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Cardiac luxation is a rare condition in cases of blunt thoracic trauma, yet it is quite fatal. We present a case of a 28-year-old man, admitted to the emergency room after a motorcycle accident in a hemodynamically unstable condition and radiographic presentation of multiple rib fractures, bilateral pneumothorax, pneumomediastinum, and significant dislocation of the heart to the right. After performing emergency bilateral tube thoracostomy and achieving hemodynamic stability, a CT scan was performed and the patient was diagnosed with pericardial rupture with right-sided luxation of the heart. An emergency sternotomy was performed with repositioning of the heart and pericardial reconstruction. In the postoperative period, suspicion of myocardial infarction was ruled out and the patient was discharged with persistent traumatic monoplegia of the left upper limb and Claude Bernard-Horner syndrome. An analysis of this very rare type of chest trauma has been made and the probable mechanism for its occurrence has been discussed., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A 65-year-old man was involved in a multivehicle collision from which he sustained blunt polytrauma involving the abdomen and chest. Imaging of the chest revealed biventricular cardiac herniation into the left chest with an associated pneumopericardium. He underwent emergent surgical management with repositioning of the heart and repair of associated pericardial rupture. Exposure was facilitated with the novel use of an off-pump coronary surgery heart positioner. This report highlights the management of these rare blunt traumatic injuries in addition to using the Urchin ® heart positioner for optimal exposure.

Introduction: Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated., Aim: To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries., Methods: At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test., Statistical Methods Used: descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation)., Results: Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion., Conclusion: Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries., Competing Interests: There are no conflicts of interest., (© 2020 Dusan Janicic, Milan Simatovic, Zoran Roljic, Ljiljana Krupljanin, Reuf Karabeg.)

Introduction: Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP., Methods: The electronic medical records of a single-center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae., Results: Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini-thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P = .99)., Conclusion: Our single-center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory., (© 2020 Wiley Periodicals, Inc.)

Patients undergoing sternotomy routinely undergo sternal closure with stainless steel wires. Occasionally these wires can fracture, although normally this presents no concern as the broken wire remains fixed and is not problematic. We report a case of a segment of a broken sternal wire that migrated through the pericardium onto the right ventricular. It was removed with a minimally invasive approach with endoscopic assistance., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 14-year-old girl suddenly developed ventricular tachycardia and severe chest pain during hospitalisation for trauma surgery. CT revealed a needle in the pericardium. Careful interview elicited that she had inserted the needle by herself, and Munchausen syndrome was diagnosed. This is the first report of ventricular tachycardia caused by a foreign body in a patient with Munchausen syndrome.

Purpose of Review: This review highlights the literature related to pericardial injury following radiation for oncologic diseases., Recent Findings: Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.

Background: Radiofrequency (RF) has become an accepted energy source for myocardial ablation but may result in discontinuous lesions and nontargeted tissue injury. We examined the feasibility and safety of lesion formation using high-amplitude, bipolar pulsed electric fields delivered from a multielectrode array catheter., Objective: The purpose of this study was to compare duty-cycled radiofrequency ablation (RFA) to pulsed field ablation (PFA) in terms of acute electrical effects, 2-week lesion formation, and injury to nontargeted tissues., Methods: Intracardiac ablations were performed in 6 pigs using a circular pulmonary vein ablation catheter. The energy source for ablation delivery was randomized to deliver either PFA or RFA to 3 atrial endocardial sites. Bipolar pace capture and electrogram amplitude measurements were recorded at each site. Histopathology and necropsies were performed after 2 weeks., Results: The circular pulmonary vein ablation catheter was used to deliver pulsed electric fields to produce cardiac lesions without skeletal muscle stimulation. Evaluating all ablations in each site, electrogram amplitudes were reduced to <0.5 mV in 67.5% of PFA vs 27.0% of RFA deliveries (P <.001). Bipolar cardiac capture was lost after 100% vs 92.0% of PFA vs RFA (P = .005). At 2 weeks, PFA resulted in consistent transmural and homogeneous replacement fibrosis devoid of lingering myocyte "sequesters." RFA lesions showed a stronger inflammatory response extending to the epicardial fat, arterial injury, and thrombosis. Neither PFA nor RFA lesions showed endocardial thrombus., Conclusion: Intracardiac PFA can be feasibly delivered from a circular catheter to create fibrotic lesions that have acute electrical effects, without injury to nontargeted tissue., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Epicardial hematoma can manifest immediately or within a few minutes to hours after coronary intervention. Review of angiogram after the diagnosis of hematoma, in our case, showed deep distal positioning of a non-polymer jacketed wire, which is the most likely cause of the adverse outcome. Multimodality imaging is critical for diagnosis and management of such cases.

