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BACKGROUND: Osimertinib is a third-generation epidermal growth factor receptor (EGFR) inhibitor that is currently the first-line treatment for metastatic EGFR-mutated non-small-cell lung cancer (NSCLC) due to its favorable efficacy and tolerability profile compared to previous generations of EGFR inhibitors. However, it can cause uncommon, yet serious, cardiovascular adverse effects. CASE PRESENTATION: We present the case of a 63-year-old man with EGFR-mutated NSCLC treated with osimertinib who developed new-onset non-ischemic cardiomyopathy with biventricular dysfunction and heart failure in the context of an enlarging pericardial effusion. For the first time, we demonstrate cardiac MR imaging findings associated with osimertinib-associated cardiomyopathy, including focal late gadolinium enhancement and myocardial edema. The patients biventricular function normalized after initiation of goal-directed medical therapy for heart failure and holding osimertinib. The patient was subsequently started on afatinib, a second-generation epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI), without recurrence of cardiomyopathy. CONCLUSIONS: This case highlights the need to better understand osimertinib-induced cardiotoxicity and strategies to optimize oncologic care in patients who develop severe cardiac toxicities from cancer therapy. It further underlines the importance of specialized multidisciplinary care of cancer patients who develop cardiotoxicities to optimize their oncologic outcomes.

Background: Pericardial effusion is a late manifestation of HIV more commonly observed in individuals with depressed CD4 counts. Although Mycobacterium tuberculosis remains to be one of the most frequently identified pathogens in the pericardial fluid among people living with HIV, less commonly described etiologies include SARS‑CoV‑2 that causes coronavirus disease and human herpesvirus‑8 which is associated with Kaposi sarcoma. Isolation of more than one pathogen in normally sterile sites remains challenging and rare. We report the first documentation of both SARS‑CoV‑2 and HHV‑8 in the pericardial fluid. Case presentation: We present the case of a young man in his 20s with a recent history of clinically diagnosed pul‑monary tuberculosis who was admitted for progressive dyspnea and cough. He had multiple violaceous cutaneous lesions on the face, neck, and trunk and diffused lymphadenopathies. He tested positive for SARS‑CoV‑2 on admission. The patient was clinically diagnosed with pneumonia, Kaposi sarcoma, and HIV/AIDS. Empiric broad spectrum antimi‑crobial regimen was subsequently initiated. HIV with low CD4 count was confirmed during hospitalization. Echocardi‑ography revealed a large pericardial effusion, in impending cardiac tamponade. Frond‑like fibrin strands, extending to the parietal pericardium, were also observed. Pericardiostomy yielded hemorrhagic, exudative effusion with lympho‑cytic predominance. SARS‑CoV‑2 and HHV‑8 were detected in the pericardial fluid, and bacterial, fungal, and tubercu‑lous studies were negative. The patient had clinical improvement after pericardial drainage. However, despite our best clinical care, he developed a nosocomial infection leading to clinical deterioration and death. Conclusion: Detection of SARS‑CoV‑2 and HHV‑8 in the pericardial fluid is rare, and interpretation of their signifi‑cance in clinical care is challenging. However, coronavirus disease and Kaposi sarcoma must be considered and adequately addressed in imm, Tropical Medicine and Health, 50(1), art. no. 72; 2022

Pericardial effusions in dogs are most often diagnosed as haemorrhagic and idiopathic. Pericardial effusions secondary to an underlying neoplastic process are infrequently diagnosed, as neoplastic cells are rarely observed in a sample of the effusion. In the present report, we describe a 9-year-old dog with pericardial effusion due to T-cell lymphoma of granular lymphocyte type. Immunophenotyping and molecular clonality PCR were performed to confirm the cytologic diagnosis. To our knowledge, this is the first report of pericardial effusion in a dog due to T-cell lymphoma of granular lymphocyte type.

Background: Pericardial effusion is a late manifestation of HIV more commonly observed in individuals with depressed CD4 counts. Although Mycobacterium tuberculosis remains to be one of the most frequently identified pathogens in the pericardial fluid among people living with HIV, less commonly described etiologies include SARS‑CoV‑2 that causes coronavirus disease and human herpesvirus‑8 which is associated with Kaposi sarcoma. Isolation of more than one pathogen in normally sterile sites remains challenging and rare. We report the first documentation of both SARS‑CoV‑2 and HHV‑8 in the pericardial fluid. Case presentation: We present the case of a young man in his 20s with a recent history of clinically diagnosed pul‑monary tuberculosis who was admitted for progressive dyspnea and cough. He had multiple violaceous cutaneous lesions on the face, neck, and trunk and diffused lymphadenopathies. He tested positive for SARS‑CoV‑2 on admission. The patient was clinically diagnosed with pneumonia, Kaposi sarcoma, and HIV/AIDS. Empiric broad spectrum antimi‑crobial regimen was subsequently initiated. HIV with low CD4 count was confirmed during hospitalization. Echocardi‑ography revealed a large pericardial effusion, in impending cardiac tamponade. Frond‑like fibrin strands, extending to the parietal pericardium, were also observed. Pericardiostomy yielded hemorrhagic, exudative effusion with lympho‑cytic predominance. SARS‑CoV‑2 and HHV‑8 were detected in the pericardial fluid, and bacterial, fungal, and tubercu‑lous studies were negative. The patient had clinical improvement after pericardial drainage. However, despite our best clinical care, he developed a nosocomial infection leading to clinical deterioration and death. Conclusion: Detection of SARS‑CoV‑2 and HHV‑8 in the pericardial fluid is rare, and interpretation of their signifi‑cance in clinical care is challenging. However, coronavirus disease and Kaposi sarcoma must be considered and adequately addressed in imm, Tropical Medicine and Health, 50(1), art. no. 72; 2022

The objective of the study was to investigate the safety profile of high-risk micro-endomyocardial biopsy (micro-EMB) compared to conventional EMB in a large animal model. Twenty pigs were subjected to a maximum of 30 consecutive biopsies, including sampling from the free ventricular wall, with either micro-EMB (n = 10) or conventional EMB (n = 10). There were no major complications in the micro-EMB group (0/10), compared to six major complications in the EMB group (6/10; p = 0.003). Survival analysis further highlighted these differences (p = 0.004). There were significantly higher volumes of pericardial effusion in the EMB group (p = 0.01). The study shows a safety advantage of micro-EMB compared to standard EMB in the experimental high-risk circumstances investigated in this animal study. These results indicate enhanced possibilities to collect samples from sensitive areas by using the micro-EMB technique instead of standard EMB., QC 20220607

BackgroundPericardial disease can be a manifestation of infection and imaging can have a role in its diagnosis. coccidioidomycosis endemic fungal infection has been more frequently reported over the past few decades. Other than case reports or series, there has been no systemic study evaluating pericardial imaging findings in patients with coccidioidomycosis to the best of our knowledge. The purpose of this study was to evaluate intrathoracic computed tomographic (CT) imaging abnormalities in patients with coccidioidal infection with specific emphasis on the pericardium.MethodsRetrospective review of radiology reports and clinical chart review was performed to identify patients with coccidioidomycosis between January 2000 and September 2021 at our medical center. Diagnosis of infection was confirmed predominately with serology. Patients were excluded if a CT was not performed within 3 months of confirmed diagnosis date and if there was concomitant additional granulomatous or fungal infection. Chest CT was reviewed for pericardial and additional intrathoracic findings.ResultsThe final retrospective cohort consisted of 37 patients. Imaging findings included lung nodules (N = 33/37), consolidation (N = 25/37), mediastinal or hilar lymphadenopathy (N = 20/37) and pleural effusions (N = 13/37). Eleven of 37 patients (30%) had either trace pericardial fluid (N = 3/37) or small pericardial effusions (N = 8/37). One patient had pericardial enhancement/thickening and history of pericardial tamponade. No other patient had clinical pericarditis or pericardial tamponade. Pericardial calcifications were not seen in any patient. Pericardial effusion was statistically associated with presence of pleural effusion as 9/13 patients with pleural effusion had pericardial effusion versus 2/26 patients without pleural effusion had pericardial effusion (p < 0.001). Otherwise patients with and without pericardial imaging findings were similar in terms of demographics, comorbidities

Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.

Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.

BackgroundPericardial disease can be a manifestation of infection and imaging can have a role in its diagnosis. coccidioidomycosis endemic fungal infection has been more frequently reported over the past few decades. Other than case reports or series, there has been no systemic study evaluating pericardial imaging findings in patients with coccidioidomycosis to the best of our knowledge. The purpose of this study was to evaluate intrathoracic computed tomographic (CT) imaging abnormalities in patients with coccidioidal infection with specific emphasis on the pericardium.MethodsRetrospective review of radiology reports and clinical chart review was performed to identify patients with coccidioidomycosis between January 2000 and September 2021 at our medical center. Diagnosis of infection was confirmed predominately with serology. Patients were excluded if a CT was not performed within 3 months of confirmed diagnosis date and if there was concomitant additional granulomatous or fungal infection. Chest CT was reviewed for pericardial and additional intrathoracic findings.ResultsThe final retrospective cohort consisted of 37 patients. Imaging findings included lung nodules (N = 33/37), consolidation (N = 25/37), mediastinal or hilar lymphadenopathy (N = 20/37) and pleural effusions (N = 13/37). Eleven of 37 patients (30%) had either trace pericardial fluid (N = 3/37) or small pericardial effusions (N = 8/37). One patient had pericardial enhancement/thickening and history of pericardial tamponade. No other patient had clinical pericarditis or pericardial tamponade. Pericardial calcifications were not seen in any patient. Pericardial effusion was statistically associated with presence of pleural effusion as 9/13 patients with pleural effusion had pericardial effusion versus 2/26 patients without pleural effusion had pericardial effusion (p < 0.001). Otherwise patients with and without pericardial imaging findings were similar in terms of demographics, comorbidities

Introduction: The DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome is a rare but serious and potentially lethal occurrence of a set of signs and symptoms associated with the use certain types of drugs. This syndrome is characterized by a heterogeneous clinical manifestation that, in many cases, results in multisystemic involvement. Case presentation: A 24-year-old man from Calarcá, Colombia, visited the emergency department of the local hospital due to a three-day history of unquantified intermittent fever associated with asthenia, adynamia, anorexia, headache, myalgia, odynophagia, and upper abdominal pain. Due to his condition and based on laboratory findings, he was referred to the Clínica Central del Quindío. The patient, 20 days before the initial assessment, had been prescribed a pharmacological treatment with non-steroidal anti-inflammatory drugs and phenytoin due to a severe cranioencephalic trauma; he also presented with generalized skin rash, elevated transaminases, and moderate eosinophilia. Complementary studies reported mild pericardial effusion, so DRESS syndrome was suspected, and corticosteroid therapy was started, achieving the complete remission of the syndrome. Conclusion: Although the DRESS syndrome has a low incidence, it should always be suspected, especially in patients with cardiac and pericardial involvement. In this case, pericardial involvement was evident, demonstrating that individuals with this syndrome may present with rare symptoms that have a serious impact on their health, as they may significantly increase adverse outcomes and mortality risk., Introducción. El síndrome de DRESS (Drug Reaction with Eosinophilia and Systemic symptoms) consiste en la ocurrencia, si bien poco frecuente, pero grave y potencialmente mortal, de un conjunto de signos y síntomas asociados al consumo de cierto tipo de medicamentos. Este síndrome se caracteriza por tener una manifestación clínica heterogénea que, en muchos casos, causa compromiso multisistémico. Presentación del caso. Hombre de 24 años de Calarcá, Colombia, que asistió al servicio de urgencias del hospital local por presentar fiebre intermitente no cuantificada durante 3 días, junto con astenia, adinamia, anorexia, cefalea, mialgias, odinofagia y dolor abdominal superior, y que, debido a su condición y resultados de laboratorio, fue remitido a la Clínica Central del Quindío. El paciente, 20 días antes de la valoración inicial, había recibido tratamiento farmacológico con antiinflamatorios no esteroides y fenitoína por traumatismo craneoencefálico severo; además presentó rash cutáneo generalizado, elevación de transaminasas y eosinofilia moderada. En los estudios complementarios se reportó derrame pericárdico leve, por lo que se sospechó síndrome de DRESS y se inició corticoterapia, lográndose así la remisión completa de la enfermedad. Conclusión. Aunque el síndrome de DRESS tiene una baja incidencia, siempre debe sospecharse, en especial en pacientes que presentan compromiso cardiaco y pericárdico. En este caso se destaca la afectación pericárdica, demostrando que en este síndrome se pueden presentar manifestaciones poco frecuentes, pero con un gran impacto en su salud, ya que pueden aumentar considerablemente los desenlaces adversos y la mortalidad en estos pacientes.

BackgroundLeft ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR.Case presentationWe present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table.ConclusionsThe occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

BackgroundLeft atrial appendage occlusion has shown promise in mitigating the risk of stroke in selected patients with atrial fibrillation.ObjectiveThe purpose of this study was to determine the real-world prevalence and in-hospital outcomes in left atrial appendage occlusion (Watchman) recipients complicated by pericardial effusion requiring percutaneous drainage or open cardiac surgery-based intervention.MethodsData were derived from the National Inpatient Sample database from January 2015 to December 2017. The primary outcomes assessed were the prevalence of pericardial effusion requiring intervention and in-hospital outcomes including mortality, other major complications, hospital stay > 1 day, and hospitalization costs. Predictors of pericardial effusion requiring intervention were also analyzed.ResultsPericardial effusion requiring intervention occurred in 220 total patients (1.24%). After multivariable adjustment, pericardial effusion requiring intervention was associated with in-hospital mortality (adjusted odds ratio [aOR] 511.6; 95% confidence interval [CI] 122-2145.3), other Watchman-related major complications (aOR 1.35; 95% CI 0.83-2.19), length of stay > 1 day (aOR 17.64; 95% CI 12.56-24.77), and hospitalization cost above the median of $24,327 (aOR 3.58; 95% CI 2.61-4.91). Independent patient predictors of pericardial effusion requiring intervention from the procedure included advanced age (aOR 1.029 per 1-year increase; 95% CI 1.009-1.05 per 1-year increase), higher CHA2DS2-VASc score (aOR 1.221 per 1-point increase; 95% CI 1.083-1.377 per 1-point increase), and obesity (aOR 2.033; 95% CI 1.464-2.823).ConclusionIn a large, contemporary real-world cohort of Watchman recipients in US practice, the prevalence of pericardial effusion requiring intervention was 1.24%. Pericardial effusion requiring intervention was associated with several adverse events including increased in-hospital mortality, other major complications, prolonged hospital stay, an

