Safety of Occlutech Septal Occluder ACCELL Flex II for Transcatheter Closure of Secundum Atrial Septal Defects in Children: A Long-Term Follow-Up

Objectives. To assess the long-term safety and efficacy of the Occlutech® ACCELL® Flex II device used for atrial septal defect (ASD) closure. This device differs from the regular device by having two very thin patches that are made of polyethylene terephthalate (PET). These patches enhance faster sealing of the defect. Background. Transcatheter closure has become the method of choice to manage most patients with secundum ASDs. There are different types of devices. The regular Occlutech device used to close an ASD is called the Occlutech Figulla Flex II. A newer modification of this device (Occlutech® ACCELL® Flex II) has been designed to eliminate/reduce thrombus formation and to enhance faster sealing. Methods. Thirty patients were followed up after occlusion of secundum ASD using the Occlutech® ACCELL® Flex II Device. The follow-up period ranged from 5.2–5.5 years with median of 5.3 years. Detailed history and full clinical examination, twelve-lead electrocardiogram (ECG), plain chest radiograph, and full 2D transthoracic echocardiography (TTE) were performed at discharge, at one month, six months, and yearly thereafter. Results. The mean age of the study group at the last follow-up was 10.4 ± 4.6 years, with 63.3% (nineteen patients) females. There were no residual shunts or complications encountered immediately after the procedure and at the latest follow-up. Conclusion. This study confirmed the transcatheter closure (TCC) of secundum ASDs using the Occlutech® ACCELL® Flex II device to be safe and effective with no complications detected in children and adolescents.

Characterisation of hemidiaphragm dysfunction using dynamic chest radiography: a pilot study

ObjectivesDynamic chest radiography (DCR) is a novel real-time digital fluoroscopic imaging system that produces clear, wide field-of-view diagnostic images of the thorax and diaphragm in motion, alongside novel metrics on moving structures within the thoracic cavity. We describe the use of DCR in the measurement of diaphragm motion in a pilot series of cases of suspected diaphragm dysfunction.MethodsWe studied 21 patients referred for assessment of diaphragm function due to suspicious clinical symptoms or imaging (breathlessness, orthopnoea, reduced exercise tolerance, and/or an elevated hemidiaphragm on plain chest radiograph). All underwent DCR with voluntary sniff manoeuvres.ResultsParadoxical motion on sniffing was observed in 14 patients, and confirmed in 6 who also underwent fluoroscopy or ultrasound. In 4 patients, DCR showed reduced hemidiaphragm excursion but no paradoxical motion; in 3, normal bilateral diaphragm motion was demonstrated. DCR was quick to perform, well-tolerated in all cases and with no adverse events reported. DCR was achieved in around five minutes per patient, with images available to view by the clinician immediately within the clinical setting.ConclusionDCR is a rapid, well-tolerated and straightforward X-ray technique that warrants further investigation in the assessment of diaphragm dysfunction.

Hoarseness in an older adult: Ortner syndrome

A detailed examination in an older adult presenting with chronic hoarseness is mandatory to exclude an upper aerodigestive tract malignancy. We describe a 71-year-old chronic smoker with essential hypertension who presented with hoarseness and vocal fatigue for 5 months. Laryngoscopic examination showed left vocal fold paralysis with phonation gap. No growth was seen at all laryngeal and hypopharyngeal subsites. The rest of the head and neck, chest, upper limbs and neurovascular examination were unremarkable. A plain chest radiograph demonstrated a cause for the left recurrent laryngeal nerve palsy. The diagnosis, complications and definitive management of the underlying cause and resultant voice problem will be discussed.