Surgical trauma to the pericardial mesothelium during open heart procedures has formation of fibrovascular adhesions. Surgeons are confronted with cardiac adhesions, leading to an increased surgical risk such as intractable bleeding and possible catastrophic hemorrhage. In order to solve the problem, the anti-adhesion membrane has been developed and used. However, their performances are far from perfect, so it has been expected to develop a novel anti-adhesive material. For preparing an anti-adhesive material, there is 1 serious problem, a lack of golden standard of animal model for evaluation of anti-adhesivity. In this study, we tried to establish a standard system for evaluation of the performance of anti-adhesive materials for the chest-area surgery using rabbit. Setting the condition of the damage to heart, the objective evaluation system was established. And we performed experimental study to evaluate prevention of adhesions with pericardial substitutes and our product under development based on this model.

Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma.

Blunt traumatic diaphragmatic hernias are most commonly seen in combination with other injuries. Right diaphragmatic ruptures with serious pericardium ruptures are relatively rare. The diagnosis of diaphragmatic hernias is not difficult; however, prior to surgery, it is difficult to judge whether pericardium damage has occurred, particularly on the right side. This injury may occur in a critical pathological state in which cardiac tissue is outside the pericardium due to the pericardial defect. Severe hemodynamic disorders or even death may occur if the patient's condition is not diagnosed and treated in a timely manner. The transportation of patients with severe trauma must be performed with extreme caution. It is necessary to weigh a wide range of differential diagnoses in a serious and thorough initial investigation.

Background: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury., Materials and Methods: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was "posterior" or "posterior + anterior." Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive., Results: One CT occurred in 1302 consecutive LARS (0.076%). The incidence is 0% when "no" (379) or "posterior" (880) graft is used as opposed to 2.3% rate in "posterior + anterior" (43) grafting. The distribution of "offensive," "nonoffensive but nearest," and "safe" tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone., Conclusion: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

Background: The mesh fixation technique used in repair of hiatal hernias and subxiphoid ventral and incisional hernias must meet strenuous requirements. In the literature, there are reports of life-threatening complications with cardiac tamponade and a high mortality rate on using tacks. The continuing practice of tack deployment for mesh fixation to the diaphragm and esophageal hiatus should be critically reviewed., Methods: In a systematic search of the available literature in May 2017, 23 cases of severe penetrating cardiac complications were identified. The authors became aware of two other cases in which they acted as medical experts. Furthermore, the instructions for use issued by the manufacturers of the tacks were reviewed with regard to their deployment in the diaphragm., Results: Twenty-three of 25 cases (92%) with severe cardiac injuries and subsequent cardiac tamponade were triggered by the use of tacks in the diaphragm. In six cases (24%), these related to ventral and incisional hernias with extension to the subxiphoid area, and in 19 cases (76%) to mesh-augmented hiatoplasty. Twelve of 25 (48%) patients died as a result of pericardial and/or heart muscle injury with cardiac tamponade despite heart surgery intervention. In the tack manufacturers' instructions for use, their deployment in the diaphragm, in particular in the vicinity of the heart, is contraindicated. Likewise, the existing guidelines urgently advise against the use of tacks in the diaphragm, recommending instead alternative fixation techniques., Conclusions: Tacks should not be used for mesh fixation in the diaphragm above the costal arch.

Background: Blunt cardiac trauma is diagnosed in less than 10% of trauma patients and covers the range of severity from clinically insignificant myocardial contusions to lethal multi-chamber cardiac rupture. The most common mechanisms of injury include: motor vehicle collisions (MVC), pedestrians struck by motor vehicles and falls from significant heights. A severe complication from blunt cardiac trauma is cardiac chamber rupture with pericardial tear. It is an exceedingly rare diagnosis. A retrospective review identified only 0.002% of all trauma patients presented with this condition. Most patients with atrial rupture do not survive transport to the hospital and upon arrival diagnosis remains difficult., Case Presentation: We present two cases of atrial and pericardial rupture. The first case is a 33-year-old female involved in a MVC, who presented unresponsive, hypotensive and tachycardic. A left sided hemothorax was diagnosed and a chest tube placed with 1200 mL of bloody output. The patient was taken to the OR emergently. Intraoperatively, a laceration in the right pericardium and a 3 cm defect in the anterior, right atrium were identified. Despite measures to control hemorrhage and resuscitate the patient, the patient did not survive. The second case is a 58-year-old male involved in a high-speed MVC. Similar to the first case, the patient presented unresponsive, hypotensive and tachycardic with a left sided hemothorax. A chest tube was placed with 900 mL of bloody output. Based on the output and ongoing resuscitation requirements, the patient was taken to the OR. Intraoperatively, a 15 cm anterior pericardial laceration was identified. Through the defect, there was brisk bleeding from a 1 cm laceration on the left atrial appendage. The injury was debrided and repaired using a running 3-0 polypropylene suture over a Satinsky clamp. The patient eventually recovered and was discharged home., Conclusions: We present two cases of uncontained atrial and pericardial rupture from blunt cardiac trauma. Contained ruptures with an intact pericardium present as a cardiac tamponade while uncontained ruptures present with hemomediastinum or hemothorax. A high degree of suspicion is required to rapidly diagnose and perform the cardiorrhaphy to offer the best chance at survival.