BackgroundLeft atrial appendage occlusion has shown promise in mitigating the risk of stroke in selected patients with atrial fibrillation.ObjectiveThe purpose of this study was to determine the real-world prevalence and in-hospital outcomes in left atrial appendage occlusion (Watchman) recipients complicated by pericardial effusion requiring percutaneous drainage or open cardiac surgery-based intervention.MethodsData were derived from the National Inpatient Sample database from January 2015 to December 2017. The primary outcomes assessed were the prevalence of pericardial effusion requiring intervention and in-hospital outcomes including mortality, other major complications, hospital stay > 1 day, and hospitalization costs. Predictors of pericardial effusion requiring intervention were also analyzed.ResultsPericardial effusion requiring intervention occurred in 220 total patients (1.24%). After multivariable adjustment, pericardial effusion requiring intervention was associated with in-hospital mortality (adjusted odds ratio [aOR] 511.6; 95% confidence interval [CI] 122-2145.3), other Watchman-related major complications (aOR 1.35; 95% CI 0.83-2.19), length of stay > 1 day (aOR 17.64; 95% CI 12.56-24.77), and hospitalization cost above the median of $24,327 (aOR 3.58; 95% CI 2.61-4.91). Independent patient predictors of pericardial effusion requiring intervention from the procedure included advanced age (aOR 1.029 per 1-year increase; 95% CI 1.009-1.05 per 1-year increase), higher CHA2DS2-VASc score (aOR 1.221 per 1-point increase; 95% CI 1.083-1.377 per 1-point increase), and obesity (aOR 2.033; 95% CI 1.464-2.823).ConclusionIn a large, contemporary real-world cohort of Watchman recipients in US practice, the prevalence of pericardial effusion requiring intervention was 1.24%. Pericardial effusion requiring intervention was associated with several adverse events including increased in-hospital mortality, other major complications, prolonged hospital stay, an

Chest pain is a frequent chief complaint in the pediatric emergency department. Pericarditis is not usually the most common cause, but because of the severity it is necessary to discard in the evaluation of the patient. We present the case of a 12-year-old man diagnosed with acute pericarditis in our hospital, presenting symptoms and signs classically described in the literature. Know the pathophysiology and recognize electrocardiographic characteristics permit to reach a diagnosis and initiate adequate treatment., El dolor torácico es un motivo frecuente de consulta en el servicio de urgencias pediátricas. La pericarditis no suele ser la causa más frecuente, pero su gravedad obliga a descartarla en la valoración del paciente. Presentamos el caso de un varón de 12 años de edad diagnosticado de pericarditis aguda en nuestro hospital, presentando síntomas y signos descritos clásicamente en la literatura. Conocer la fisiopatología y reconocer las características electrocardiográficas es importante para llegar a un diagnóstico e iniciar un tratamiento adecuado.

Background: Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery. Methods: In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA2DS2-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete. Findings: Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0–70·0), 102 (24%) patients were female, and 318 (76%) were male, with a me

Objectives: This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC). Background: Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC. Methods: In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected. Results: In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (<1.5 mm) for the stabilizing wires to cause risk for DR-PAI, configuration called ''cuddling lobe orientation''. On CT measurements middle lobe-PA distance was 4.7 mm (IQR = 2.7–9.5), with close proximity in 4 (4%) patients, and distal lobe-PA distance was 3.2 mm (IQR = 1.8–7.2 mm), with close proximity in 17 (17%) patients. Stabilizing wires were pointing toward PA in 47 patients (47%) with median wire-to-PA distance 5.7 mm (IQR = 3.6–8.5 mm). ''Cuddling'' was found in 2 (2%) patients and resulted in shorter wires-to-PA distance vs no ''cuddling'' group (2.3 vs 5.8 mm p <.01). At 2.9 ± 1.0 yrs of follow-up, the two patients with ''cuddling lobe orientation'' on post-LAAC CT scan developed late cardiac tamponades (p <.001). One of those required surgery, which confirmed DR-PAI. Conclusions: ''Cuddling lobe orientation'' of Amulet device with the PA was associated with short wires-to-PA distance and late pericardial effusions, including DR-PAI. Hence, such device-to-PA configuration should be avoided.

BackgroundInformation on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described.Case presentationA previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized.ConclusionsThis case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.

Introduction: Hybrid epicardial and endocardial ablation has been proven to be an effective method for attaining rhythm control in persistent atrial fibrillation where anti-arrhythmic drug therapy and lone catheter ablation has been disappointing. We present mid-term findings on the safety and effectiveness of hybrid ablation in persistent atrial fibrillation. Method(s): Between 2017 and 2019, nineteen patients with persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation with pulmonary vein isolation, posterior left atrial box lesion and left atrial appendage exclusion with Atriclip. They subsequently underwent endocardial mapping three months later. Any gaps from epicardial ablation were re-ablated. All patients were followed up prospectively. Result(s): Mean age of patients was 59.8+/-6.8 years. Median time of duration of atrial fibrillation preoperatively was 24 months. The average number of failed DCRs was 2.1+/-1.1. Average left atrial volume index was 55.45+/-11.5mL/m2. Average LVEF was 50.8+/-7.3%. At a mean follow-up of 395 days post hybrid ablation, all patients were in sinus rhythm at their most recent follow-up. 21% of patients had a recurrence of atrial arrhythmias. One patient had a minor complication of a left sided pleural effusion after the epicardial ablation. One patient had a pericardial effusion without tamponade requiring pericardiocentesis after epicardial ablation. There were no deaths, conversion to median sternotomy, strokes or pacemaker implantation. Conclusion(s): Sequential hybrid ablation for persistent atrial fibrillation is safe and effective.Copyright © 2020, CONFERENCE ABSTRACT

BackgroundInformation on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described.Case presentationA previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized.ConclusionsThis case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.