1008 Incidental Solitary Cystic Mediastinal Lymphangioma with Mass Effect Complications: A Case Report

Introduction Cystic mediastinal lymphangiomas (CML) are exceedingly rare, representing <1% of cystic lymphangiomas (CL), and typically present before 2 years of age. Few cases describe adult presentations of solitary CML and none describe symptomatic cases with ‘mass-effect’ complications. We describe an incidental finding of a symptomatic solitary CML causing mass effect complications and our definitive surgical management. Case Report A 44-year-old Caucasian male presented with reduced responsiveness due to mixed drug overdose of fluoxetine and ibuprofen. Plain chest radiograph (CXR) revealed incidental new mediastinal widening. Thoracic computed tomography (CT) showed a well-defined lesion (75x63mm) in the right paratracheal region, with associated compression of the superior vena cava, left brachiocephalic vein and displacement of the azygos vein. Further questioning revealed 6-months history of non-productive cough, worsening dyspnoea on exertion and chest pain radiating to the right of the chest. Complete surgical resection was performed via posterolateral thoracotomy. It was seen compressing the 2nd and 3rd intercostal nerves. Enlarged lymph nodes at station 4 and 10 were excised and sent for analysis with aspirate from the excised lesion. Pathological gross examination showed a multiloculated cystic lesion containing thin straw-coloured fluid. Microscopically, it was thin walled with smooth muscle and scattered clusters of lymphocytes; its lining was markedly attenuated comprising bland flat endothelial cells, positive for CD-31. Lymph node samples showed reactive changes. Conclusions Although CMLs are benign, their location and growth in the mediastinum can result in compression of surrounding structures. Early detection and complete surgical resection are paramount to prevent such complications and lesion recurrence.

Clinical Presentation and Management of Patients with Peptic Ulcer Perforation in Kashmir - A Prospective Study

BACKGROUND Around 4 million people are affected by peptic ulcer diseases worldwide annually. The incidence of around 1.5 % to 3 % has been estimated. Peptic ulcer perforation presents with an overall mortality of 10 %. The management is also associated with significant post-operative morbidity and mortality regardless of whether laparoscopic or open repair is performed. In this study, we wanted to find out the incidence of peptic ulcer perforation and its management. METHODS Our study was a prospective observational study conducted in post graduate Department of Surgery, Government Medical College Srinagar, from October 2018 to November 2020. All patients were evaluated properly with all baseline investigations followed by X-ray chest and abdomen and ultrasonography (USG). RESULTS In our study, 136 patients were diagnosed as cases of peptic ulcer perforation. The maximum number of patients were in age group of 41 - 50 years (27.20 %). The male : female ratio was 14.1 : 1. Abdominal pain was present in all patients as presenting symptom followed by abdominal distension. In this study, 124 patients (91.2 %) had perforation in first part of duodenum, 9 patients (6.6 %) had perforation in prepyloric region and 3 (2.2 %) patients had perforation in body of stomach. Graham’s Patch repair was done in 133 patients, 1 patient underwent primary closure, and 2 patients underwent distal gastrectomy with gastrojejunostomy. CONCLUSIONS Our study shows that young people with perforated peptic ulcer have fewer coexisting medical illness, a lower complication rate and a more favorable outcome as compared to elderly patients with perforated peptic ulcer. A majority of such perforations are in 1st part of duodenum with male preponderance. A plain chest radiograph is sufficient to make diagnosis in the classic case of sudden onset epigastric pain. KEYWORDS Perforation Peritonitis, Management of Peptic Ulcer Perforation, Graham’s Repair, Clinical Presentation of Peptic Ulcer Perforation

Pericardial calcification with plain radiographic features of tuberculosis in a child: incidental finding and a case report

Tuberculous pericarditis is frequently reported as the primary cause of pericardial calcification and occurs in about 1-2% of individuals with pulmonary tuberculosis, this however is a rare finding in the Western world. This is a 12-year-old male child that was referred from a peripheral health care center for plain radiograph of the chest on account of cough, easy fatiguability, night sweats, loss of weight, loss of appetite and dyspnea most times on excersion for more than a month duration. The plain chest radiograph demonstrated normal cardiac size with a cardiothoracic ratio of about 55/120, there is circumferential radio-opacity of calcic density around the peripheral walls of the heart; the pericardial calcification. The vascular pedicle appears slightly widened. The lung fields show extensive streaky opacities with cystic lung changes bilaterally more marked on the left lung field where consolidation, loss of lung volume and pleural effusion are also demonstrated. A two-dimensional echocardiography showed mild-moderate pericardial effusion, thickening of both visceral and parietal pericardium, and echogenic fond-like structures protruding in to the pericardial cavity. A diagnosis of pulmonary tuberculosis with features of tuberculous pericarditis in a 12-year-old male child was established. The patient has been placed on anti-tuberculous drugs, hematinic, and parents advised on good and adequate diet with adequate rehydration and strict drug compliance. Screening of the siblings and members of the family with close contact have also been emphasized. We report the radiographic features of pulmonary tuberculosis and pericardial calcification in a 12-year-old male child due to its peculiar presentation.

