials and Methods: We reviewed 150 patients (79 males) aged between 22 to 68 years (mean±SD 49.25±12.9 years) receiving a composite aortic conduit between January 1998 to December 2020 for annuloaortic ectasia (n=100), aortic dissection (n=49), and dilated aortic root in repaired tetralogy of Fallot (n=1). Twenty-five patients had Marfan’s syndrome. Modified “button technique” was performed by interposing a glutaraldehyde treated pericardial strip at the graft coronary anastomoses, and proximal aortic conduit suturing using interlocking interrupted, pledgeted mattress suture. On completion, the pericardial cavity was reconstructed using St. Jude Medical Biocor pericardial patch. To detect evidence of pericardial constriction, survivors underwent echocardiography and computed tomography. The Kaplan-Meier curve was drawn to show the probability of survival over a period of follow-up time. Results: Seven (4.7%) patients died of cardiac-related cause, 45% had transient hemodynamic instability, 55% had low cardiac output, and 87.1% had spontaneous return of sinus rhythm. The average 12-hour postoperative drainage was 245±70 ml and there was no mediastinal infection. At a mean follow-up of 172.4 (SD± 58.9) months, the actuarial survival was 94.2±0.04% (95% CI: 88.5-96.8), and there was no pericardial constriction or calcification. Conclusion: Reconstruction of pericardial cavity using Biocor bovine pericardial patch minimizes diffuse oozing of blood, graft infection, and is not associated with later development of pericardial constriction, or calcification.

ДЕКОМПЕНСОВАНИЙ ВИПАДОК ГІПОТИРЕОЗА З УРАЖЕННЯМ СЕРЦЕВО-СУДИННОЇ СИСТЕМИ

We present a clinical case that demonstrates a lack of compliance in a patient with hypothyroidism, which led to severe complications of the cardiovascular system. The clinical feature of this case is the development of severe complications of hypothyroidism due to the patient’s low adherence to therapy and untimely treatment. The patient had all characteristic signs of severe hypothyroidism with heart and skin lesions (total alopecia, edema, dryness and peeling of the skin). Fully available diagnostic criteria were as follows: critical disorders of thyroid hormone levels in the blood, hyperenzymemia, hypothyroidism, fluid in the pleural cavity, increased heart shadow, fluid in the pericardial cavity, left ventricular dilatation, decreased ejection fraction, arrhythmia. The predominant lesion of the cardiovascular system is characteristic of such cases and prevailed in the clinical presentation of the disease and was the direct reason for seeking medical help. Under the influence of treatment, the patient's sinus rhythm was restored, myocardial contractility improved, there was no fluid in the pericardial cavity and pleural cavity, edema decreased, mental activity and emotional state improved. However, the patient flatly refused further observation and treatment. As a result, hypothyroidism is underdiagnosed. Initiation of treatment in the early stages of the disease and prevention of complications relies on early diagnosis through systematic screening according to the recommendations. Heart disease, associated with hypothyroidism is a condition that can be prevented if it is detected and treated by family doctors in a timely manner in an outpatient setting. Timely detection of the disease and hospitalization will allow avoiding serious complications of hypothyroidism, timely diagnosing this pathology and prescribing adequate therapy according to the stage of the disease.

Introduction to the second edition of ‘Diagnostic Cytopathology of Serous Fluids’ as CytoJournal Monograph (CMAS) in Open Access

Serous fluids are excessive accumulation of fluids in a serous cavity as effusion. However, traditionally this area also covers cytopathologic evaluation of washings of these cavities including pelvic/peritoneal washing. This is the introductory review article in series on this topic with the application of simplified algorithmic approaches. The series would be compiled finally as a book after minor modifications of individual review articles to accommodate the book layout on the topic as second edition of ‘Diagnostic Cytopathology of Serous Fluids’ book. The approach is primarily directed towards detection of neoplastic cells based on morphology alone or with the help of various ancillary tests, including commonly applied immunocytochemistry to be interpreted as second foreign population with application of SCIP (subtractive coordinate immunoreactivity pattern) approach in effusion fluid tapings. As the role of molecular pathology tests is increasing, this component as ancillary testing will also be covered as applicable. Because a picture and sketches are worth a thousand words, illustrations and figures are included generously even at the risk of moderate repetition. The clinically important serous cavities include peritoneal cavity, pericardial cavity, and two pleural cavities. The primary topic of this series is specimens from these cavities as effusion fluids and washings including cytopathologic evaluation of peritoneal/pelvic washing. It is expected that some readers may not read the entire series or the final book from beginning to end, but refer to the individual review articles and chapters sporadically during their clinical practice. Considering this practical limitation, some brief repetition may be observed throughout the book. Some of the important themes will be highlighted as italicized and bolded text for quick reference. Dedicated articles/chapters are assigned for technical and other reference material as appendices. Tables, algorithms, sketches, and combination of pictures are included generously for quick reference. Most of the illustrations are attempted to be labeled appropriately with arrows and other indicators to avoid equivocation, especially for beginners in the field. This introductory review article describes general details under the following three broad headings: Histology and general cytology of serous cavity lining Effusion (general considerations) Ancillary techniques in brief.