Introduction: The DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome is a rare but serious and potentially lethal occurrence of a set of signs and symptoms associated with the use certain types of drugs. This syndrome is characterized by a heterogeneous clinical manifestation that, in many cases, results in multisystemic involvement. Case presentation: A 24-year-old man from Calarcá, Colombia, visited the emergency department of the local hospital due to a three-day history of unquantified intermittent fever associated with asthenia, adynamia, anorexia, headache, myalgia, odynophagia, and upper abdominal pain. Due to his condition and based on laboratory findings, he was referred to the Clínica Central del Quindío. The patient, 20 days before the initial assessment, had been prescribed a pharmacological treatment with non-steroidal anti-inflammatory drugs and phenytoin due to a severe cranioencephalic trauma; he also presented with generalized skin rash, elevated transaminases, and moderate eosinophilia. Complementary studies reported mild pericardial effusion, so DRESS syndrome was suspected, and corticosteroid therapy was started, achieving the complete remission of the syndrome. Conclusion: Although the DRESS syndrome has a low incidence, it should always be suspected, especially in patients with cardiac and pericardial involvement. In this case, pericardial involvement was evident, demonstrating that individuals with this syndrome may present with rare symptoms that have a serious impact on their health, as they may significantly increase adverse outcomes and mortality risk., Introducción. El síndrome de DRESS (Drug Reaction with Eosinophilia and Systemic symptoms) consiste en la ocurrencia, si bien poco frecuente, pero grave y potencialmente mortal, de un conjunto de signos y síntomas asociados al consumo de cierto tipo de medicamentos. Este síndrome se caracteriza por tener una manifestación clínica heterogénea que, en muchos casos, causa compromiso multisistémico. Presentación del caso. Hombre de 24 años de Calarcá, Colombia, que asistió al servicio de urgencias del hospital local por presentar fiebre intermitente no cuantificada durante 3 días, junto con astenia, adinamia, anorexia, cefalea, mialgias, odinofagia y dolor abdominal superior, y que, debido a su condición y resultados de laboratorio, fue remitido a la Clínica Central del Quindío. El paciente, 20 días antes de la valoración inicial, había recibido tratamiento farmacológico con antiinflamatorios no esteroides y fenitoína por traumatismo craneoencefálico severo; además presentó rash cutáneo generalizado, elevación de transaminasas y eosinofilia moderada. En los estudios complementarios se reportó derrame pericárdico leve, por lo que se sospechó síndrome de DRESS y se inició corticoterapia, lográndose así la remisión completa de la enfermedad. Conclusión. Aunque el síndrome de DRESS tiene una baja incidencia, siempre debe sospecharse, en especial en pacientes que presentan compromiso cardiaco y pericárdico. En este caso se destaca la afectación pericárdica, demostrando que en este síndrome se pueden presentar manifestaciones poco frecuentes, pero con un gran impacto en su salud, ya que pueden aumentar considerablemente los desenlaces adversos y la mortalidad en estos pacientes.

BackgroundLeft ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR.Case presentationWe present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table.ConclusionsThe occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

Immune-related adverse events including cardiac toxicity are increasingly described in patients receiving immune checkpoint inhibitors. We described a malignant pericardial effusion complicated by a cardiac tamponade in an advanced non-small cell lung cancer patient who had received five infusions of atezolizumab, a PDL-1 monoclonal antibody, in combination with cabozantinib. The definitive diagnosis was quickly made by cytology examination showing typical cell abnormalities and high fluorescence cell information provided by the hematology analyzer. The administration of atezolizumab and cabozantinib was temporarily discontinued due to cardiogenic hepatic failure following cardiac tamponade. After the re-initiation of the treatment, pericardial effusion relapsed. In this patient, the analysis of the pericardial fluid led to the final diagnosis of pericardial tumor progression. This was afterwards confirmed by the finding of proliferating intrapericardial tissue by computed tomography scan and ultrasound. This report emphasizes the value of cytology analysis performed in a hematology laboratory as an accurate and immediate tool for malignancy detection in pericardial effusions.

A 54-year-old man had a history of subxiphoid pericardial window due to suspected tuberculous effusions. Seventeen years later, following chronic heart failure and implantation of a pacemaker, he again developed pericardial and pleural effusion, requiring repeated percutaneous pericardiocentesis, pleurocentesis and chest tube drainage. A 5×5-cm section of pericardium was successfully resected with video-assisted thoracic pericardial window. No recurrence of pericardial effusion has since been encountered during 36 months follow-up. An 85-year-old woman had a history of percutaneous pericardiocentesis and pleurocentesis due to chronic pericarditis. The effusion of unknown origin was refractory to medication and additional pericardiocentesis and percutaneous pericardial and chest tube drainage. A 4×4-cm section of pericardium was also successfully resected. No recurrence of pericardial effusion has been seen during 8 months follow-up. Video-assisted thoracoscopic pericardial window is an effective procedure for treating intractable pericardial effusion., identifier:Acta medica Nagasakiensia, 57(3), pp.105-107; 2013

Introduction: Pericardial effusions are infrequent in pregnant patients, but its presence has been seen in some isolated cases without hemodynamic involv e- ment. Therefore, neither outcome nor treatment of these cases are described. Objectives: To characterize pregnant patients with pericardial effusion, according to clinical, epidemiological and laboratory variables and determine the recovery time from post-delivery pericardial effusion.Method: A prospective descriptive observational study was carried out with 15 pregnant women with pericardial effusion, diagnosed by transthoracic echocardiogram, intentionally selected from a population of 256 pregnant women who were treated at the Hospital Universitario Gineco-Obstétrico Mariana Grajales in the city of Santa Clara (Villa Clara, Cuba) during the period from July 2018 to March 2019. Results: Of the 256 patients, only 15 (5.9%) presented pericardial effusion. Eighty percent of these effusions were found in patients with pre- eclampsia. A total of 66.7% were aged between 20 and 29 years and 73.3% were white. Effusions were predominantly mild (66.7%) and never severe, and the affected patients also had chronic high blood pressure (40%), obesity (20%) and collagen disease (13.3%). In 86.7% of cases the pericardial effusion resolved in the first 15 days postpartum. Conclusions: Pericardial effusion was more frequently found in patients with pre- eclampsia, chronic arterial hypertension, proteinuria, hypoproteinemia and hipoalbuminemia, and in most cases resolved within the first 15 days postpartum., Introducción: El derrame pericárdico en la paciente embarazada es infrecuente, pero se ha visto su presencia en algunos casos aislados sin repercusión hemodi- námica, por lo que no se describe la evolución y la conducta a seguir en esta pacientes. Objetivos: Caracterizar a la paciente embarazada con derrame pericárdico, según variables clínicas, epidemiológicas y de laboratorio; y determinar el tiempo de evolución del derrame pericárdico posterior al parto. Método: Se realizó un estudio observacional descriptivo prospectivo con 15 embarazadas con diagnóstico de derrame pericárdico, definido por ecocardiograma transtorácico, seleccionadas de forma intencional de una población de 256 mujeres en estado de gravidez, que fueron atendidas en el Hospital Universitario Gine co-Obstétrico Mariana Grajales de la ciudad de Santa Clara (Villa Clara, Cuba) durante el período de julio 2018 a marzo 2019. Resultados: De las 256 pacientes, solo 15 (5,9%) presentaron derrame pericárdico. El 80% de estos derrames fue encontrado en pacientes con preeclampsia. El 66,7% tenía entre 20 y 29 años de edad, y el 73,3%, color blanco de piel. El derrame fue predominantemente leve (66,7%) y nunca grave, y las pacientes afectadas tenían, además, hipertensión arterial crónica (40%), obesidad (20%) y enfermedad del colágeno (13,3%). En el 86,7% de los casos el derrame pericárdico desapareció en los primeros 15 días posparto. Conclusiones: El derrame pericárdico fue encontrado con más frecuencia en pacientes con preeclampsia, hipertensión arterial crónica, obesidad, proteinuri a, hipoproteinemia e hipoalbuminemia; y desapareció, en la mayoría de los casos, en los primeros 15 días posparto.

