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Background Coronary artery fistula is a rare, but recognized complication of surgical myectomy. Although most communicate with the right heart, a large fistula into the left ventricular cavity may result in a shunt haemodynamically analogous to aortic regurgitation. Understanding the variable presentation of iatrogenic coronary fistulae and the optimal evaluation strategy is critical to obtaining a timely diagnosis and instituting treatment. Case summary We report the case of a 57-year-old renal transplant recipient admitted for evaluation of presyncope, one-year post-surgical myectomy for hypertrophic obstructive cardiomyopathy. An iatrogenic coronary artery fistula was suspected by transthoracic echocardiography, and later confirmed with both non-invasive and invasive coronary angiography. Discussion We highlight various cardiac imaging modalities that confirmed the diagnosis of coronary artery fistula and helped to determine the clinical significance. We report the tailored approach often required to determine the anatomic and haemodynamic characteristics of coronary fistulae and outline potential management strategies. [ABSTRACT FROM AUTHOR]

This article, titled "Miscellany of instruments part 17: urological and gynaecological surgery," discusses various instruments used in urological and gynecological surgeries. It provides historical background on the development of these instruments, including the McCarthy resectoscope, Clutton's urethral sounds, Sims' uterine curettes, and Doyen's uterine myoma screw. The article highlights the importance of proper training and care in using these instruments to avoid complications. The author also provides brief biographical information on the individuals associated with the development of these instruments. [Extracted from the article]

Trocar site hernia is a rare, serious operation-related complication after robotic gynecologic surgery. Here, we present two 8-mm port-site hernia cases after three-port robotic myomectomy with a review of reported previous cases. In the first case, small bowel obstruction was found postoperatively due to herniation at the left mid-axillary line 8-mm trocar site. Small bowel herniation through the same site as the first case was found in the second case. Emergency exploration was performed in both cases by extending the left trocar site. There was no sign of bowel ischemia, and successful bowel reduction and hernia repair were done. Unlike previously reported cases, these cases occurred in a normal body mass index (BMI) patient (first case 20.28 kg/m2, second case BMI 24.80 kg/m2) and were pelvic drain insertion sites. These sites were the weak points of the abdominal muscle coverage. Therefore, the closure of 8-mm trocar sites should be considered. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES A novel transapical beating-heart septal myectomy (TA-BSM) procedure was performed for patients with latent obstruction through the left intercostal incision and without cardiopulmonary bypass. This study aims to demonstrate the experience of the TA-BSM procedure for patients with latent obstruction and compare outcomes to patients with resting obstruction. METHODS We studied 120 symptomatic hypertrophic obstructive cardiomyopathy patients (33 with latent obstruction and 87 with resting obstruction) who underwent TA-BSM. Demographic profiles, echocardiogram-derived ventricular morphology and haemodynamics and clinical outcomes were analysed. RESULTS There were no important differences in baseline clinical characteristics between patients with latent obstruction and resting obstruction, including age, symptoms, comorbidities and medical history. Patients with latent obstruction had lower basal septum thickness, higher midventricular wall thickness, smaller left atrial chamber size and more frequency of mitral subvalvular anomalies. There was no difference in early (<30 days) deaths (0/33 vs 1/87, P  > 0.999) and mid-term survival between patients with latent obstruction and resting obstruction. At 6 months after surgery, 31 (93.9%) patients with latent obstruction and 80 (92.0%) with resting obstruction achieved optimal procedural success, which was defined as a maximal gradient (after provocation) <30 mmHg and mitral regurgitation ≤ grade 1+ without mortality. Maximal left ventricular outflow tract gradient, basal septum thickness, midventricular wall thickness, mitral regurgitation grade and left atrial chamber size were significantly decreased after TA-BSM. In the follow-up, the New York Heart Association class was significantly improved following surgery. CONCLUSIONS TA-BSM preserved favourable gold-standard guideline desired outcomes through real-time echocardiographic-guided resection. Equipoise of outcomes for this procedure regardless of degree of resting left ventricular outflow tract gradients supports operative management with this approach in symptomatic patients with latent obstruction. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES This study aimed to assess the effectiveness of three-dimensional printing (3DP) in patients with complex hypertrophic cardiomyopathy requiring combined transaortic and transapical septal myectomy. METHODS We created 3DP models for 7 patients undergoing this surgery approach between June and October 2022 using silicone-like resin and conducted mock operations. The models were compared with echocardiography to identify abnormal muscle bundles and heart structures. These patients were then compared with a 1:2 matched group without 3DP, considering age, sex and additional operations. RESULTS The models mostly presenting with midventricular obstruction showed high consistency with original computed tomography data (r  = 0.978, P  <   0.001). 3DP identified more abnormal muscle bundles than echocardiography, primarily between the interventricular septum and apex. Excised specimens in mock operations mirrored those in actual myectomies. While cardiopulmonary bypass time was not significantly different, a near-20-min decrease was observed in the 3DP group (135.5 ± 31.1 vs 154.4 ± 36.6 min, P  =   0.054). CONCLUSIONS While no significant differences in surgical outcomes were observed, 3DP appeared to enhance the visualization and understanding of spatial structures (average Likert scale score 4.0), potentially contributing to surgical proficiency (overall rating score 3.9). The use of 3DP may offer additional value in the preparation and execution of operations for complex hypertrophic cardiomyopathy cases. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To elucidate the optimal septal reduction therapy for obstructive hypertrophic cardiomyopathy, we conducted a meta-analysis comparing alcohol septal ablation (ASA) and septal myectomy. METHODS MEDLINE, EMBASE and Cochrane CENTRAL were searched to identify studies investigating the outcomes of ASA and septal myectomy in patients with obstructive hypertrophic cardiomyopathy in January 2023. The primary outcome of interest was all-cause mortality in studies with ≥1 year of follow-up. The secondary outcomes of interest comprised left ventricular outflow tract (LVOT) pressure gradient reduction and reoperations of LVOT. A subgroup analysis of all-cause mortality including studies with follow-up ≥5 years was performed. RESULTS 27 observational studies were included (15 968 patients). Analysis demonstrated similar all-cause mortality [hazard ratio (HR) (95% confidence interval) (CI) 1.24 (0.88–1.76); P  = 0.21; I 2 = 56%]. In contrast, ASA was associated with less reduction of LVOT pressure gradient and a reoperation rate [weighted mean difference (95% CI) 11.04 mmHg (5.60–16.48); P  < 0.01; I 2 = 64%, HR (95% CI) 9.14 (6.55–12.75); P  < 0.001; I 2 = 0%, respectively]. The subgroup analysis with follow-up ≥5 years revealed higher long-term mortality with ASA [HR (95% CI) 1.50 (1.04–2.15); P  = 0.03; I 2 = 52%]. CONCLUSIONS Although both septal reduction therapies were associated with similar all-cause mortality, ASA was associated with a higher rate of reoperation and less reduction of LVOT pressure gradient. Furthermore, all-cause mortality with follow-up ≥5 years showed favourable outcomes with septal myectomy, although the result is only hypothesis-generating given a subgroup analysis. [ABSTRACT FROM AUTHOR]

We present a case of a 58-year-old man for surgical myectomy due to recurrent left ventricular outflow tract (LVOT) obstruction, who had prior transaortic septal myectomy and embolization of the septal branch. On admission, transthoracic echocardiography showed a typical hypertrophic obstructive cardiomyopathy (HOCM) with asymmetric septal hypertrophy, significant LVOT obstruction and severe mitral regurgitation due to the systolic anterior movement of the anterior mitral valve leaflet. We performed a novel procedure of the transapical beating-heart septal myectomy, following which the LVOT obstruction was resolved. And a decreased grade of systolic anterior movement and a reduction in the severity of mitral regurgitation were observed. [ABSTRACT FROM AUTHOR]

Background Abnormalities of the mitral subvalvular apparatus are not uncommon in hypertrophic obstructive cardiomyopathy (HOCM). Where invasive treatment is indicated in these patients to reduce left ventricular outflow tract (LVOT) obstruction, surgical myectomy with mitral valve repair is recommended. Case summary In this report, we describe the case of a patient with HOCM and anomalous papillary muscle anatomy, successfully treated by percutaneous transluminal septal myocardial ablation (PTSMA). Discussion PTSMA effectively reduced septal myocardial thickness and LVOT gradient, with only mild residual systolic anterior motion and mitral regurgitation despite anomalous papillary muscle anatomy. Upon careful anatomical evaluation, PTSMA may be a suitable therapeutic option for patients with LVOT obstruction and mitral valve abnormalities who are poor surgical candidates. [ABSTRACT FROM AUTHOR]

The article focuses on the use of multimodal cardiac imaging in diagnosing iatrogenic coronary artery fistulas after surgical myectomy. Topics include the importance of surgical myectomy in hypertrophic cardiomyopathy, the role of advanced imaging techniques like photon-counting computed tomography, and the clinical significance of detecting coronary fistulas, particularly in post-operative patients.