Traumatic pericardial rupture is a rare event with high mortality. We present the case of a 15-year-old boy who sustained thoracic and abdominal trauma secondary to motor vehicle collision, with a delayed diagnosis of traumatic pericardial rupture with cardiac herniation. Out of concern for torsion and hemodynamic collapse, surgical repair was advised. We have developed a novel surgical approach to this rare condition, utilizing a combination of thoracoscopic and open surgical techniques. The guiding principles of our repair include the utilization of fenestrated pieces of bovine pericardium to create a tension free repair, minimizing the likelihood of pericardial effusion, and returning the cardiac mass to normal anatomic position., (© 2018 Forum Multimedia Publishing, LLC.)

Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.

We describe a case of polymicrobial bacterial pericarditis with Klebsiella pneumoniae and Proteus mirabilis , caused by pericardial penetration of the tip of the catheter of a laparoscopic adjustable gastric band (LAGB). The patient developed a cardiac tamponade, and subsequently emergency pericardiocentesis was performed. Analysis of earlier CT scans showed that the tip of the catheter had migrated through the liver and through the diaphragm into the pericardium, and was in contact with the myocardium. After stabilisation he was operated to remove the LAGB. In this case report, we describe the chain of events that led to the polymicrobial pericarditis-a complication of LAGB placement that to our knowledge has thus far never been reported. We furthermore present a detailed literature review of all published cases of polymicrobial pericarditis and its causes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Pneumothorax in preterm infants is associated with an increased risk of chronic lung disease, intraventricular hemorrhage and mortality. In mechanically ventilated preterm infants, for the management of tension pneumothorax if needle aspiration is not successful a thoracostomy is needed. In the last two decades management of tension pneumothorax has changed from the use of traditional chest tubes to percutaneous pigtail catheter thoracostomy (PPCT) as the most commonly used technique. When compared to placement of traditional chest tubes, PPCT is touted as being faster requiring, less analgesia and less training for proficiency and having fewer complications. There are only infrequent reports of complications with this procedure. Here, a rare complication, which previously has only been reported at autopsy, is described in an extreme preterm with prompt diagnosis and early management.

A 58-year-old man presented with fever and chest pain 11 days after atrial fibrillation catheter ablation. The diagnosis of pericardio-oesophageal fistula was made. Aggressive surgical management was decided. The patient was managed using extracorporeal life support, aortic valve replacement and a pulmonary patch, as well as an oesophageal stent. The patient was discharged from hospital approximately 2 months later. The use of a pulmonary patch is a rare but a highly effective technique that can be used in this indication., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Epicardial ablation is often necessary for the treatment of complex arrhythmias refractory to endocardial ablation. Conventional needle access to the pericardial space is considered quite challenging, and it is often associated with several potential complications, particularly inadvertent right ventricular puncture. The novel EpiAccess needle tip is embedded with a pressure sensor able to report the pressure waveform in real time when used with the EpiAccess System., Objective: We prospectively evaluated the feasibility and safety of the EpiAccess System by EpiEP, Inc., with a novel epicardial access needle in a multicenter study., Methods: Twenty-five patients with a clinical need for epicardial access were enrolled. The EpiAccess needle and EpiAccess System were used for epicardial access in each case. Successful epicardial access, defined as the ability to introduce a guidewire into the epicardial space, was assessed via the device and confirmed with fluoroscopy. Significant pericardial bleeding was defined as >80 mL of blood by using peer review article definitions., Results: Patients were men (76%) with a mean age of 62 years (range 28-84 years). Epicardial access for ventricular tachycardia ablation was indicated in 80% of the patients. Successful epicardial access was obtained in all cases, with pressure monitoring guiding pericardial wire access in all cases. One delayed pericardial effusion occurred., Conclusion: Epicardial access with the novel EpiAccess needle and System with real-time pressure monitoring is feasible and safe. The pressure monitoring capability identifies successfully the epicardial space, facilitating access and potentially minimizing complications. This has relevant clinical implications., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