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres

Introduction: Hybrid epicardial and endocardial ablation has been proven to be an effective method for attaining rhythm control in persistent atrial fibrillation where anti-arrhythmic drug therapy and lone catheter ablation has been disappointing. We present mid-term findings on the safety and effectiveness of hybrid ablation in persistent atrial fibrillation. Method(s): Between 2017 and 2019, nineteen patients with persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation with pulmonary vein isolation, posterior left atrial box lesion and left atrial appendage exclusion with Atriclip. They subsequently underwent endocardial mapping three months later. Any gaps from epicardial ablation were re-ablated. All patients were followed up prospectively. Result(s): Mean age of patients was 59.8+/-6.8 years. Median time of duration of atrial fibrillation preoperatively was 24 months. The average number of failed DCRs was 2.1+/-1.1. Average left atrial volume index was 55.45+/-11.5mL/m2. Average LVEF was 50.8+/-7.3%. At a mean follow-up of 395 days post hybrid ablation, all patients were in sinus rhythm at their most recent follow-up. 21% of patients had a recurrence of atrial arrhythmias. One patient had a minor complication of a left sided pleural effusion after the epicardial ablation. One patient had a pericardial effusion without tamponade requiring pericardiocentesis after epicardial ablation. There were no deaths, conversion to median sternotomy, strokes or pacemaker implantation. Conclusion(s): Sequential hybrid ablation for persistent atrial fibrillation is safe and effective.Copyright © 2020

Introduction: Patients with clinically significant unusual antibodies can cause challenges in the Blood Bank Laboratory in their identification. The problems are further complicated in the pregnant patient when the fetus requires an intrauterine transfusion (IUT). Case Report: A 34-year-old woman (G3P2) with no atypical red cell antibodies at booking presented for a routine ultrasound at 20 weeks gestation. A significant fetal pericardial effusion and a thickened nuchal fold were noted. The fetus developed significant hydrops by 24/40. The mean cerebral artery peak systolic velocity (MCA-PSV) measurements by Doppler predicted fetal anaemia and a sample was collected for routine pre-transfusion testing for a planned IUT. Atypical red cell antibodies were detected by IAT, but specificity could not be resolved by the routine hospital laboratory. The Blood Service identified the antibody as anti-Doa, which would not explain the significant fetal anaemia. Logistical difficulties were encountered when sourcing suitable blood for the IUT, because of the unavailability of commercial antisera. Most panels do not have Doa typing stated on their antigrams, which made testing problematic. Close interaction between the treating team and Blood Service sourced suitable red cells and the fetus was transfused from 21g/L to 128g/L. Extensive investigations including a TORCH screen, Kleihauer test, FISH test and chromosomal microarray failed to elucidate the cause of the hydrops. However, the fetus was also noted to have skeletal abnormalities with short long bones. The fetus was closely monitored but no further IUTs were required. At birth the baby had a positive DAT and jaundice that resolved with phototherapy. Conclusion(s): Anti-Doa is rarely encountered as a single specificity, and has not been reported to cause significant haemolytic disease of the fetus and newborn. We report a case of unexplained fetal anaemia in the presence of anti-Doa, which required close co-ordination bet

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres

Introduction: Hybrid epicardial and endocardial ablation has been proven to be an effective method for attaining rhythm control in persistent atrial fibrillation where anti-arrhythmic drug therapy and lone catheter ablation has been disappointing. We present mid-term findings on the safety and effectiveness of hybrid ablation in persistent atrial fibrillation. Method(s): Between 2017 and 2019, nineteen patients with persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation with pulmonary vein isolation, posterior left atrial box lesion and left atrial appendage exclusion with Atriclip. They subsequently underwent endocardial mapping three months later. Any gaps from epicardial ablation were re-ablated. All patients were followed up prospectively. Result(s): Mean age of patients was 59.8+/-6.8 years. Median time of duration of atrial fibrillation preoperatively was 24 months. The average number of failed DCRs was 2.1+/-1.1. Average left atrial volume index was 55.45+/-11.5mL/m2. Average LVEF was 50.8+/-7.3%. At a mean follow-up of 395 days post hybrid ablation, all patients were in sinus rhythm at their most recent follow-up. 21% of patients had a recurrence of atrial arrhythmias. One patient had a minor complication of a left sided pleural effusion after the epicardial ablation. One patient had a pericardial effusion without tamponade requiring pericardiocentesis after epicardial ablation. There were no deaths, conversion to median sternotomy, strokes or pacemaker implantation. Conclusion(s): Sequential hybrid ablation for persistent atrial fibrillation is safe and effective.Copyright © 2020

Introduction: Patients with clinically significant unusual antibodies can cause challenges in the Blood Bank Laboratory in their identification. The problems are further complicated in the pregnant patient when the fetus requires an intrauterine transfusion (IUT). Case Report: A 34-year-old woman (G3P2) with no atypical red cell antibodies at booking presented for a routine ultrasound at 20 weeks gestation. A significant fetal pericardial effusion and a thickened nuchal fold were noted. The fetus developed significant hydrops by 24/40. The mean cerebral artery peak systolic velocity (MCA-PSV) measurements by Doppler predicted fetal anaemia and a sample was collected for routine pre-transfusion testing for a planned IUT. Atypical red cell antibodies were detected by IAT, but specificity could not be resolved by the routine hospital laboratory. The Blood Service identified the antibody as anti-Doa, which would not explain the significant fetal anaemia. Logistical difficulties were encountered when sourcing suitable blood for the IUT, because of the unavailability of commercial antisera. Most panels do not have Doa typing stated on their antigrams, which made testing problematic. Close interaction between the treating team and Blood Service sourced suitable red cells and the fetus was transfused from 21g/L to 128g/L. Extensive investigations including a TORCH screen, Kleihauer test, FISH test and chromosomal microarray failed to elucidate the cause of the hydrops. However, the fetus was also noted to have skeletal abnormalities with short long bones. The fetus was closely monitored but no further IUTs were required. At birth the baby had a positive DAT and jaundice that resolved with phototherapy. Conclusion(s): Anti-Doa is rarely encountered as a single specificity, and has not been reported to cause significant haemolytic disease of the fetus and newborn. We report a case of unexplained fetal anaemia in the presence of anti-Doa, which required close co-ordination bet

We present a unique case of a broken fragment of a hypodermic needle breaking and embolizing to the heart. This needle subsequently penetrated the right ventricle and the patient developed hemopericardium which resulted in cardiac tamponade physiology.Data sourcesNone.Study selectionNone.Data extractionNone.Data synthesisRecognizing the potential for unusual and serious complications of IV illicit drug use is an important part of providing effective and timely medical care in this vulnerable population.ConclusionsAn embolic needle phenomenon can have significant sequela, including direct cardiac trauma leading to tamponade and subsequent cardiac collapse. Partnering with the patient to take a detailed history was critical in uncovering the underlying etiology of this patient's cardiogenic shock.

A 52-year man was admitted to the emergency department after being crushed between his truck and its trailer. He quickly showed a cardiovascular collapse and an extracorporeal membrane oxygenation was placed. Transthoracic echocardiography (TTE) revealed a severe tricuspid regurgitation (TR), a pericardial effusion, and a laceration of the right ventricular free wall (Panel A, Supplementary data online, Loop S1). Transoesophageal echocardiography confirmed the severe TR due to a rupture of the posterior papillary muscle (Panel B, Supplementary data online, Loop S2) and also showed an interatrial communication due to a tear of the interatrial septum (Panel C), with a left-to-righ shunt that reversed during the cardiac systole because of the TR (Panel D, Supplementary data online, Loop S3). [...]