The article focuses on the unique case of a coronary cameral fistula (CCF) after surgical myectomy in hypertrophic cardiomyopathy patients and the role of multimodal imaging in its diagnosis. Topics include the clinical characteristics of post-septal myectomy CCFs, the factors contributing to their development, and the differences in diagnostic imaging techniques, such as Doppler echocardiography, to distinguish them from other conditions like ventricular septal defects.

Disseminated peritoneal leiomyomatosis (DPL) is a rare gynecologic disease involving multifocal proliferation of myomas. The pathogenesis remains unclear. Although there is no standard treatment, medical therapies have attempted to suppress estrogen levels by using gonadotrophin-releasing hormone agonist and aromatase inhibitor (AI) therapy with differing degrees of success. Surgery is also an option in symptomatic patients, and in the event of partial or no response to medical treatments. We report a case of DPL in a young woman with a previous history of myomectomy. She was treated sequentially with ulipristal acetate and AI. [ABSTRACT FROM AUTHOR]

The article discusses a new surgical option for treating obstructive hypertrophic cardiomyopathy (oHCM) called transapical beating heart septal myectomy (TA-BSM). The authors present the results of a study on 120 patients with subaortic left ventricular outflow obstruction (LVOT) who underwent TA-BSM. The procedure, which is performed without cardiopulmonary bypass and with real-time echocardiographic guidance, achieved optimal success rates with minimal morbidity and mortality. The authors suggest that TA-BSM may be a less invasive and effective alternative to traditional septal myectomy, and it may have wider applications in other patient populations. [Extracted from the article]

Background Hypertrophic cardiomyopathy is estimated to affect 1 out of every 500 adults in the USA. One of its main complications is left ventricular outflow obstruction, which may require surgical septal myectomy in severe cases. We report a rare complication of postoperative septal akinesis leading to thrombus formation presenting as an acute ischaemic stroke. Case summary A 48-year-old woman presented with acute stroke 2 years after surgical septal myectomy for hypertrophic obstructive cardiomyopathy. Diagnostic workup identified an intraventricular thrombus arising in the left ventricular outflow tract (LVOT). After comprehensive evaluation, it was determined that the thrombus development was a complication of the prior septal myectomy causing focal septal akinesis. Treatment with anticoagulation resulted in improvement of neurological symptoms and resolution of the intraventricular thrombus. Discussion This case illustrates the rarity and unusual presentation of an intracardiac thrombus that arises from septal myectomy site. A thrombus arising in the LVOT, which is characterized by high gradient laminar flow, is highly unusual. This suggests microscopic and macroscopic alteration in the ventricular septal wall structure, as evident by the septal wall akinesis seen on echocardiography. Recognition of this complication is critical to the selection of appropriate anticoagulation as secondary stroke prevention in these patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Left ventricular outflow tract obstruction causes symptoms of heart failure in most patients with hypertrophic cardiomyopathy. Resection of the secondary mitral valve (MV) chordae has recently been shown to move the MV apparatus posteriorly, thereby eradicating the outflow gradient. The aim of this study was to evaluate whether secondary chordal resection concomitant to septal myectomy improves outcomes. METHODS Between 2005 and 2020, a total of 165 patients underwent septal myectomy without MV repair or replacement in our Medical Center. Secondary MV chordal resection was performed in 60 patients, and their outcomes were compared with those of the remaining 105 patients who did not undergo chordal resection (controls). Mean age was 61 ± 13 and 58 ± 16 years, respectively (P  = 0.205). RESULTS There were no in-hospital deaths throughout the entire cohort. Of those patients who underwent secondary chordal resection, New York Heart Association functional class decreased from 3 (interquartile range 2–3) preoperatively to 1 (interquartile range 1–2) postoperatively (P  < 0.001), and resting outflow gradient decreased from 91 ± 39 mmHg to 13 ± 8 mmHg (86% change, P  < 0.001). Compared with controls, patients who underwent secondary chordal resection had a significant lower resting outflow gradient at follow-up (14 ± 7 mmHg vs 21 ± 15 mmHg, P  = 0.002). The rate of moderate or more than moderate mitral regurgitation at 5 years was 2% in the secondary chordal resection group and 5% in the controls (hazard ratio 1.05, confidence interval 0.11–10.32; P  = 0.965). CONCLUSIONS In this observational study, we report that secondary chordal resection concomitant to septal myectomy for left ventricular outflow tract obstruction is safe, relieves heart failure symptoms and reduces left ventricular outflow tract gradient in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Study Question: What are the differences in ease of use between two different embryo transfer (ET) techniques: the preload direct approach and the afterload approach.Summary Answer: The afterload technique seems to reduce the rate of difficult ETs.What Is Known Already: Numerous published trials now document that the ET procedure has an impact on pregnancy and delivery rates after IVF. Difficult transfers should be avoided, as they reduce implantation and pregnancy rates. Preload direct ETs with soft catheters under ultrasound guidance is currently considered the best procedure. However, when using soft catheters, it is not known which technique is preferable or which one should be implemented to reduce the operator factor.Study Design, Size, Duration: This prospective randomised unblinded controlled clinical trial, included 352 ultrasound-guided ETs assigned to either direct ET or afterload ET, between September 2017 and March 2019. The sample size was calculated based on the historical rate of difficult ETs encountered between 2014 and 2015 with a direct ET procedure.Participants/materials, Setting, Methods: The inclusion criteria were women 18-38 years old, with BMI between 18 and 28, receiving a single-thawed blastocyst transfer. The exclusion criteria were use of testicular sperm and preimplantation genetic testing (PGT) cycles. The primary outcome was the rate of difficult or suboptimal transfers defined as: advancement of the outer sheath (specific for the direct transfer), multiple attempts, use of force, required manipulation, use of a stylet or tenaculum, dilatation, or use of a different catheter. The secondary outcome was clinical pregnancy rate.Main Results and the Role Of Chance: A total of 352 frozen ETs were randomised, with 176 patients in each group. The two arms were homogeneous for female and male age, female BMI, duration of infertility, secondary infertility, previous deliveries or miscarriages, myomas, previous surgery to the uterine cavity, cycle day at ovulation trigger, freeze all cycles, first transfers, indication for treatment, endometrial preparation protocol and duration, endometrial thickness, and blastocyst grade at vitrification. Across the entire population, 85 (24.1%) ETs were defined as difficult. The rate of difficult transfers was significantly higher in the direct ET group than in the afterload group: 68 (38.6%) versus 17 (9.7%), respectively (OR 0.17, 95% CI 0.09-0.30, P < 0.001). The mean percentage in the rate of difficult transfers per operator was 22.5% (SD ± 14.5%), of which 36.1% (SD ± 23.4%) were in the direct group compared with 8.6% (± 8.2%) in the afterload group (P < 0.001). The difficult transfer rate among operators varied from 0 to 43.8% (0-77.8% in the direct group and 0 to 25.0% in the afterload group). The clinical pregnancy rates (42.0% vs 48.3%, P = 0.239 in the direct and afterload groups, respectively) were not significantly different between the groups.Limitations, Reasons For Caution: There were 18 experienced operators who participated in the trial. Conclusions about the pregnancy rate should not be generalised, since the sample analysis was not performed on this outcome and, although clinically relevant, the difference was not significantly different.Wider Implications Of the Findings: The rate of difficult transfers was significantly higher in the direct ET group compared with the afterload ET group, although a wide variation was observed among operators. Further studies regarding the association between transfer technique and ART outcomes are required.Study Funding/competing Interest(s): No specific funding was sought and there are no competing interests.Trial Registration Number: NCT03161119.Trial Registration Date: 5 April 2017.Date Of First Patient's Enrolment: 26 September 2017. [ABSTRACT FROM AUTHOR]

