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An adolescent female patient presented for cardiology follow-up as well as worsening menorrhagia. A review of her medications revealed she has been on chronic prophylaxis for prevention of arterial thrombosis since childhood, likely now exacerbating her menorrhagia. A chest radiograph (figure 1A,B) and subsequent cardiac computed tomography angiography (CTA) were obtained (figure 1C and online supplementary video). ### Supplementary data [heartjnl-2019-314997supp001.avi] Figure 1 (A,B) Chest X-ray and (C) cardiac computed tomography angiography. What childhood diagnosis is most commonly associated with the imaging findings of this patient? 1. Kawasaki disease. …

Peripherally inserted central catheters (PICC) and implantable venous access devices with an attached catheter such as a Port-A-Cath are common types of central venous catheters (CVC) that are used to deliver chemotherapy and other medications. Subclavian vein (SVC) access for CVC, although widely practiced, presents risks for catheter complications such as the compression of the catheter in the space anterior to the first rib and posterior to the clavicle (1). This compression is rated on a scale of grades 0 to 3 pinch-off syndrome (POS). Grade 0 exhibits a regular catheter course without luminal narrowing; grade 1 exhibits an altered catheter course without luminal narrowing; grade 2 exhibits luminal narrowing; and grade 3 exhibits catheter fracture (2). POS may present with pain or swelling of the shoulder region but patients may also be asymptomatic (3). Additionally, POS can be an incidental finding seen on a chest X-ray (4). Regardless, clinicians should suspect a possible POS if there is patient-reported pain or an abnormal catheter pathway seen on a chest X-ray. Further investigation via radiographic or fluoroscopic evaluation is warranted. Early detection of POS requires only catheter replacement but failure to intervene may result in life-threatening complications caused by catheter fragmentation. In such cases, pieces of the catheter may break off to cause ventricular tachycardia, vessel embolization, and cardiac perforation (5-7). In this report, we discuss two cases of grade 3 POS that were detected based on clinical and radiographic signs.

Autogenous arteriovenous vascular access with an arteriovenous fistula (AVF) is the gold standard for attaining long-term hemodialysis vascular access (1). When compared to prosthetic arteriovenous grafts (AVGs) and tunneled hemodialysis catheters, an AVF has less frequent rates of thrombosis, stenosis, and infection.

Catheter-directed thrombolysis (CDT) for the treatment of acute pulmonary embolism (PE) has gained popularity in recent years, but potential complications during the procedure and their management are not frequently discussed in the literature. In this case report, we describe the clinical dilemma regarding the postoperative anticoagulation management of a 60-year-old male who developed cardiac perforation during a CDT of an acute saddle PE. Early resumption of systemic heparin in such cases may help in clot resolution; however, it can worsen the hemopericardium. On the other hand, delaying restarting heparin may help in healing of the cardiac perforation but can lead to clot propagation. As the chest tube output was minimal initially, anticoagulation was started, which, however, led to disastrous outcome. With limited published medical literature to help guide such a complex situation, it may be prudent to carefully weigh the risks and benefits of resuming systemic heparin versus delaying it for 1–2 days to allow for definitive resolution of the cardiac perforation.

Background and Aims: Patients often undergo paracentesis prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure to improve respiratory mechanics. However, the effect of large volume paracentesis (LVP) on intraoperative hemodynamics and anesthetic management when it is performed immediately before the TIPS procedure is not well documented. Material and Methods: This is a retrospective study in patients undergoing the TIPS procedure between 2004 and 2017. Patients were divided into two groups based on the volume of preoperative paracentesis, namely, small volume paracentesis (SVP), defined as paracentesis volume less than 5 L and LVP, defined as paracentesis volume of at least 5 L. Patients' demographics and perioperative information were collected through chart review. The Wilcoxon signed-rank test, student's t-test, and Fisher's exact test were used when appropriate. Uni- and multivariate linear regression analyses were used to determine the predictive value of paracentesis volume in relation to intraoperative hemodynamics and management of hypotension. Results: Of 49 patients, 19 (39%) received LVP and the remainder received SVP. Baseline demographics were comparable between groups as were intraoperative hypotension and volume of infused crystalloid and colloid. However, vasopressor use (P = 0.02) and packed red blood cell transfusion (P = 0.01) were significantly higher in the large volume group. Paracentesis volume was an independent predictor of the phenylephrine dose (P = 0.0004), and of crystalloid (P = 0.05) and colloid (P = 0.009) volume administered after adjusting for age, sex, body mass index, alcohol use, hemoglobin, and model for end-stage liver disease score. Conclusion: The anesthetic management of patients who undergo LVP just prior to a TIPS procedure may require larger doses of vasopressors and colloids to prevent intraoperative hemodynamic instability during the TIPS placement but may be as well tolerated as SVP.

PURPOSEKeratoconus (KC) is the most common corneal ectasia. We aimed to determine the differential expression of coding and long noncoding RNAs (lncRNAs) in human corneas affected with KC.METHODS200ng total RNA from the corneas of 10 KC patients and 8 non-KC normal controls was used to prepare sequencing libraries with the SMARTer Stranded RNA-Seq kit after ribosomal RNA depletion. Paired-end 50bp sequences were generated using Illumina HiSeq 2500 Sequencer. Differential analysis was done using TopHat and Cufflinks with a gene file from Ensembl and a lncRNA file from NONCODE. Pathway analysis was performed using WebGestalt. Using the expression level of differentially expressed coding and noncoding RNAs in each sample, we correlated their expression levels in KC and controls separately and identified significantly different correlations in KC against controls followed by visualization using Cytoscape.RESULTSUsing |fold change| ≥ 2 and a false discovery rate ≤ 0.05, we identified 436 coding RNAs and 584 lncRNAs with differential expression in the KC-affected corneas. Pathway analysis indicated the enrichment of genes involved in extracellular matrix, protein binding, glycosaminoglycan binding, and cell migration. Our correlation analysis identified 296 pairs of significant KC-specific correlations containing 117 coding genes enriched in functions related with cell migration/motility, extracellular space, cytokine response, and cell adhesion, suggesting the potential functions of these correlated lncRNAs, especially those with multiple pairs of correlations.CONCLUSIONSOur RNA-Seq based differential expression and correlation analyses have identified many potential KC contributing coding and noncoding RNAs.