PERICARDIAL PUNCTURE: WHEN AND HOW?

Pericardial effusion is a very common condition, due to the accumulation of fluid in the pericardial cavity (the impact depends on the volume, rate of accumulation and elasticity of the pericardium), it results in a: 1. Increased intrapericardial pressure. 2. Increase in intracardiac pressure 3. Decrease in ventricular filling 4. Decrease in ejection volume 5. Decrease in cardiac output The etiologies of effusions are diverse. Tamponade requires emergency decompression of the pericardium to achieve hemodynamic stabilization. Two techniques are possible, either percutaneous puncture with or without ultrasound guidance, or surgical drainage. The choice of drainage method depends on the medical-surgical teams, their experience with each method and the etiology.

Hydropneumopericardium: A rare complication of pericardiocentesis

Hydropneumopericardium is defined as the presence of air and water in the pericardial cavity. Several causes have been postulated which can lead to hydropneumopericardium including trauma, infections secondary to gas-producing bacilli, fistula formation, positive pressure ventilation or even spontaneously without an underlying cause in healthy adults and rarely after pericardiocentesis. We report an uncommon instance of hydropneumopericardium after pericardiocentesis in a 35-year-old man, which developed due to a leaky drainage system. It was immediately drained through the subxiphoid approach under echocardiographic guidance, and the patient was relieved. Hydropneumopericardium is an uncommon but easily diagnosable and avoidable complication of pericardiocentesis. It should be suspected whenever the patient develops increasing dyspnoea following a temporary relief by pericardiocentesis.

Immune-Inflammatory Predictors of Diastolic Dysfunction of Left Ventricle in Patients with Rheumatoid Arthritis Combined with Hypertension

Hypertension is the most common concomitant disease in patients with rheumatoid arthritis. Diastolic dysfunction of left ventricle is an important predictor of chronic heart failure, which can be asymptomatic for a long time. Therefore, it is advisable to detect diastolic dysfunction of left ventricle as early as possible, which can slow the progression of chronic heart failure. The purpose of the study was to determine the value of lipid peroxidation, endothelial function and systemic inflammatory response markers for diagnostic of diastolic dysfunction of left ventricle and for diagnostic of pericardial effusion in patients with rheumatoid arthritis combined with hypertension. Materials and methods. 93 patients with rheumatoid arthritis in combination with stage II hypertension were studied. The ultrasound examination of heart was performed. The serum laboratory markers of lipid peroxidation, concentration of pro-inflammatory cytokines, markers of endothelial function were determined. Results and discussion. Signs of diastolic dysfunction of left ventricle were found in 79 patients and no signs of diastolic dysfunction were found in 14 patients. It was detected that there was a significant increase of concentration of asymmetric dimethylarginine by 16.3%, interleukin-1β by 35.3%, interleukin-10 by 24.3%, the ratio of interleukin-1β / interleukin-10 by 62.0%, C-reactive protein by 52.6% and there was a significant decrease of total nitric oxide metabolites by 36.9%, nitrires by 37.5% and nitrates by 37.0% in patients with signs of diastolic dysfunction of left ventricle compared to the patients without diastolic dysfunction of left ventricle (p <0.01). It was found that the levels of isolated double bonds, diene conjugates, diene ketones, schiff bases and malonic aldehyde in patients with diastolic dysfunction of left ventricle were significantly higher by 24.4%, 25.2%, 20.4%, 17.6% and 21.4% respectively compared to the corresponding markers in patients without signs of diastolic dysfunction of left ventricle (p <0.01). The levels of vitamin A, vitamin E and catalase in patients with diastolic dysfunction of left ventricle were significantly lower by 18.2%, 27.4% and 13.4% compared to the corresponding markers of patients with normal left ventricle diastolic function (p <0.01). The highest predictor value for the diagnostic of diastolic dysfunction of left ventricle was detected in interleukin-1β area under the ROC curve 0.882, sensitivity 72.15% and specificity 100%, 95% CI [0.798-0.939] at the optimal distribution point >9.67 pg/ml and in asymmetric dimethylarginine area under the ROC curve 0.879 sensitivity 75.95% and specificity of 100%, 95% CI [0.795-0.937] at the optimal distribution point >0.715 μmol/l. In 17 (18.28%) patients, the effusion in the pericardial cavity was detected. It was detected that there was a significant increase of isolated double bonds by 18.65%, diene conjugates by 19.73%, diene ketones by 25.25%, schiff bases by 20%, malonic aldehyde by 26.76% and there was a significant decrease of vitamin A by 38.4%, vitamin E by 55.4% and catalase by 37.2% in patients with effusion in the pericardial cavity. The significant increase of asymmetric dimethylarginine was detected by 25.25%, interleukin-1β – by 52.24%, interleukin-10 – by 15.76%, the ratio of interleukin-1β / interleukin-10 – by 38.86% and C-reactive protein – by 26.9% in patients with effusion in the pericardial cavity. In addition, patients with cavity effusion have significant decrease of nitric oxide metabolites by 25.0%, nitrires by 30.0% and nitrates by 11.11% compared to the patient without effusion. The highest predictor value for the detection of effusion in the pericardial cavity was found in asymmetric dimethylarginine area under the ROC curve 0.913, 95% CI area under the ROC curve [0.836-0.961] at the optimal distribution point >0.841 μmol/l, sensitivity 94.12% and specificity 85.53%. Conclusion. The markers, which have the highest prognostic value for diagnostic of diastolic dysfunction of left ventricle in patients with rheumatoid arthritis combined with hypertension, are interleukin-1β and asymmetric dimethylarginine. In addition, asymmetric dimethylarginine has the highest predictor value for detecting fluid in the pericardial cavity