Study Question: What are the distributions and associated clinical characteristics of mediator complex subunit 12 (MED12), high mobility group AT-hook 2 (HMGA2) and fumarate hydratase (FH) aberrations in uterine leiomyomas from fertile-aged myomectomy patients?Summary Answer: These driver mutations account for the majority (83%) of tumours in fertile-aged patients.What Is Known Already: Alterations affecting MED12, HMGA2 and FH account for 80-90% of uterine leiomyomas from middle-aged hysterectomy patients, while the molecular background of tumours from young myomectomy patients has not been systematically studied.Study Design, Size, Duration: A retrospective series of 361 archival uterine leiomyoma samples from 234 women aged ≤45 years undergoing myomectomy in 2009-2014 was examined. Associations between the molecular data and detailed clinical information of the patients and tumours were analysed.Participants/materials, Setting, Methods: DNA was extracted from formalin-fixed paraffin-embedded samples and MED12 exons 1 and 2 were sequenced to identify mutations. Level of HMGA2 expression was evaluated by immunohistochemistry. Biallelic FH inactivation was analysed with 2-succinylcysteine staining, which is an indirect method of assessing FH deficiency. All patients' medical histories were reviewed, and clinical information of patients and tumours was combined with molecular data.Main Results and the Role Of Chance: The median age at operation was 34 years. The majority (58%) of patients were operated on for a single leiomyoma. Known driver mutations were identified in 83% of tumours (71% MED12; 9% HMGA2; 3% FH). In solitary leiomyomas, the MED12 mutation frequency was only 43%, and 29% were wild-type for all driver alterations. MED12 mutations were associated with multiple tumours, smaller tumour size and subserosal location.Limitations, Reasons For Caution: Although comprehensive, the study is retrospective in nature and all samples have been collected for routine diagnostic purposes. The use of paraffin-embedded samples and immunohistochemistry may have led to an underestimation of mutations. Due to the limited sample size and rarity of especially FH-deficient leiomyomas, the data are partly descriptive.Wider Implications Of the Findings: The contribution of driver mutations in leiomyomas from young myomectomy patients is comparable to tumours obtained from hysterectomies of mostly middle-aged women. Our results support the earlier findings that MED12 mutations are associated with multiple tumours, smaller tumour size and subserosal location. The study emphasizes the distinct molecular background of solitary leiomyomas, and more research is needed to clarify the underlying causes of the notable proportion of wild-type leiomyomas.Study Funding/competing Interest(s): The study was supported by the Academy of Finland (307773), the Sigrid Jusélius Foundation, the Cancer Foundation Finland and the iCAN Digital Precision Cancer Medicine Flagship. The authors declare no conflicts of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Study Question: How does the risk of cardiovascular disease (CVD) vary with type and age of menopause?Summary Answer: Earlier surgical menopause (e.g. <45 years) poses additional increased risk of incident CVD events, compared to women with natural menopause at the same age, and HRT use reduced the risk of CVD in women with early surgical menopause.What Is Known Already: Earlier age at menopause has been linked to an increased risk of CVD mortality and all-cause mortality, but the extent that this risk of CVD varies by type of menopause and the role of postmenopausal HRT use in reducing this risk is unclear.Study Design, Size, Duration: Pooled individual-level data of 203 767 postmenopausal women from 10 observational studies that contribute to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE) consortium were included in the analysis.Participants/materials, Setting, Methods: Postmenopausal women who had reported menopause (type and age of menopause) and information on non-fatal CVD events were included. Type of menopause (natural menopause and surgical menopause) and age at menopause (categorised as <35, 35-39, 40-44, 45-49, 50-54 and ≥55 years) were exposures of interest. Natural menopause was defined as absence of menstruation over a period of 12 months (no hysterectomy and/or oophorectomy) and surgical menopause as removal of both ovaries. The study outcome was the first non-fatal CVD (defined as either incident coronary heart disease (CHD) or stroke) event ascertained from hospital medical records or self-reported. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CI for non-fatal CVD events associated with natural menopause and surgical menopause.Main Results and the Role Of Chance: Compared with natural menopause, surgical menopause was associated with over 20% higher risk of CVD (HR 1.22, 95% CI 1.16-1.28). After the stratified analysis by age at menopause, a graded relationship for incident CVD was observed with lower age at menopause in both types of natural and surgical menopause. There was also a significant interaction between type of menopause and age at menopause (P < 0.001). Compared with natural menopause at 50-54 years, women with surgical menopause before 35 (2.55, 2.22-2.94) and 35-39 years (1.91, 1.71-2.14) had higher risk of CVD than those with natural menopause (1.59, 1.23-2.05 and 1.51, 1.33-1.72, respectively). Women who experienced surgical menopause at earlier age (<50 years) and took HRT had lower risk of incident CHD than those who were not users of HRT.Limitations, Reasons For Caution: Self-reported data on type and age of menopause, no information on indication for the surgery (e.g. endometriosis and fibroids) and the exclusion of fatal CVD events may bias our results.Wider Implications Of the Findings: In clinical practice, women who experienced natural menopause or had surgical menopause at an earlier age need close monitoring and engagement for preventive health measures and early diagnosis of CVD. Our findings also suggested that timing of menopause should be considered as an important factor in risk assessment of CVD for women. The findings on CVD lend some support to the position that elective bilateral oophorectomy (surgical menopause) at hysterectomy for benign diseases should be discouraged based on an increased risk of CVD.Study Funding/competing Interest(s): InterLACE project is funded by the Australian National Health and Medical Research Council project grant (APP1027196). GDM is supported by Australian National Health and Medical Research Council Principal Research Fellowship (APP1121844). There are no competing interests. [ABSTRACT FROM AUTHOR]

Background Iatrogenic membranous ventricular septal defects (VSDs) are rare complications of cardiothoracic surgery, such as septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM). Transcatheter closure is considered an appealing alternative to surgery, given the increased mortality associated with repeated surgical procedures, but reports are extremely limited. Case summary We herein report the case of a 63-year-old woman with HOCM who underwent successful percutaneous closure of an iatrogenic VSD after septal myectomy. Two percutaneous techniques are discussed, namely the 'muscular anchoring' and the 'buddy wire delivery', aimed at increasing support and providing stability to the system during percutaneous intervention. Discussion Transcatheter closure represents an attractive minimally invasive approach for the management of symptomatic iatrogenic VSDs. The new techniques described could help operators to cross tortuous and tunnelled defects and to deploy closure devices in case of complex VSD anatomy. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The aim of this study was to assess the effect of surgical septal myectomy performed during early childhood for severe, drug-refractory hypertrophic cardiomyopathy with left ventricular outflow tract obstruction on the extent of septal myocardial extracellular volume fraction and the potential risk of developing atrioventricular cardiac conduction system disease. METHODS In this retrospective study, data from 30 patients with a confirmed diagnosis of childhood-onset hypertrophic cardiomyopathy were reviewed including cardiovascular magnetic resonance (CMR) with myocardial T1 mapping and late gadolinium enhancement, histopathology of myocardial specimens, transthoracic echocardiography, electrocardiography, 24-h Holter and cardiopulmonary exercise testing. Eighteen patients without were compared to 12 patients with prior septal myectomy performed during childhood (non-operated versus myectomy patients). RESULTS Late gadolinium enhancement on CMR as a correlate for focal myocardial fibrosis was found in 53% of patients, predominantly located in the septal region, with no difference between groups. As compared to non-operated patients, those after myectomy showed a similar amount of total and septal extracellular volume fraction, as calculated from pre- and post-contrast CMR T1 mapping, which is a correlate for diffuse interstitial myocardial fibrosis. PQ-intervals or the occurrence of higher degree conduction system disease were equal between the 2 groups. CONCLUSIONS Data from CMR and electrocardiography suggest that surgical septal myectomy performed during early childhood for severe obstructive hypertrophic cardiomyopathy does not cause an increased septal extracellular volume fraction or delayed atrioventricular conduction time on long-term follow-up. [ABSTRACT FROM AUTHOR]