A 56-year-old woman presented with acute onset of typical chest pain. She was diagnosed with acute coronary syndrome with ST-segment elevation myocardial infarction. Although significant obstructive coronary artery disease was ruled out by coronary angiography, cardiac MRI showed transmural necrosis of the lateral free wall with extensive microvascular obstruction consistent with ischaemic heart disease. Within 48 hours after initial presentation, the patient suddenly arrested due to pulseless electrical activity with futile resuscitation efforts. Autopsy revealed myocardial perforation with extensive haematothorax due to pericardial laceration, caused by the mechanical chest compressions. Eventually, histology identified diffuse necrotising coronary vasculitis as a rare cause of ischaemic heart disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

We report the case of a 64-year-old woman with recurrent mediastinal dedifferentiated liposarcoma. She had undergone surgical resection twice. Subsequently, on regular follow-up visits, chest computed tomography demonstrated a third local recurrence of the tumor with invasion into adjacent intrathoracic organs. Adhesion of the heart to the anterior chest wall through a pericardial defect that had been inadvertently created at the second operation was suspected. We decided to use a thoracoabdominal approach with four-dimensional computed tomography (4DCT) for preoperative guidance. The patient had also undergone MRI; however, the result was equivocal regarding adhesion of intrathoracic organs. The use of 4DCT enabled successful en bloc resection of the tumor. Results of the pathology examination showed complete resection of a dedifferentiated liposarcoma. The patient's postoperative course was uneventful, and she was discharged on postoperative day 19.

Objective: Percutaneous thoracostomy tubes are widely used in neonates, infants and children. The technique has a low complication rate. Lung perforation by a pigtail catheter is described in a single case report., Study Design: This is a multi-center case series of neonates and infants who experienced thoracic organ injury following percutaneous chest tube placement between 2006 and 2015., Result: Eleven patients had chest tube-related thoracic organ injury. In six, tubes were placed during resuscitation. Gestational ages ranged from 24+6 weeks to term. Most of the chest tubes were pigtail catheters, and the most common injury was lung lobe perforation. Pericardium and mediastinum were also sites of injury. Some patients had small pleural effusions, with no other complications identified., Conclusion: Thoracic organ injury by percutaneous catheters may be more common than previously appreciated. Clinical and radiological findings are non-specific, and the diagnosis may not be apparent until autopsy.

Background: The adult mammalian heart responds to cardiac injury by formation of persistent fibrotic scar that eventually leads to heart failure. In contrast, the neonatal mammalian heart reacts to injury by the development of transient fibrotic tissue that is eventually replaced by regenerated cardiomyocytes. How fibrosis occurs in the neonatal mammalian heart remains unknown. To start elucidating the molecular underpinnings of neonatal cardiac fibrosis, we investigated Wnt signaling in the neonatal heart after cryoinjury., Methods and Results: Using expression of the Wnt target gene Axin2 as an indicator of Wnt/β-catenin signaling activation, we discovered that epicardial cells in the ventricles are responsive to Wnt in the uninjured neonatal heart. Lineage-tracing studies of these Wnt-responsive epicardial cells showed that they undergo epithelial-to-mesenchymal transition and infiltrate into the subepicardial space and exhibit fibroblast phenotypes after injury. In addition, we showed that-similar to adult ischemic injury-neonatal cryoinjury results in activation of Wnt signaling in cardiac fibroblasts near injured areas. Furthermore, through in situ hybridization of all 19 Wnt ligands in injured neonatal hearts, we observed upregulation of Wnt ligands (Wnt2b, Wnt5a, and Wnt9a) that had not been implicated in the adult cardiac injury response., Conclusions: These results demonstrate that cryoinjury in neonatal heart leads to the formation of fibrotic tissue that involves Wnt-responsive epicardial cells undergoing epithelial-to-mesenchymal transition to give rise to fibroblasts and activation of Wnt signaling in resident cardiac fibroblasts., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

A 65-year-old male developed acute myocardial infarction due to coronary artery dissection and tricuspid valve injury after blunt chest trauma. Acute myocardial infarction was treated by coronary artery intervention; however, refractory heart failure with pleural effusion remained. The first transthoracic echocardiography (TTE) on admission failed to clearly visualize the tricuspid valve and right ventricle due to poor image quality. A follow-up TTE with contrast ultrasonography revealed pericardial rupture in addition to tricuspid regurgitation. Ruptures of the tricuspid papillary muscle and pericardium were confirmed during surgery and were repaired successfully. Blunt chest trauma results in various cardiac injuries including cardiac rupture, intramural hematoma, valvular injury, coronary artery injury, and electrical disturbances, leading to critical conditions and high mortality. Of such blunt trauma-induced injuries, coronary artery dissection, tricuspid valve injury, and pericardial rupture caused by blunt chest trauma are rare, and simultaneous occurrence of the three types of injuries that were successfully repaired has not been reported. In addition, this case indicates the utility of contrast ultrasonography for diagnosis of pericardial rupture caused by blunt chest trauma.