958 Encapsulating Peritoneal Sclerosis with Pericardial Tamponade: A Case Report

Aim Encapsulating peritoneal sclerosis (EPS) is a rare morbidity associated primarily with peritoneal dialysis. Definitive diagnosis and management can often be prolonged and complicated. The pathogenesis is a two-hit hypothesis of inflammation and myofibroblast differentiation. This report aims to demonstrate the pathogenesis of EPS and provide insight into management. Method We present a unique case of a patient with EPS who follows a ‘classical’ disease course before developing a concomitant pericardial sclerosis, presenting with cardiac tamponade. We explore the proposed pathophysiology and provide a hypothesis for both uncommon pathologies presenting in the same patient. Results A 45-year-old male was treated for EPS and went on to develop a concomitant pericardial sclerosis. Following referral to our centre, the patient underwent a semi-elective surgical enterolysis and peritonectomy for EPS, with excision of all sclerotic and obstructing peritoneal membrane. Two weeks following the surgery, he developed a pericardial tamponade with cardiovascular compromise, unresolved by two separate episodes of pericardiocentesis, leading to surgical intervention. A pericardial pleural window was created via open thoracotomy and 800ml of thick clotted blood was removed from the pericardial cavity. Histology demonstrated pericardial sclerosis. Conclusions This case of EPS is unique given the concomitant pericardial sclerosis. Uraemia may be a common mediator of inflammation in the peritoneum and pericardium, predisposing to sclerosis of both membranes of identical embryological origin. Pericardial sclerosis may be present in EPS patients but may not manifest itself clinically by and large. It also demonstrates that effective surgical intervention can lead to excellent patient outcomes.

Shunt coronarography in patients with recurrent stenocardia in long term after aorto-coronary bypass