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

A 53-year-old female patient known to have Cowden disease (PTEN mutation positive) was found to have a mass at the left atrium on a CT coronary angiography performed as part of a preoperative workup for an unrelated surgery. Further radiological characterisation of the lesion was achieved using MRI and positron emission tomography. Interval growth prompted surgical excision; however, surgery was expedited after the patient presented with haemopericardium and cardiac tamponade. The patient was discharged home 8 days postoperatively, and no intraoperative or postoperative complications were encountered. A diagnosis of cavernous haemangioma was made on histology.Copyright © 2019 BMJ Publishing Group Limited.

A 53-year-old female patient known to have Cowden disease (PTEN mutation positive) was found to have a mass at the left atrium on a CT coronary angiography performed as part of a preoperative workup for an unrelated surgery. Further radiological characterisation of the lesion was achieved using MRI and positron emission tomography. Interval growth prompted surgical excision; however, surgery was expedited after the patient presented with haemopericardium and cardiac tamponade. The patient was discharged home 8 days postoperatively, and no intraoperative or postoperative complications were encountered. A diagnosis of cavernous haemangioma was made on histology.Copyright © 2019 BMJ Publishing Group Limited.

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

Cardiac neoplasms are uncommon, but secondary or metastatic neoplasms are relatively frequent, with an incidence 60 times higher than the primary ones. A particularly high frequency of metastatic cardiac involvement has been observed in lung squamous cell carcinomas, urinary tract tumors, and melanomas. However, the incidence is low because of breast tumors in dogs. Cardiac tumors may be symptomatic or, more commonly, an incidental finding observed during the investigation of unrelated problems. The clinical presentation is associated with that of a disseminated neoplasm, and cardiac metastases are generally asymptomatic but should be considered in patients with a history of neoplasia who present with impaired conduction, breathlessness, cardiomegaly, or arrhythmias. The present report aimed to describe a clinical case of cardiac metastasis of breast neoplasia in a dog in which we focusedon conservative clinical treatment and the importance of investigating the incidental clinical findings., As neoplasias cardíacas são incomuns, contudo as secundárias ou metastáticas são mais frequentes dentre estas, apresentando uma incidência 60 vezes superior às primárias. Uma frequência particularmente elevada de envolvimento cardíaco metastático tem sido observada em carcinoma epidermóide de pulmão, tumores do trato urinário e melanomas. Contudo, existe baixa ocorrência por conta de tumor de mama em cadelas. Os tumores cardíacos podem ser sintomáticos ou, mais comumente, achados incidentais, observados durante investigação de um problema não-relacionado. A apresentação clínica é relacionada à de uma neoplasia disseminada, sendo as metástases cardíacas, via de regra, assintomáticas, contudo devem ser lembradas em pacientes com história de neoplasia, que apresentem distúrbios de condução, sopro, cardiomegalia ou arritmias. O presente relato visa descrever um caso clínico de metástase cardíaca, decorrente de neoplasia mamária em cadela, onde o enfoque é o tratamento clínico conservador, bem como a importância da investigação dos achados clínicos incidentais.

Patients with Chronic Kidney Disease may present all typical pericardial clinical entities but some of them are surely more common than others. Last decades have witnessed to a dramatic improvement in caring patients with kidney failure and uremic pericarditis (as seen in the past) is quite rare to observe. Pericardial effusion (idiopathic or secondary) is more frequent, especially in hemodialysis patients and in those patients who start renal replacement therapy in critical care conditions (i.e. patients with chronic and or acute heart failure). In CKD patients following clinical conditions can be present: pericardial effusion (idiopathic or secondary), acute pericarditis, constrictive pericarditis. Pericardial effusion can be classified as mild, moderate or severe; acute pericarditis could be idiopathic or secondary to wide spectrum of infectious, immunologic or neoplastic diseases. Constrictive pericarditis can represent final pathway of many secondary conditions leading to pericardic and myocardic fibrosis.  (Cardionephrology), I pazienti affetti da malattia renale cronica possono andare incontro a tutta una serie di patologie che colpiscono il pericardio ma, sicuramente, alcune entità nosologiche sono più frequenti di altre. Gli ultimi decenni hanno assistito, per fortuna nostra e dei nostri pazienti, a un netto miglioramento per quanto concerne i protocolli terapeutici per i pazienti nefropatici e le forme tipiche di pericardite uremica, così frequenti negli anni passati, sono ormai uno sbiadito ricordo. È tuttora frequente osservare pazienti con versamento pericardico (idiopatico, ovvero secondario a malattie sistemiche), soprattutto per quanto concerne i pazienti sottoposti a trattamenti depurativi extracorporei ed i pazienti che iniziano il trattamento dialitico in condizioni di emergenza/urgenza (ad esempio, pazienti affetti da scompenso cardiaco congestizio); il versamento pericardico viene schematicamente classificato in lieve, moderato e severo in base all'interessamento più o meno globale del pericardio. Meno frequenti sono gli episodi di pericardite acuta (anch'essa idiopatica o secondaria), spesso su base virale, neoplasticae/o immunologica (vedi pazienti trapiantati in terapia immunosoppressiva). Le forme di pericardite costrittiva sono più rare a documentarsi in corso di malattia renale cronica e, in genere, rappresentano lo stadio finale di diverse patologie sistemiche: l'esito finale è, in genere, la fibrosi pericardica. (Cardionephrology)