A 62-yr-old man was transferred to our institution with blunt chest trauma after being pinched between a car and a wall. Chest computed tomography revealed left-sided rib fractures, bilateral pneumothorax, and pneumopericardium, but no displacement of the heart. The pneumopericardium caused us to suspect a tear in the pericardium. Since the left pneumothorax was slightly more marked than the right, we planned a left-sided thoracoscopic exploration. As a result, a right-sided pericardial rupture was found and repaired under thoracotomy. It was difficult to judge the injured side of the pericardial tear. We learned a valuable lesson from this case: The extent of pleural air may be, but is not always, reliable for identification of the injured side of a pericardial rupture. Direct observation of the pleural space using a thoracoscope is necessary for definitive diagnosis.

Late onset cardiac tamponade is a rare and particularly challenging (both from diagnostic and management perspectives) complication of intracardiac lead implantation. We present a case of a late tamponade leading to cardiogenic shock, which occurred 1,164 days after implantable cardioverter-defibrillator (ICD) implantation. Open repair revealed unusual and, to our knowledge, not yet reported mechanism of the disease. A pressure sore caused by an ICD lead was found in the parietal layer of pericardium with no visible damage to the visceral layer. Conservative management in the described clinical scenario could be fatal, thus awareness of this pathomechanism of tamponade is critical., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The Focused Assessment with Sonography for Trauma examination is an invaluable tool in the initial assessment of any injured patient. Although highly sensitive and accurate for identifying hemoperitoneum, occasional false negative results do occur in select scenarios. We present a previously unreported case of survival following blunt cardiac rupture with associated negative pericardial window due to a concurrent pericardial wall laceration., Case Presentation: A healthy 46-year-old white woman presented to our level 1 trauma center with hemodynamic instability following a motor vehicle collision. Although her abdominal Focused Assessment with Sonography for Trauma windows were positive for fluid, her pericardial window was negative. After immediate transfer to the operating room in the setting of persistent instability, a subsequent thoracotomy identified a blunt cardiac rupture that was draining into the ipsilateral pleural space via an adjacent tear in the pericardium. The cardiac injury was controlled with digital pressure, resuscitation completed, and then repaired using standard cardiorrhaphy techniques. Following repair of her injuries (left ventricle, left atrial appendage, and liver), her postoperative course was uneventful., Conclusions: Evaluation of the pericardial space using Focused Assessment with Sonography for Trauma is an important component in the initial assessment of the severely injured patient. Even in cases of blunt mechanisms however, clinicians must be wary of occasional false negative pericardial ultrasound evaluations secondary to a concomitant pericardial laceration and subsequent decompression of hemorrhage from the cardiac rupture into the ipsilateral pleural space.

A female longfin mako shark Isurus paucus (Guitart-Manday, 1966) was found moribund on the Atlantic Ocean beach near Canaveral National Seashore, Florida; the shark died shortly after stranding. Macroscopic lesions included a partially healed bite mark on the left pectoral fin, a clefted snout, pericardial effusion and a pericardial mass surrounding a 12/0 circle fishing hook. The heart, pericardial mass, gills, ovary, oviduct, shell gland, epigonal organ, liver, kidney and intrarenal and interrenal glands were processed for histopathology and examined by brightfield microscopy. Microscopic examination revealed chronic proliferative and pyogranulomatous pericarditis and myocarditis with rhabdomyolysis, fibrosis and thrombosis; scant bacteria and multifocal granular deposits of iron were found intralesionally. In addition, acute, multifocal infarcts within the epigonal organ and gill filaments were found in association with emboli formed by necrocellular material. The ovary had high numbers of atretic follicles, and the liver had diffuse, severe hepatocellular degeneration, multifocal spongiosis and moderate numbers of melanomacrophage cells. This report provides evidence of direct mortality due to systemic lesions associated with retained fishing gear in a prohibited shark species. Due to the large numbers of sharks released from both recreational and commercial fisheries worldwide, impact of delayed post-release mortality on shark populations is an important consideration., (© 2014 John Wiley & Sons Ltd.)