Проблема профилактики и диагностики стеноза - окклюзирования шунтов после аорто - коронарного шунтирования в отдаленном периоде остается нерешенной. Наиболее часто закрываются шунты в течение первого года, возникновение окклюзии венозных шунтов в течение первого года после операции наблюдаются у 25-30% больных, в дальнейшем в течении 5-7 лет частота окклюзии составляет около 2% в год, после этого срока 5% в год. Артериальные шунты остаются проходимы до 98%, и в основном причиной их дисфункции является прогрессирование атеросклеротического процесса и технические погрешности. Основными причинами которые могут привести к нарушению функции шунта в отдаленном периоде считают [1, 2, 4, 6, 8] следующие: 1-техническое (повреждение эндотелиального слоя и стенки аутовенозного трансплантата при его взятии (ретроспективный анализ), чрезмерная длина и перегиб шунта (на шунтографии), натяжение шунта из-за недостаточной его длины, неправильный выбор места наложения дистального анастомоза) [11,12,13]. 2- анатомические факторы[3, 5, 7] . 3 - общие факторы (низкая объемная скорость кровотока по шунту, нестабильность общей гемодинамики, массивные сращения в полости перикарда, гиперкоагуляция, гнойный медиастинит, длительное лихорадочное состояние и неадекватный прием антикоагулянтов. 4 - прогрессирование атеросклероза [9]. 5- использование венозных трансплантантов как одна из важных причин стеноза - окклюзии шунта [10]. The Problem of stenosis prevention and diagnostics - occlusion of shunts after aorto-coronary bypass in long term remains unaddressed. Typically, shunts are closed within the first year, emergence of phleboid shunts occlusion within the first year after surgical intervention is observed in 25-30% of patients, and further frequency of occlusion within 5-7 years is about 2% per year, 5% per year after this term. Arterial shunts is passable up to 98%, and mainly the reason for their dysfunction is the atherosclerotic process progression and technical faults. The main reasons which can results in shunt dysfunction in long term are the following [1, 2, 4, 6, 8]: 1-technical (damage of endothelial layer and paries of autovenous transplant during its drawing (retrospective analysis), excess length and shunt bend (at the shuntography), shunt tension because of its insufficient length, improper location of distal anastomosis application) [11,12,13]. 2- anatomical factors [3, 5, 7] . 3 - general factors (low volumetric blood flow along the shunt, instability of general hemodynamics, dense adhesion in pericardial cavity, hypercoagulability, purulent mediastinitis, prolonged febrile state and inadequate intake of anticoagulants. 4 - atherosclerosis prgression [9]. 5- using venous transplants as one of the important reasons of stenosis - shunt occlusion [10].

Spatiotemporal imaging and pharmacokinetics of fluorescent compounds in zebrafish eleuthero-embryos after different routes of administration

Zebrafish (Danio rerio) is increasingly used to assess the pharmacological activity and toxicity of compounds. The spatiotemporal distribution of seven fluorescent alkyne compounds was examined during 48 h after immersion (10 µM) or microinjection (2 mg/kg) in the pericardial cavity (PC), intraperitoneally (IP) and yolk sac (IY) of 3 dpf zebrafish eleuthero-embryos. By modelling the fluorescence of whole-body contours present in fluorescence images, the main pharmacokinetic (PK) parameter values of the compounds were determined. It was demonstrated that especially in case of short incubations (1–3 h) immersion can result in limited intrabody exposure to compounds. In this case, PC and IP microinjections represent excellent alternatives. Significantly, IY microinjections did not result in a suitable intrabody distribution of the compounds. Performing a QSPkR (quantitative structure-pharmacokinetic relationship) analysis, LogD was identified as the only molecular descriptor that explains the final uptake of the selected compounds. It was also shown that combined administration of compounds (immersion and microinjection) provides a more stable intrabody exposure, at least in case of a prolonged immersion and compounds with LogD value > 1. These results will help reduce the risk of false negative results and can offer an invaluable input for future translational research and safety assessment applications.

Lipoma across the Wall of the Right Atrium

A 44‑year‑old male patient was referred to our department with unremarkable physical examination and laboratory data due to a mass which was incidentally found in the right atrial during a routine examination.Transthoracic and transesophageal echocardiography revealed a 46×30 mm, well-delimited, non-mobile mass in the superior portion of the right atrium. Besides the intracardiac mass, another low density was detected in adjacent pericardial cavity at cardiac computed tomography ;he extracardiac mass appeared to be caused by invasive growth from the intracardiac mass.An operation was performed through right anterolateral minithoracotomy with the patient under hypothermic cardiopulmonary bypass. During operation, it was found that the surface of the right atrium was covered by an adipose mass (30×40 mm; Fig. 2A). Intracardiac mass also showed yellow adipose tissue (40×50 mm; Fig. 2B). Both parts of the mass infiltrated the myocardium. The mass was resected completely; and right atrium was reconstructed by using bovine pericardium pad. After the operation, the pathology confirmed the both intracardiac and extracardiac tissues as lipoma; transthoracic echocardiogram showed the atrial mass was removed completely and the left ventricular ejection fraction was normal . The patient’s postoperative course was uneventful and he was discharged home after 7 days.