Ексудативні перикардити є найчастішою патологією перикарду та мають різноманітну етіологію. При неефективності консервативної терапії та рецидивуючому перебігу захворювання методом вибору є хірургічне лікування. На сьогоднішній день запропоновано багато втручань при лікуванні перикардіального випоту, але відсутній системний підхід до вибору та об’єму операції, що може забезпечити ефективність лікування та скорочення періоду реабілітації.Мета дослідження. Оцінити результати хірургічного лікування ексудативних перикардитів з використанням міні-інвазивних втручань та провести їх порівняння з іншими, що запропоновані на сьогоднішній день.Матеріали та методи. Проаналізовані результати хірургічного лікування 171 пацієнтів з ексудативними перикардитами, що знаходилися на лікуванні у ДУ «Інститут загальної та невідкладної хірургії ім. В.Т. Зайцева НАМНУ» з 2000 по 2017 рр. Оцінені безпосередні та віддалені результати та тривалість реабілітаційного періоду.Результати. За час використання системного та диференційного підходу до хірургічного лікування було прооперовано 77 пацієнтів. Рівень післяопераційних ускладнень склав 2,60 % – гостра правошлуночкова недостатність у 1 (1,30 %) пацієнта, розвиток пневмотораксу на стороні втручання у 1 (1,30 %) пацієнта. Рівень післяопераційної летальності склав 1,30 % (1 пацієнт із гострою правошлуночковою недостатністю у ранньому післяопераційному періоді). Середня кількість загальних ліжко-днів склала 9,2±2,3 днів, післяопераційних ліжко-днів – 5,3±2,0 днів. Статистичної різниці у кількості рецидивуючих випадків в залежності від обраного виду та обсягу втручання встановлено не було. Висновок. Використання диференційного підходу до вибору тактики та об’єму оперативного втручання дозволяє достовірно знизити кількість післяопераційних ускладнень та рівень летальності. Застосування міні-інвазивних втручань сприяє скороченню тривалості періоду лікування та реабілітації, Экссудативные перикардиты являются наиболее частой патологией перикарда и имеют разнообразную этиологию. При неэффективности консервативной терапии и рецидивирующем течении заболевания методом выбора является хирургическое лечение. На сегодняшний день предложено множество вмешательств, используемых при лечении перикардиального выпота, но отсутствует системный подход к выбору и объема операции, что позволит повысить эффективность лечения и сократить период реабилитации.Цель исследования. Оценить результаты хирургического лечения экссудативных перикардитов с использованием мини-инвазивных вмешательств и провести их сравнение с другими предложенными на сегодняшний день.Материалы и методы. Проанализированы результаты хирургического лечения 171 пациентов с экссудативными перикардитами, находившихся на лечении в ГУ «Институт общей и неотложной хирургии им. В.Т. Зайцева НАМНУ» с 2000 по 2017 гг. Оценены непосредственные и отдаленные результаты и продолжительность реабилитационного периода.Результаты. За время использования системного и дифференцированного подхода к хирургическому лечению было прооперировано 77 пациентов. Уровень послеоперационных осложнений составил 2,60 % – острая правожелудочковая недостаточность у 1 (1,30 %) пациента, развитие пневмоторакса на стороне вмешательства у 1 (1,30 %) пациента. Уровень послеоперационной летальности составил 1,30 % (1 пациент с острой правожелудочковой недостаточностью в раннем послеоперационном периоде). Среднее количество общих койко-дней составило 9,2±2,3 дней, послеоперационных койко-дней – 5,3±2,0 дней. Статистической разницы в количестве рецидивирующих случаев в зависимости от выбранного вида и объема вмешательства установлено не было.Выводы. Использование дифференцированного подхода к выбору тактики и объема оперативного вмешательства позволяет достоверно снизить количество послеоперационных осложнений и уровень летальности. Использование мини-инвазивных вмешательств способствует сокращению продолжительности периода лече, Pericardial effusion is the most common pathology of the pericardium and has a diverse etiology. In case of ineffective conservative therapy and recurrent disease, surgical treatment became the method of choice. Many interventions have been proposed for the treatment of pericardial effusion, but there is no systematic approach to the choice and capacity of the surgical treatment, that can improve the effectiveness of treatment and reduce the rehabilitation period.Aim of the study. Evaluate the results of surgical treatment of pericardial effusion using minimally invasive interventions and compare it with others proposed for now.Materials and methods. We present the results of surgical treatment of 171 patients with pericardial effusion, treated at the ST “Zaycev V.T. Institute of General and Urgent Surgery AMS of Ukraine” from 2000 to 2017. The immediate and long-term results and the duration of the rehabilitation period are estimated.Results. In the period of using the systemic and differentiated approach to surgical treatment, 77 patients were operated. The level of postoperative complications was 2.60% - acute right ventricular failure in 1 (1.30%) patient, pneumothorax on the side of intervention in 1 (1.30%) patient. The level of postoperative mortality was 1.30% (1 patient with acute right ventricular failure in the early postoperative period). The average number of total bed-days was 9.2 ± 2.3 days, postoperative days-days – 5.3 ± 2.0 days. The statistical difference in the number of recurrent cases, depending on the type and extent of the intervention, was not established.Conclusions. Using a differentiated approach to the choice of tactics and the capacity of surgical interventions can reliably reduce the number of postoperative complications and level of mortality. The use of mini-invasive interventions reduces the duration of the period of treatment and rehabilitation.

We report a preterm (35 4/7 weeks) male neonate with Down's syndrome (DS) diagnosed with isolated pericardial effusion (PE) at 20 weeks of gestation. He was born by precipitous delivery, needed no resuscitation and presented within first 24 hours of life with respiratory distress, anemia due to feto-maternal bleed, hypotension, hepatomegaly, and coagulopathy. Postnatal echocardiography confirmed a 5 mm rim of PE without tamponade, normal cardiac structure, and function. He was stabilized with ventilation, packed red cell, fresh frozen plasma, inotropes (dopamine, dobutamine, and adrenaline), and steroid (hydrocortisone). Subsequent evaluation confirmed hypothyroidism, transient myeloproliferative disorder (TMD), hepatic failure due to fibrosis/cirrhosis with portal hypertension, and steroid sensitive hypotension on two occasions possibly due to adrenal insufficiency. PE completely resolved over 2 weeks. In view of progressively worsening liver failure with ascites and portal hypertension, the family opted for palliation. Literature review has been discussed regarding perinatal onset of PE in DS.Copyright © 2018 by Thieme Medical Publishers, Inc.

We report a preterm (35 4/7 weeks) male neonate with Down's syndrome (DS) diagnosed with isolated pericardial effusion (PE) at 20 weeks of gestation. He was born by precipitous delivery, needed no resuscitation and presented within first 24 hours of life with respiratory distress, anemia due to feto-maternal bleed, hypotension, hepatomegaly, and coagulopathy. Postnatal echocardiography confirmed a 5 mm rim of PE without tamponade, normal cardiac structure, and function. He was stabilized with ventilation, packed red cell, fresh frozen plasma, inotropes (dopamine, dobutamine, and adrenaline), and steroid (hydrocortisone). Subsequent evaluation confirmed hypothyroidism, transient myeloproliferative disorder (TMD), hepatic failure due to fibrosis/cirrhosis with portal hypertension, and steroid sensitive hypotension on two occasions possibly due to adrenal insufficiency. PE completely resolved over 2 weeks. In view of progressively worsening liver failure with ascites and portal hypertension, the family opted for palliation. Literature review has been discussed regarding perinatal onset of PE in DS.Copyright © 2018 by Thieme Medical Publishers, Inc.

Cardiac tamponade is a life-threatening emergency for which pericardiocentesis may be required. Real-time bedside ultrasound has obviated the need for routine blind procedures in cardiac arrest and the number of pericardiocenteses being performed has declined. Despite this fact, pericardiocentesis remains an essential skill in emergency medicine. While commercially available training models exist, cost, durability, and lack of anatomical landmarks limit their usefulness. We sought to create a pericardiocentesis model that is realistic, simple to build, reusable, and cost efficient. The model was constructed utilizing a red dye filled ping-pong ball (simulating the left ventricle) and a 250cc NS bag (simulating the effusion) encased in an artificial rib cage and held in place by gel-wax. The inner saline bag was connected to a 1L saline bag outside of the main assembly to act as a fluid reservoir for repeat uses. The entire construction process takes approximately 16-20 hours, most of which is attributed to cooling of the gel-wax. Actual construction time is approximately 4 hours at a cost of less than $200. The model was introduced to Emergency Medicine residents and medical students during a procedure simulation lab and compared to a model previously described by dell’Orto1. The learners performed ultrasound guided pericardiocentesis using both models. Learners were given a survey comparing realism of the two models. Learners felt our model was more realistic than the previously described model. On a scale of 1-9 with 9 being very realistic, the previous model was rated a 4.5. Our model was rated a 7.8. There was also a marked improvement in the perceived recognition of the pericardium, the heart, and the pericardial sac. Additionally, 100% of the students were successful at performing the procedure using our model. In simulation, our model provided both palpable and ultrasound landmarks and held up to several months of repeated use. It was less expensive tha