Study Question: Are selective markers for the neuronal differentiation such as microtubule-associated protein 2 (MAP-2) and synaptophysin (SYP) as well as the nerve growth factor (NGF) expressed by fibroids, myometrium and eutopic endometrium?Summary Answer: Neuronal markers NGF, MAP-2 and SYP are highly expressed in fibroids compared with matched myometrium, and this neurogenic pathway is upregulated by tumor necrosis factor (TNF) alpha in cultured smooth muscle cells (SMCs).What Is Known Already: Uterine fibroids or leiomyomas are the most common benign tumors, accounting for approximately one-third of hysterectomies. The present trend is to improve the medical treatment avoiding surgery, also for fertility sparing; hence, the pathogenic mechanisms are investigated, aiming to develop new therapeutic strategy.Study Design, Size, Duration: This laboratory-based case-control study is focused on fibroids and myometrial specimens obtained between 2015 and 2017 from 15 women of reproductive age at the proliferative phase of the menstrual cycle. Leiomyomas, matched myometrium and endometrium from each woman were analyzed. Control endometrium was obtained from women undergoing surgery for ovarian cyst (n = 15).Participants/materials, Setting, Methods: qRT-PCR, western blotting and immunostaining were applied to evaluate the expression of neurogenic markers; the effects of TNF on NGF, MAP-2 and SYP expression in cultured SMCs from leiomyomas and matched myometrium were analyzed.Main Results and the Role Of Chance: qRT-PCR analyses using tissues from clinical patients showed that the levels of NGF, MAP-2 and SYP mRNA were significantly higher in uterine leiomyomas compared with their matched myometrium (P < 0.05), whereas only NGF was significantly increased in eutopic endometrium compared with healthy endometrium. In primary SMCs, isolated from fibroids or from the adjacent myometrium, NGF, MAP-2 and SYP mRNA expression were significantly increased by TNF treatment (P < 0.05). Finally, human endometrial stromal cells prepared from the endometrium of patients affected by uterine fibroids display higher TNF expression (P < 0.001).Limitations, Reasons For Caution: qRT-PCR analysis and immunofluorescence validation are robust methods demonstrating a clear upregulation of neurogenic factors in leiomyomas, even though additional studies are needed to establish a correlation between increased neuronal gene expression and degree of pain, as well as the involvement of inflammation mediators in the development of the neurogenic unhinge. Therefore, more in vivo studies are needed to confirm the results achieved from primary cultured SMCs.Wider Implications Of the Findings: The increased expression of neurogenic factors in uterine fibroids and endometrium may contribute to explain the painful stimuli. Accordingly, these neurogenic pathways may represent potential therapeutic avenues to treat the fibroid-related disorders.Study Funding/competing Interest(s): This study was supported by research grants from the University of Siena. The authors declare no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Surgical treatment is challenging in pediatric patients with left ventricular outflow tract (LVOT) stenosis (LVOTS). We herein present the case of a 2-year-old male patient with porencephaly who was diagnosed with LVOTS accompanied by moderate mitral valve regurgitation (MR) with systolic anterior motion (SAM). Edge-to-edge mitral valve reconstruction and myectomy of the abnormal cardiac muscle were performed, with an uneventful postoperative course. LVOT myectomy and edge-to-edge mitral valve repair may be considered as a safe and acceptable approach with good clinical outcomes in pediatric patients with LVOTS accompanied by MR with SAM. [ABSTRACT FROM AUTHOR]

Uterine fibroids are a common gynaecological condition. A key factor when deciding on surgical approach for fibroid management is a patient's age and desire for fertility with uterine-sparing treatment generally recommended in women who are aiming for future pregnancies. This case report discusses a woman who presented with a very large multi-fibroid uterus. In this case, a hysterectomy was recommended due to safety concerns however, this advice was declined as the patient desired uterine preservation. Fertility testing showed that the patient was not peri-menopausal and abdominal myomectomy was safely performed to good effect. This case report outlines the surgical approach undertaken, in addition to considerations for fertility and pregnancy management. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Surgical strategies for patients with midventricular obstruction remain underappreciated. We sought to assess clinical and haemodynamic results, summarize the surgical technique of extended myectomy and provide reliable pre- and intraoperative methods of evaluating patients with midventricular obstruction. METHODS The preoperative evaluation process, intraoperative surgical strategy and early outcomes were thoroughly reviewed in 40 patients with midventricular obstruction. RESULTS Isolated transaortic myectomy was conducted in 38 (95.0%) patients, and 2 (5.0%) other patients with an apical aneurysm were treated with a combined transaortic and transapical myectomy. The median resection length of the removed muscle was 50 mm (45–55 mm), approximately 5 mm more than the obstruction length measured using preoperative transthoracic echocardiography. There were no early or late deaths, complete heart blocks or iatrogenic septal perforations in our study series with a median follow-up time of 19 months (13–54 months). Instantaneous pressure gradients at the subaortic level decreased from 70.5 mmHg (51–89.5 mmHg) preoperatively to 7.7 mmHg (6–11 mmHg) (P  < 0.001) at the most recent evaluation and at the midventricular level from 61.0 mmHg (42.8–85.5 mmHg) to 8.5 mmHg (6.3–11.8 mmHg) (P  < 0.001). In all patients, the New York Heart Association functional classifications improved, with a better haemodynamic status. CONCLUSIONS Transaortic myectomy can be extended to the midventricular level, improving haemodynamic status and yielding satisfactory early outcomes in selected patients. Additional transapical myectomy should be considered in patients with a long obstruction, limited exposure of the midventricular area or a concomitant apical aneurysm. [ABSTRACT FROM AUTHOR]

OBJECTIVES This study aims to assess the impact of morphological type on the prognosis of obstructive hypertrophic cardiomyopathy patients who underwent myectomy. METHODS We recruited 469 obstructive hypertrophic cardiomyopathy patients refractory to medicinal treatment who have undergone surgical myectomy at a nationwide referral centre. All patients were divided into 3 groups based on the morphological classification of left ventricular hypertrophy and were followed up by telephone every year. The primary end-points were sudden cardiac death, aborted sudden cardiac death and death due to heart failure or stroke. The secondary end-points were non-fatal cardiovascular events. RESULTS Typical hypertrophy limited to the basal septum, hypertrophy of the whole ventricular septum and hypertrophy that involved the whole left ventricle were presented in 248 (52.9%), 141 (30.1%) and 80 (17.0%) patients, respectively. During the follow-up of 2.5 ± 1.4 years after myectomy, 10 (2.1%) and 43 (9.2%) patients met the primary end-point and secondary end-points, respectively. The maximal thickness of the ventricular septum, the left ventricular mass and the presence of extensive late gadolinium enhancement were lower in patients with hypertrophy limited to the basal septum than in other patients. Patients with the basal septum hypertrophy showed better survival after myectomy compared with other patients. For the secondary and composite end-points, there was no significant difference between the 3 groups. CONCLUSIONS Patients with hypertrophy limited to the basal septum represented a special clinical subtype of obstructive hypertrophic cardiomyopathy showing better clinical outcomes, while diffuse hypertrophy of the ventricular septum and free wall indicated lower survival after surgical myectomy. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy is the most common genetic cardiovascular disorder and is associated with symptoms of heart failure and increased risk of sudden cardiac death. The most common condition is obstruction of the left ventricular outflow tract. Surgical septal myectomy and alcohol septal ablation are the 2 accepted modes of septal reduction therapy and are indicated when there are advanced symptoms and a peak left ventricular outflow gradient >50 mmHg. Advantages of alcohol septal ablation are limited groin approach, reduction of obstruction of the left ventricular outflow tract and functional improvement, but there are higher chances for intracardiac device implantation and residual obstruction. Septal myectomy offers very low mortality, absolute and immediate resolution of obstruction of the left ventricular outflow tract and survival comparative to a matched general population with almost negligible residual obstruction. It is recommended that patients with obstructive hypertrophic cardiomyopathy should be treated at experienced centres. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Patients with hypertrophic obstructive cardiomyopathy and basal septal thickness <18mm are often considered unsuitable candidates for myectomy. Mitral valve (MV) replacement is frequently performed instead. We aimed to determine whether septal thickness affects outcomes and adequacy of myectomy. METHODS: Clinical and echocardiographic data were reviewed for 1486 consecutive adult patients with hypertrophic obstructive cardiomyopathy who underwent transaortic septal myectomy from January 2005 through December 2014. Comparisons between patients, grouped by septal thickness (<18 mm, n = 369; 18-21 mm, n = 612 and >21 mm, n = 505), were performed with the Kruskal-Wallis and the Pearson χ² tests and semiparametric analysis of covariance. RESULTS: Median group ages were 57, 57 and 54 years (P = 0.007); men comprised 50.4%, 56.7% and 62.0%, respectively (P = 0.003). Intrinsic MV disease was present in 5.9%, 5.2% and 4.6%, respectively (P = 0.80). All patients underwent transaortic septal myectomy. Additional mitral procedures were performed in 7.6%, 7.8% and 8.1%, respectively (P = 0.90). Reasons for MV surgery included intrinsic MV disease (66.7%), residual mitral regurgitation (30.8%) and residual gradient (2.6%). All groups had postoperative gradient relief (median reduction: 51, 54 and 50 mmHg; P = 0.11). Ventricular septal defect occurred in 4 patients (0.3%), and risk did not differ by group (P = 0.24). CONCLUSIONS: Adequate relief of left ventricular outflow tract obstruction can be achieved via transaortic septal myectomy without concomitant MV procedures when septal thickness is < 18 mm, and the risk of ventricular septal defect is minimal. Concomitant MV repair/replacement should be reserved for patients with intrinsic MV disease or inadequate relief of mitral regurgitation/left ventricular outflow tract obstruction following adequate extended septal myectomy. [ABSTRACT FROM AUTHOR]