Imaging in alpha-1 antitrypsin deficiency: a window into the disease

Imaging modalities such as plain chest radiograph and computed tomography (CT) are important tools in the assessment of patients with chronic obstructive pulmonary disease (COPD) of any etiology. These methods facilitate differential diagnoses and the assessment of individual lung pathologies, such as the presence of emphysema, bullae, or fibrosis. However, as emphysema is the core pathological consequence in the lungs of patients with alpha-1 antitrypsin deficiency (AATD), and because AATD is associated with the development of other lung pathologies such as bronchiectasis, there is a greater need for patients with AATD than those with non-AATD-related COPD to undergo more detailed assessment using CT. In the field of AATD, CT provides essential information regarding the presence, distribution, and morphology of emphysema. In addition, it offers the option to quantify the extent of emphysema. These data have implications for treatment decisions such as initiation of alpha-1 antitrypsin (AAT) therapy, or suitability for surgical or endoscopic interventions for reducing lung volume. Furthermore, CT has provided vital insight regarding the natural history of emphysema progression in AATD, and CT densitometry has underpinned research into the efficacy of AAT therapy. Moving forward, hyperpolarized xenon gas (129Xe) lung magnetic resonance imaging (MRI) is emerging as a promising complement to CT by adding comprehensive measures of regional lung function. It also avoids the main disadvantage of CT: the associated radiation. This chapter provides an overview of technological aspects of imaging in AATD, as well as its role in the management of patients and clinical research. In addition, perspectives on the future potential role of lung MRI in AATD are outlined.

Extensive pulmonary metastases in young boy with primary cardiac angiosarcoma: a case report

Background Malignant primary cardiac neoplasms are rare and primary cardiac angiosarcoma is the most common and aggressive subtype. It most commonly presents in middle-aged males and due to its non-specific clinical presentation, the diagnosis is often delayed until advanced disease is already present. Clinical presentation is determined by manifestations of local infiltration or metastatic disease and making an early diagnosis is extremely challenging. Case summary A 15-year-old previously healthy boy was admitted to the emergency department with a history of pathological weight loss and functional decline. The patient was found to have a left-sided pneumothorax as well as bilateral diffusely spread pulmonary nodules on plain chest radiograph. Computed tomography chest confirmed widespread pulmonary metastases and a right atrial filling defect. Echocardiography revealed a right atrial tumour and transvenous endomyocardial biopsy of the tumour was done under fluoroscopic and echocardiographic guidance. A diagnosis of primary cardiac angiosarcoma was made. The patient demised shortly after presentation. Discussion Primary cardiac angiosarcoma is rare and even more so in patients as young as the case described. The diagnostic process poses several challenges to the clinician, of which the obtaining of a histological sample is one. This case report demonstrates aspects both unique and typical of this rare disease. It also describes an effective option for obtaining tissue for a histological diagnosis in patients whose clinical condition may not allow biopsy under general anaesthesia.

Suspecting a fatal condition on a plain chest radiograph; Boerhaave syndrome

Spontaneous oesophagus rupture, also known as Boerhaave syndrome, is a rare but near-fatal medical condition and despite recent medical advancements, it remains a diagnostic challenge for front-door clinicians. The authors describe a similar presentation in an elderly gentleman who presented to the emergency department with sudden chest pain post vomiting. His initial chest radiograph showed bilateral dense consolidations and pleural effusions, and was treated as sepsis secondary to bilateral pneumonia. He underwent computed tomography pulmonary angiogram to rule out pulmonary embolism because of his chest pain with elevated D-dimer which confirmed the diagnosis of oesophagus rupture. His care was transferred to Surgical and Intensive care colleagues with plans for radiological chest drain insertion to limit contamination of mediastinum, however the patient became hypoxic and hypotensive and despite maximal organ support passed away within 6 hours of admission. Retrospect review of chest radiograph revealed Peri-oesophageal air tracking, a sign of Boerhaave syndrome. The aim of this case is to emphasise the importance of raising the suspicion of Boerhaave syndrome in patients with sudden chest pain, unexplained pleural effusion or pneumothorax with a history of recent vomiting as early diagnosis holds the key to prompt lifesaving management.