Background: Point of Care ultrasound is defined as a limited scan performed to answer a specific clinical question, enabling fast tracked patient management1. Ultrasound has been hailed as the new visual stethoscope of the 21st century, providing a valuable clinical tool for more accurate patient assessment2. The FAST scan (now updated EFAST: Extended Focused Assessment with Sonography in Trauma) was developed to triage trauma patients with life-threatening internal bleeding3,4. Prior to this, invasive peritoneal lavage was needed to determine the presence of blood in the abdomen. Summary of work: At Monash Health, a large collaborative Point of Care program has been established for training clinicians in specialties including Emergency, Intensive Care and Respiratory Medicine. The program is led by a senior sonographer, training and credentialing Point of Care scans such as EFAST in the Emergency Department. Summary of results: The EFAST scan is now routine management of trauma and other types of acute patients, assessing for haemoperitoneum, haemothorax, pericardial effusion (tamponade), pleural effusion and pneumothorax. This presentation will cover how to perform an EFAST scan and review interesting cases. Discussion and conclusions: Point of Care ultrasound is growing in specialties like Emergency Medicine, and sonographers should stay updated on important examinations such as EFAST.

Background: Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc). Annual screening with echocardiogram (ECHO) is recommended. We present the methodological aspects of a PAH screening programme in a large Australian SSc cohort, the epidemiology of SSc-PAH in this cohort, and an evaluation of factors influencing physician adherence to PAH screening guidelines. Method(s): Patient characteristics and results of PAH screening were determined in all patients enrolled in a SSc longitudinal cohort study. Adherence to PAH screening guidelines was assessed by a survey of Australian rheumatologists. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of risk factors with PAH. Result(s): Among 1636 patients with SSc, 194 (11.9%) had PAH proven by right-heart catheter. Of these, 160 were detected by screening. The annual incidence of PAH was 1.4%. Patients with PAH diagnosed on subsequent screens, compared with patients in whom PAH was diagnosed on first screen, were more likely to have diffuse SSc (p = 0.03), be in a better World Health Organisation (WHO) Functional Class at PAH diagnosis (p = 0.01) and have less advanced PAH evidenced by higher mean six-minute walk distance (p = 0.03), lower mean pulmonary arterial pressure (p = 0.009), lower mean pulmonary vascular resistance (p = 0.006) and fewer non-trivial pericardial effusions (p = 0.03). Adherence to annual PAH screening using an ECHO-based algorithm was poor among Australian rheumatologists, with less than half screening their patients with SSc of more than ten years disease duration. Conclusion(s): PAH is a common complication of SSc. Physician adherence to PAH screening recommendations remains poor. Identifying modifiable barriers to screening may improve adherence and ultimately patient outcomes.Copyright © 2017 The Author(s).

Background: Point of Care ultrasound is defined as a limited scan performed to answer a specific clinical question, enabling fast tracked patient management1. Ultrasound has been hailed as the new visual stethoscope of the 21st century, providing a valuable clinical tool for more accurate patient assessment2. The FAST scan (now updated EFAST: Extended Focused Assessment with Sonography in Trauma) was developed to triage trauma patients with life-threatening internal bleeding3,4. Prior to this, invasive peritoneal lavage was needed to determine the presence of blood in the abdomen. Summary of work: At Monash Health, a large collaborative Point of Care program has been established for training clinicians in specialties including Emergency, Intensive Care and Respiratory Medicine. The program is led by a senior sonographer, training and credentialing Point of Care scans such as EFAST in the Emergency Department. Summary of results: The EFAST scan is now routine management of trauma and other types of acute patients, assessing for haemoperitoneum, haemothorax, pericardial effusion (tamponade), pleural effusion and pneumothorax. This presentation will cover how to perform an EFAST scan and review interesting cases. Discussion and conclusions: Point of Care ultrasound is growing in specialties like Emergency Medicine, and sonographers should stay updated on important examinations such as EFAST.

Background: Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc). Annual screening with echocardiogram (ECHO) is recommended. We present the methodological aspects of a PAH screening programme in a large Australian SSc cohort, the epidemiology of SSc-PAH in this cohort, and an evaluation of factors influencing physician adherence to PAH screening guidelines. Method(s): Patient characteristics and results of PAH screening were determined in all patients enrolled in a SSc longitudinal cohort study. Adherence to PAH screening guidelines was assessed by a survey of Australian rheumatologists. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of risk factors with PAH. Result(s): Among 1636 patients with SSc, 194 (11.9%) had PAH proven by right-heart catheter. Of these, 160 were detected by screening. The annual incidence of PAH was 1.4%. Patients with PAH diagnosed on subsequent screens, compared with patients in whom PAH was diagnosed on first screen, were more likely to have diffuse SSc (p = 0.03), be in a better World Health Organisation (WHO) Functional Class at PAH diagnosis (p = 0.01) and have less advanced PAH evidenced by higher mean six-minute walk distance (p = 0.03), lower mean pulmonary arterial pressure (p = 0.009), lower mean pulmonary vascular resistance (p = 0.006) and fewer non-trivial pericardial effusions (p = 0.03). Adherence to annual PAH screening using an ECHO-based algorithm was poor among Australian rheumatologists, with less than half screening their patients with SSc of more than ten years disease duration. Conclusion(s): PAH is a common complication of SSc. Physician adherence to PAH screening recommendations remains poor. Identifying modifiable barriers to screening may improve adherence and ultimately patient outcomes.Copyright © 2017 The Author(s).

Cardiac tamponade is a life-threatening emergency for which pericardiocentesis may be required. Real-time bedside ultrasound has obviated the need for routine blind procedures in cardiac arrest and the number of pericardiocenteses being performed has declined. Despite this fact, pericardiocentesis remains an essential skill in emergency medicine. While commercially available training models exist, cost, durability, and lack of anatomical landmarks limit their usefulness. We sought to create a pericardiocentesis model that is realistic, simple to build, reusable, and cost efficient. The model was constructed utilizing a red dye filled ping-pong ball (simulating the left ventricle) and a 250cc NS bag (simulating the effusion) encased in an artificial rib cage and held in place by gel-wax. The inner saline bag was connected to a 1L saline bag outside of the main assembly to act as a fluid reservoir for repeat uses. The entire construction process takes approximately 16-20 hours, most of which is attributed to cooling of the gel-wax. Actual construction time is approximately 4 hours at a cost of less than $200. The model was introduced to Emergency Medicine residents and medical students during a procedure simulation lab and compared to a model previously described by dell’Orto1. The learners performed ultrasound guided pericardiocentesis using both models. Learners were given a survey comparing realism of the two models. Learners felt our model was more realistic than the previously described model. On a scale of 1-9 with 9 being very realistic, the previous model was rated a 4.5. Our model was rated a 7.8. There was also a marked improvement in the perceived recognition of the pericardium, the heart, and the pericardial sac. Additionally, 100% of the students were successful at performing the procedure using our model. In simulation, our model provided both palpable and ultrasound landmarks and held up to several months of repeated use. It was less expensive tha

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