Study Question: What is the prevalence of leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of fibroids in reproductive age women?Summary Answer: No case of leiomyosarcomas but seven atypical leiomyomas were found in 1216 subjects.What Is Known Already: Although uterine sarcoma is a rare entity affecting usually older peri- or post-menopausal women, the Food and Drug Administration discourages use of laparoscopic power morcellation of uterine fibroids.Study Design, Size, Duration: Retrospective review of data extracted from a single center database of 1216 consecutive women who underwent laparoscopic morcellation of 2582 unsuspicious leiomyomas between June 2003 and December 2015 and were followed-up until December 2016.Participants/materials, Settings, Methods: A total of 1216 women, aged 18-45 years, underwent laparoscopic morcellation of 2582 apparently benign leiomyomas by the same surgeon and all specimen slides were examined by the same experienced pathologist.Main Results and the Role Of Chance: The prevalence of leiomyosarcomas and atypical leiomyomas was 0% (95% CI: 0-0.3%) and 0.6% (95% CI: 0.23-1.18%) (six atypical-bizarre and one mitotically active leiomyoma) respectively. In addition, there were identified 34 cases of adenomyomas, 45 leiomyomas with infarcts, 81 cellular leiomyomas and 133 degenerated leiomyomas. No morcellator-associated complication was recorded and none of the patients included in this study required conversion to laparotomy.Limitations, Reasons For Caution: Retrospective and single referral center study design.Wider Implications Of the Findings: Laparoscopic morcellation of unsuspicious leiomyomas after careful preoperative work up seems to be safe in women of reproductive age.Study Funding/competing Interest(s): None. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Although septal myectomy is the technique of choice for hypertrophic cardiomyopathy, the surgical management of concomitant mitral valve lesions is controversial. Various complex surgeries have been proposed to address mitral valve lesions. We propose a simple option using an edge-to-edge mitral valve repair through the aortic valve in addition to the septal myectomy. METHODS: We performed an observational analysis of our prospectively collected database. The clinical follow-up was done by telephone contact with each patient. The echocardiographic follow-up was performed in our Department of Cardiology or by the referring cardiologist. RESULTS: Between January 2009 and March 2016, we operated 22 symptomatic patients (mean age 48.5 years, males 59%). The mean interventricular septum diameter and resting intraventricular gradient were 25.8mm and 75.4 mmHg, respectively. The systolic anterior motion was present in every patient. The mean mitral regurgitation grade was 2.4. There were no in-hospital deaths. Two (9%) patients required a pacemaker. After a mean follow-up of 26.3 months, the mean New York Heart Association functional class decreased from 2.5 to 1.2 (P < 0.001). The echocardiographic follow-up showed a sustained significant reduction of the septal thickness (P < 0.001), resting intraventricular gradient (P < 0.001), presence of systolic anterior motion (P < 0.001) and grade of mitral regurgitation (P = 0.002). CONCLUSIONS:Septal myectomy remains the gold standard of any surgery for hypertrophic cardiomyopathy owing to its good clinical and echocardiographic results. The edge-to-edge mitral valve repair is an additional simple option to avoid the systolic anterior motion and effectively reduce the grade of mitral regurgitation. [ABSTRACT FROM AUTHOR]

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Valsartan in early-stage hypertrophic cardiomyopathy. Topics include remarkable improvements in the knowledge of the disease mechanisms and of the progress in the contemporary management; implantable cardiac defibrillators for the prevention of sudden death and myectomy/alcohol septal ablation for relief of LV outflow tract (LVOT) outflow tract obstruction.

OBJECTIVES: Biventricular obstruction in hypertrophic cardiomyopathy (HCM) is uncommon, and some clinicians believe that, when symptoms are refractory to medical treatment, this severe form of HCM is best treated by transplantation. We describe our conventional surgical approach and outcomes to treat biventricular obstruction in HCM. METHODS: From 1993 to 2013, we treated 11 symptomatic patients with biventricular outflow obstruction. Relief of left ventricular (LV) obstruction was obtained by performing a transaortic extended septal myectomy and/or a left apical ventriculotomy. Right ventricular outflow tract (RVOT) obstruction was relieved with patch enlargement in all patients and selective resection of muscle bundles. RESULTS: The mean age at surgery was 13 years (2 months-28 years); of the total, 7 (63%) were males. All were symptomatic with shortness of breath, reduced exercise tolerance or failure to thrive. All patients had preserved biventricular systolic function and systolic anterior motion (SAM) of the mitral valve (9 patients had ≥moderate mitral regurgitation). Preoperative RVOT and LV outflow tract gradients were 60 ± 18 and 78 ± 24 mmHg, respectively. There were no early deaths. Mitral regurgitation secondary to SAM resolved following LV myectomy. The median follow-up time was 4.6 years (maximum 16.3 years). Eight patients (72%) were in NYHA class I. There have been no late ventricular arrhythmias, sudden deaths, reoperations or heart transplantations at follow-up. CONCLUSIONS: Biventricular obstruction is rare in HCM. Surgical relief of left- and right-sided obstruction can be achieved with good early outcomes. Symptoms are improved at intermediate-term follow-up and sudden death is rare. [ABSTRACT FROM AUTHOR]

STUDY QUESTION When compared with vaginal delivery, is Cesarean delivery associated with reduced childbearing, a prolonged inter-birth interval or infertility? SUMMARY ANSWER Women whose first delivery was by Cesarean section were not significantly different from those who delivered vaginally with respect to subsequent deliveries, inter-birth interval or infertility after delivery. WHAT IS ALREADY KNOWN Some studies have suggested that delivery by Cesarean section reduces subsequent fertility, while others have reported no association. STUDY DESIGN, SIZE, DURATION This was a planned secondary analysis of the Mothers' Outcomes After Delivery study, a longitudinal cohort study. This analysis included 956 women with 1835 deliveries, who completed a study questionnaire at 6–11 years (median [interquartile range]: 8.1 [7.1, 9.8]) after their first delivery. PARTICIPANTS/MATERIALS, SETTING, METHODS Exclusion criteria regarding the first birth were: maternal age <15 or >50 years, delivery at <37 weeks gestation, placenta previa, multiple gestation, known fetal congenital abnormality, stillbirth, prior myomectomy and abruption. Of the 956 women included, the first delivery was by Cesarean section for 534 women and by vaginal birth for 422 women. Infertility was self-reported. To compare maternal characteristics by mode of first delivery, P-values were calculated using Fisher's exact test or Pearson's χ2 test for categorical variables and a Kruskall–Wallis test for continuous variables. We also considered whether, across all deliveries to date, a prior Cesarean is associated with decreased fertility. In this analysis, self-reported infertility after each delivery (across all participants) was considered as a function of one or more prior Cesarean births, using generalized estimating equations to control for within-woman correlation. MAIN RESULTS AND THE ROLE OF CHANCE No differences were observed between the Cesarean and vaginal groups (for first delivery) with respect to infertility after their most recent delivery (7 versus 6%, P = 0.597), the interval between their first and second births (30.8 versus 30.6 months, P = 0.872), or multiparity (75 versus 76%, P = 0.650). Across all births, a history of Cesarean delivery was not significantly associated with infertility (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.64–1.26). Women who reported infertility prior to their first delivery were significantly more likely to report infertility after each subsequent delivery (OR, 5.16; 95% CI, 3.60–7.39). LIMITATIONS, REASONS FOR CAUTION Due to the use of self-reported infertility, the fertility status of some participants may be misclassified. Also, the small sample size may result in insufficient power to detect small differences between groups. Finally, a relatively high proportion of our participants were over age 35 at the time of first delivery (26%) and highly educated (37% with graduate degrees), which may indicate that our population may not be generalizable. WIDER IMPLICATIONS OF THE FINDINGS While some prior studies have shown decreased family size among women who deliver by Cesarean, our results suggest that the rate of infertility is not different after Cesarean compared with vaginal birth. Our findings should be reassuring to women who deliver by Cesarean section. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the US National Institutes of Health (NIH, R01-HD056275). No competing interests are declared. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM PUBLISHER]

Massive hemoperitoneum from spontaneous bleeding of uterine myoma is an extremely rare condition, that needs urgent surgical exploration. We report a 40-year-old woman, admitted for acute onset of abdominal pain. Physical examination revealed hypovolemic shock. The hemoglobin level was of 5 g/dL. Ultrasonography revealed hemoperitoneum. Emergency surgical exploration was planned. There was hemoperitoneum of 3 L, uterine myomas with multiple subserous myomas, bleeding from superficial ruptured varice overlying the most largest subserous myoma, which measured 15 cm. Glove adapted as a tourniquet, was applied at the base of the uterus, and myomectomies were performed with removal of around twenty myomas. The postoperative course was uneventful. Myomectomies can be safely and effectively performed by using a tourniquet, for massive hemoperitoneum with precarious hemodynamic status due to subserous myoma bleeding, despite the number and the size of myomas. [ABSTRACT FROM AUTHOR]

Objective Adequate postoperative analgesia may enhance recovery. The efficacy of continuous wound infusion vs intermittent epidural ropivacaine for postoperative analgesia was investigated. Design Prospective randomized, observer blind trial. Setting Aretaieio University Hospital. Subjects Patients scheduled for open abdominal hysterectomy or myomectomy. Methods Patients received 10 mL of 0.75% ropivacaine along the skin incision before skin closure, followed by wound infusion 2 mL/hour of 0.375% ropivacaine or epidurally 10 mL of 0.75% ropivacaine in the beginning of surgery followed by 10 mL of 0.2% ropivacaine 6 hourly. The epidural injections or the wound infusion of ropivacaine lasted 48 hours. Rescue analgesia consisted of patient-controlled analgesia morphine up to 48 hours and acetaminophen/codeine tablets the next 24 hours. Analgesic consumption and visual analog scale pain at rest and during cough were assessed 2, 4, 8, 24, 48, and 72 hours postoperatively. One and three months later, patients were interviewed by phone for analgesic consumption at home and presence of pain. Results The subcutaneous group consumed more morphine during the first 2, 4, and 8 hours postoperatively ( P < 0.001, P < 0.001, and P < 0.001, respectively). Subsequent morphine and acetaminophen/codeine requirements did not differ between the two groups. Pain intensity during cough was higher only 2 hours after surgery in the subcutaneous group ( P = 0.002). Three months postoperatively, the two groups did not differ in the analgesic requirements and presence of persisting and/or burning pain. Conclusion Based on our results, there is no clinical significant difference between the epidural ropivacaine and the subcutaneous ropivacaine group or a clear superiority to one management strategy. [ABSTRACT FROM AUTHOR]

STUDY QUESTION What is the risk of complications after uterine leiomyoma embolization and what are the factors associated with complications? SUMMARY ANSWER The cumulative risk of complications after embolization is relatively low even in the long term, but submucosal leiomyoma location may increase the risk. WHAT IS KNOWN ALREADY A broad spectrum of complications after leiomyoma embolization have been described with widely varying rates. There is uncertainty over the actual risk of complications and the factors associated with this risk. STUDY DESIGN, SIZE, DURATION This was a prospective cohort study of 288 consecutive women undergoing leiomyoma embolization in the general gynaecology clinic of a university teaching hospital between January 2001 and December 2010. PARTICIPANTS/MATERIALS, SETTING, METHODS Complications occurring after embolization were categorized as major or minor according to the severity of their impact on health, the level of care required and the outcome. Cumulative complication rates were estimated by survival analysis and log-rank tests according to baseline variables. Multivariable Cox proportional hazards analysis was performed to adjust for confounders. MAIN RESULTS AND THE ROLE OF CHANCE There were 48 patients who experienced a complication at a median of 5 months (95% confidence interval, 4.1–11.4) after embolization. Complications were minor in 38 patients and major in 10 patients. The cumulative overall complication rate was 13% (95% CI, 9.0–17.0) at 6 months, 16% (95% CI, 11.0–20.0) at 1 year, 17% (95% CI, 12.0–22.0) at 3 years and 18% (95% CI, 12.9–22.8) at 5 years. The most frequent complication (19/48, 39.6%) was leiomyoma expulsion, which occurred spontaneously in 13 (68.4%) of these cases and required assistance in 6 (31.6%) cases. Eight (2.8%) patients underwent re-intervention, including six hysteroscopic myomectomies, one laparoscopic myomectomy and one hysteroscopic adhesiolysis, as a result of a complication. Submucosal leiomyoma location was the only baseline variable associated with an increased risk for complications [Hazard ratio (HR), 2.28, 95% CI, 1.24–4.18, P = 0.008]. LIMITATIONS, REASONS FOR CAUTION Our population did not include women of African descent, who have been reported to be at higher risk of post-procedural complications compared with Causcasian women. If such women were involved in the study, higher morbidity rates might have been observed. WIDER IMPLICATIONS OF THE FINDINGS Women with submucosal leiomyomas at the time of embolization are more likely to have post-procedural complications. This is important new information for counselling patients contemplating this therapeutic approach. STUDY FUNDING/COMPETING INTEREST(S) The authors have no competing interests to declare. The study was not supported by any external grant. [ABSTRACT FROM PUBLISHER]

STUDY QUESTION Does uterine artery embolization (UAE) permit fertility in childbearing women who have extensive symptomatic fibroids and are not eligible for surgery? SUMMARY ANSWER Although UAE was effective in improving bleeding, bulking and pain symptoms, and in sparing the ovarian reserve, no woman in this study delivered successfully after UAE. WHAT IS KNOWN ALREADY Although pregnancies have been reported after UAE, the actual fertility rate after this treatment remains uncertain. STUDY DESIGN, SIZE, DURATION This prospective cohort study included 66 women who desired a future pregnancy and were treated with UAE for symptomatic fibroids. PARTICIPANTS/MATERIALS, SETTING, METHODS This cohort of consecutive patients had extensive symptomatic fibroids but were not eligible for abdominal myomectomy because of fibroid recurrence despite previous surgery, because of current risks of surgery, or because of patient refusal. The patients were enrolled in a tertiary referral center for fibroid treatment. All patients had a pre-operative ovarian function assessment and underwent bilateral superselective embolization of both uterine arteries using 500–1200 µm Tris acryl microspheres. MAIN RESULTS AND THE ROLE OF CHANCE Fibroid symptoms including menorrhagia (OR 0.08, 95% CI 0.02–0.27), metrorrhagia (OR 0.05, 95% CI 0.01–0.39), pain (OR 0.08, 95% CI 0.03–0.22) and bulk syndrome (OR 0.02, 95% CI 0.01–0.07) were significantly improved after UAE. According to magnetic resonance imaging, the dominant fibroid volume decreased by 31.8% (95% CI 12.2–51.3%). Ovarian reserve demonstrated no change after embolization. Thereafter the women were prospectively followed, and 31 of them (aged 37.3 ± 3.5 years) were actively trying to conceive. In spite of 33.4 ± 14.5 months of attempts, only 1 in 31 women became pregnant and she finally miscarried (monthly fecundability rate 0.1% 95% CI 0–0.3%). LIMITATIONS, REASONS FOR CAUTION The high rate of associated infertility factors in our population, and the high frequency of previous surgery, could in part explain these poor reproductive outcomes; however, they should not account for the total absence of ongoing pregnancy. Embolization might have had a negative impact on fertility in our population, which may not be related to ovarian function. WIDER IMPLICATIONS OF THE FINDINGS The low reproductive outcomes reported in the present study suggest that UAE should not be performed routinely in young women of childbearing age with extensive fibroids. Although this finding was established in a population for whom abdominal myomectomy was declined, a possible adverse effect of UAE on fertility potential should be considered for woman of childbearing age scheduled for embolization. STUDY FUNDING/COMPETING INTEREST(S) No particular funding was obtained for this study and the authors have no conflict of interest. [ABSTRACT FROM AUTHOR]

Aims We studied the relationship between myofilament Ca2+ sensitivity and troponin I (TnI) phosphorylation by protein kinase A at serines 22/23 in human heart troponin isolated from donor hearts and from myectomy samples from patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods and results We used a quantitative in vitro motility assay. With donor heart troponin, Ca2+ sensitivity is two- to three-fold higher when TnI is unphosphorylated. In the myectomy samples from patients with HOCM, the mean level of TnI phosphorylation was low: 0.38 ± 0.19 mol Pi/mol TnI compared with 1.60 ± 0.19 mol Pi/mol TnI in donor hearts, but no difference in myofilament Ca2+ sensitivity was observed. Thus, troponin regulation of thin filament Ca2+ sensitivity is abnormal in HOCM hearts. HOCM troponin (0.29 mol Pi/mol TnI) was treated with protein kinase A to increase the level of phosphorylation to 1.56 mol Pi/mol TnI. No difference in EC50 was found in thin filaments containing high and low TnI phosphorylation levels. This indicates that Ca2+ sensitivity is uncoupled from TnI phosphorylation in HOCM heart troponin. Coupling could be restored by replacing endogenous troponin T (TnT) with the recombinant TnT T3 isoform. No difference in Ca2+ sensitivity was observed if TnI was exchanged into HOCM heart troponin or if TnT was exchanged into the highly phosphorylated donor heart troponin. Comparison of donor and HOCM heart troponin by mass spectrometry and with adduct-specific antibodies did not show any differences in TnT isoform expression, phosphorylation or any post-translational modifications. Conclusion An abnormality in TnT is responsible for uncoupling myofibrillar Ca2+ sensitivity from TnI phosphorylation in the septum of HOCM patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim was to assess the early and mid-term clinical effects of transaortic extended septal myectomy (TAESM) on obstructive hypertrophic cardiomyopathy (HCM) in China. METHODS Ninety-three consecutive patients [57 men; mean age 45.8 ± 13.4 (11–74) years] with obstructive HCM underwent TAESM in Fuwai hospital. Their clinical data were analysed retrospectively. All the patients had drug-refractory symptoms and left ventricular outflow tract (LVOT) obstruction with a resting or physically provoked gradient of ≥50 mmHg. Preoperative transthoracic, intra-operative transoesophageal and postoperative transthoracic echocardiography was performed to assess LVOT gradients, septal thickness, LVOT diameter, mitral valve function, etc. Systolic anterior motion (SAM) of the anterior mitral valve leaflet had been detected in all preoperatively. RESULTS All the surgical procedures of the 93 patients were technically successful. The average length of postoperative stay was 7.8 ± 3.7 days. The 30-day and in-hospital mortality was 0%. Initial postoperative transoesophageal echocardiography (TEE) demonstrated marked reduction in LVOT gradient (91.76 ± 25.08 to 14.34 ± 13.44 mmHg, P < 0.0005) and significant improvement in mitral regurgitation (MR; P < 0.0005). Concomitant surgical procedures were carried out in 37 (39.8%). Complete atrioventricular block occurred in 3, complete left bundle branch block in 44, intraventricular conduction delay in 18, complete right bundle branch block in 2, transient renal dysfunction in 2 and transient intra-aortic-balloon-pumping was needed in 2. No other complications were observed during hospital stay. During a follow-up of 10.72 ± 11.02 (1–24) months, there were no readmissions or deaths, and all patients subjectively reported an obvious decrease in limiting symptoms and a significant increase in physical ability. At the latest follow-up, the New York Heart Association functional class decreased from 3.09 ± 0.60 (2–4) preoperatively to 1.12 ± 0.32 (1–2) (P < 0.0005); the LVOT gradient remained low at 14.78 ± 14.01 mmHg; MR remained absent (51) or at mild-(41)-to-moderate-(1) levels and SAM resolved completely in 98.9% (92 of 93) patients. CONCLUSIONS TAESM provides excellent relief from LVOT obstruction in HCM patients, with a conspicuous clinical and echocardiographic outcome at early and mid-term follow-up. For obstructive HCM and cardiac comorbidities, concomitant cardiac procedures with TAESM can be performed with low risk and satisfactory results. [ABSTRACT FROM AUTHOR]

STUDY QUESTION What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? SUMMARY ANSWER Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. WHAT IS KNOWN ALREADY Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. STUDY DESIGN, SIZE, DURATION This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005–November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. PARTICIPANTS/MATERIAL, SETTING, METHODS Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. MAIN RESULTS AND ROLE OF CHANCE Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. GENERALIZABILITY TO OTHER POPULATIONS Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. STUDY FUNDING/COMPETING INTEREST(S) There was no funding source for this study. [ABSTRACT FROM PUBLISHER]

STUDY QUESTION Can uterine scar healing after laparoscopic intracapsular myomectomy (LIM) be adequately monitored by traditional two-dimensional (2D) ultrasound (US) and Doppler velocimetry? SUMMARY ANSWER The myometrial area of the scar after LIM can be followed by 2D US and Doppler velocimetry. WHAT IS KNOWN ALREADY Apart from post-surgical adhesions, the main concern linked to laparoscopic myomectomy is the quality of healing of the myometrial incision: it has been suggested that US could be useful for assessing uterine scars after myomectomy. However, no diagnostic method has yet been widely accepted to assess the healing process. STUDY DESIGN, SIZE, DURATION A cohort prospective study (level of evidence II-2), run in University-affiliated hospitals: 149 women with symptomatic uterine fibroids (UFs) underwent LIM, between January 2007 and October 2011. During follow up 13 patients withdrew from the study. PARTICIPANTS/MATERIALS, SETTING, METHODS After LIM, all patients were followed by traditional 2D US scanning and Doppler velocimetry on Days: 0, 1, 7, 30 and 45. Authors evaluated: number, size and location of UFs, scar diameter and Doppler velocimetry and resistance index (RI) of the uterine arteries, at their ascending branch. MAIN RESULTS AND THE ROLE OF CHANCE The uterine examination showed a significant (P < 0.05) progressive reduction of uterine scar area from 78% of the previous UF location on the first day, to 19% on 30th day, and <4% on the 45th day. There was no correlation with the size of the fibroid or the relative reduction in the size of the scar, on both Days 1 and 45. There was a significant (P < 0.05) increase in the RI of the ipsilateral uterine arteries from 0.65 on the first post-operative day to 0.83 after 7 days followed by a decrease to 0.71 on the 30th and 0.61 on the 45th post-operative day. LIMITATIONS, REASONS FOR CAUTION This is a cohort investigation on a limited number of patients and it does not surgically compare LIM and ‘classic’ myomectomy in the scar US follow up. WIDER IMPLICATIONS OF THE FINDINGS LIM avoided intraoperative bleeding and excessive tissue damage, as post-operative US follow up showed, with just two intra-myometrial hematomas (1.5%). The 2D US and Doppler velocimetry, a non-invasive safe method to check the myometrium after LIM, can detect post-operative hematoma and disechogenic, heterogeneous or ill-defined scar area, all unfavorable signs for myometrial scarring. Moreover, Doppler transvaginal monitoring, evaluating the pulsatility index (PI) and RI of the uterine arteries at their ascending branch, could identify patients with altered PI and RI parameters, possible markers of impaired wound healing. STUDY FUNDING/COMPETING INTEREST(S) None. [ABSTRACT FROM AUTHOR]

BACKGROUND Our aim was to assess surgical complaints and reproductive outcomes of laparoscopic intracapsular myomectomies by a prospective observational study run in University affiliated hospitals. METHODS Between 2005 and 2010, 235 women underwent subserous and intramural laparoscopic myomectomy of fibroids (4–10 cm in diameter) for indications of pelvic pain, menstrual disorders, a large growing myoma or infertility. The main outcome measures were post-surgical parameters, including complications, the need for subsequent surgery or symptomatic relief, resumption of normal life and reproductive outcome. RESULTS Pelvic pain occurred in 27%, menorrhagia or metorrhagia in 21%, a large growing myoma in 10% and infertility in 42% of women. Single fibroids occurred in 51.9% of patients while 48.1% had multiple myomas. Of all patients, 58.2% had subserosal and 41.8% had intramural myomas. No laparoscopies were converted to laparotomy. In 3 years, 1.2% of patients had a second laparoscopic myomectomy for recurrent fibroids. The mean total operative laparoscopic time was 84 min (range 25–126 min), with mean blood loss of 118 ± 27.9 ml. By 48 h after surgery, 86.3% were discharged with no major post-operative complications. No late complications, such as bleeding, urinary tract infections or bowel lesions, occurred. Of the women who underwent myomectomy for infertility, 74% finally conceived. At term, 32.9% of patients underwent Caesarean section, 24.8% delivered by vacuum extractor and 42.2% had spontaneous deliveries. No case of uterine rupture occurred. CONCLUSIONS Intracapsular subserous and intramural myomectomy saving the fibroid pseudocapsule showed few early and no late surgical complications, enhanced healing by preserving myometrial integrity and allowed a good fertility rate and delivery outcome. In young patients suffering fibroids, laparoscopic intracapsular myomectomy is a potential recommended surgical treatment. [ABSTRACT FROM PUBLISHER]

BACKGROUND Although uterine fibroids have been associated with spontaneous miscarriage, to our knowledge there have been no studies in the literature assessing their role in the recurrent miscarriage (RM) population. The aims of this study are to examine the impact of different types of fibroids on the pregnancy outcome of women with RM and to investigate to what extent resection of fibroids distorting the uterine cavity affects the outcome of a future pregnancy. METHODS The study analysed retrospective and prospective data from a large tertiary referral RM clinic. Couples were investigated as per an established protocol. Fibroids were diagnosed using combined transvaginal ultrasound and hysterosalpingography. Fibroids distorting the uterine cavity were resected via hysteroscopy. Two study groups were subsequently examined: women with cavity-distorting fibroids who underwent surgery (n =25) and women with fibroids not distorting the cavity who did not undergo any intervention (n =54). The latter was compared with a control group of women with unexplained RM (n =285). RESULTS The prevalence of fibroids was found to be 8.2% (79/966). In total, 264 pregnancies of women with fibroids and 936 pregnancies of women with unexplained RM were analysed. Women with intracavitary distortion and undergoing myomectomy significantly reduced their mid-trimester miscarriage rates in subsequent pregnancies from 21.7 to 0% (P< 0.01). This translated to an increase in the live birth rate from 23.3 to 52.0% (P< 0.05). Women with fibroids not distorting the cavity behaved similarly to women with unexplained RM achieving a 70.4% live birth rate in their subsequent pregnancies without any intervention. CONCLUSIONS Fibroids are associated with increased mid-trimester losses amongst women with RM. Resection of fibroids distorting the uterine cavity can eliminate the mid-trimester losses and double the live birth rate in subsequent pregnancies. Women with fibroids not distorting the uterine cavity can achieve high live birth rates without intervention. [ABSTRACT FROM AUTHOR]

Fibroid in pregnancy is common in clinical obstetric practice. The topic is becoming more relevant in contemporary obstetrics due to the demographic shift towards delayed childbearing, the rising rate of obesity, and many pregnancies occurring after the treatment of fibroids. However, there are conflicting reports in the literature on many so-called fibroid complications in pregnancy, and there are inadequate data on the optimum management strategy. An evidence base is lacking on the pregnancy outcome of many conventional and newer treatment modalities of fibroids. This review addresses the characteristics and behaviour of fibroids during pregnancy, their incidence and demography, diagnosis, the complications that can arise during pregnancy and their antenatal management, the labour pattern, mode of delivery and the postpartum course, with critical appraisal of the literature together with certain special situations such as pregnancy after various types of myomectomy and uterine arterial embolisation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To ascertain the impact of uterine leiomyomas on pregnancy outcome, and to determine the effectiveness of myomectomy at the time of caesarean delivery. METHODS: A retrospective study was conducted on pregnant women with uterine leiomyomas. Clinical information including the course of the pregnancy, mode of delivery, pathology findings, and postpartum course were extracted from medical records and analysed for statistical significance. RESULTS: There were 50 pregnancies associated with uterine leiomyomas. During pregnancy, the leiomyomas grew >2 cm in 46% of cases. Only 6% were affected by symptoms of red degeneration. There were 2% mid trimester inductions of labour, 6% vaginal deliveries, and 92% caesarean sections. Of the 46 caesarean sections, 47% were due to obstetrical factors and 89% of patients underwent myomectomy at the time of caesarean delivery. The mean blood loss from myomectomy at the time of caesarean section was 260 ml (200–700 ml), and 5% of patients who underwent myomectomy were transfused. CONCLUSIONS: It is possible to carry a pregnancy successfully to term when the pregnancy is complicated by uterine leiomyomas. When caesarean delivery is needed, myomectomy can be performed at the time of caesarean section routinely without significant complications. [ABSTRACT FROM AUTHOR]

BACKGROUND To determine the optimal surgical approach for laparoscopic uterine artery ligation (LUAL) combined with myomectomy in the management of women with symptomatic uterine fibroids. METHODS This is a prospective study. One hundred and six women with symptomatic uterine myomas underwent LUAL + laparoscopic morcellation after enucleation (enucleation group) (n = 51) or LUAL + laparoscopic in situ morcellation (ISM group) (n = 55). The outcome was measured by comparing surgical techniques, symptom control, recurrence and pregnancy during a 3-year follow-up in both groups. RESULTS General characteristics of the patients were similar in both groups, except the myomas were larger in the ISM group. The operative time (mean ± SD) was significantly shorter in the ISM group than the enucleation group (107 ± 30 min versus 128 ± 49 min, P = 0.009). There were no differences in the therapeutic outcomes of the two groups at the 3-year follow-up, with low recurrence rates and good symptom control rates. Of the sexually active patients without contraception, the pregnancy and live birth rates were 87.5 and 100% in the ISM group and 66.7 and 83.3% in the enucleation group (all NS). CONCLUSIONS The LUAL + myomectomy, either by enucleation or ISM, is acceptable in the management of symptomatic uterine fibroids. However, the LUAL + ISM technique might be more feasible, as it requires less operative time. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: Anatomic alterations of the mitral valve such as increased mitral leaflet area, length and laxity, and anterior displacement of the papillary muscles in hypertrophic obstructive cardiomyopathy predispose patients to residual systolic anterior motion and persistence of outflow obstruction and mitral regurgitation after septal myectomy. We investigate the long-term results of combined anterior mitral leaflet retention plasty and septal myectomy in children with hypertrophic obstructive cardiomyopathy. Methods and results: Anterior mitral leaflet retention plasty and subaortic septal myectomy were performed in 12 children (mean age 10.8±1.7 years) with hypertrophic obstructive cardiomyopathy. Mean preoperative left ventricular outflow tract pressure gradient was 49±11mmHg. After careful assessment of the mobility of the anterior leaflet and subvalvular apparatus, segments of the anterior leaflet nearest the trigones were sutured to the corresponding posterior annulus with polypropylene reinforced with untreated autologous pericardial pledgets. Intraoperative valve orifice measurement based on age-related valve diameter ensures that no mitral stenosis is produced. Mean intraoperative pre- and post-septal myectomy pressure gradient was 60±25mmHg and 5±6mmHg, respectively. Post-myectomy mitral insufficiency was reduced to a regurgitant fraction of 0–10%. Mean follow-up is 11.85±1.22 years. Mean left ventricular outflow tract pressure gradient was 6.2±3.95mmHg. No mortality, no repeat myectomy or repeat mitral valve repair or replacement, no mitral stenosis and no systolic anterior motion occurred. Conclusions: Long-term follow-up shows sustained absence of systolic anterior motion, attenuation of mitral regurgitation, sustained improvement in functional status, and reduction of outflow tract obstruction. [Copyright &y& Elsevier]

Introduction. This is a report about the effects of myoma uteri and myomectomy on sexual function in women. Aim. The aim of this article was to determine the effects of myoma uteri and myomectomy on sexual function in women. Method. The study was designed as a controlled clinical study in an academic clinical research center. The study patients consisted of 80 women with myoma uteri and 75 control women. Baseline characteristics and properties of the myomas were recorded. A validated questionnaire was used to determine pre- and postoperative sexual function in the patients. Main Outcome Measure. Female sexual function index (FSFI) scores of the women were recorded before and after surgery. Results. Women with myoma uteri had lower FSFI pain and satisfaction scores than women without it, even after correction for possible confounders. Fundal and posterior myomas were associated with pain, whereas only posterior myomas were related to the overall FSFI scores. However, although there was no relation between the volume of the myomas and the FSFI scores, women with a uterine volume over 200 cm3 had significantly lower mean FSFI satisfaction, pain, and total scores. The mean FSFI pain and total scores of the patients improved significantly after undergoing a myomectomy. Conclusions. The findings of this study suggest that a potential impairment of sexual function exists in women with myomas. This is mainly because of pain during sexual intercourse, although it does not seem to have an effect on either the arousal or orgasmic phases. Furthermore, the performance of a myomectomy may alleviate pain during intercourse, and thereby improve sexual function in the patients. Ertunc D, Uzun R, Tok EC, and Dilek S. The effect of myoma uteri and myomectomy on sexual function. J Sex Med **;**:**–**. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 64-year-old woman with hypertrophic obstructive cardiomyopathy and severe calcific mitral stenosis. Topics include transthoracic echocardiography revealing asymmetric septal hypertrophy and calcific mitral stenosis; undergoing extended septal myectomy and mitral valve replacement; and patient with hypertrophic cardiomyopathy and premature systolic partial closure due to dynamic outflow obstruction showing as a ‘heart within a heart' pattern.