Central Tendon Of Diaphragm Research Articles

Pericardial hernia: an unusual complication of convergent atrial fibrillation ablation.

A 59-year-old woman with highly symptomatic recurrent paroxysmal atrial fibrillation had failed antiarrhythmic therapy and pulmonary vein isolation. Owing to her large left atrial size and failed pulmonary vein isolation, she underwent the convergent atrial fibrillation ablation. A 3-cm subxiphoid incision was made at the central tendon of diaphragm above the liver, medial to the falciform ligament. Through this port, the VisiTrax ablation device (nContact, Inc., Morrisville, NC, USA) was advanced into the pericardial space and ablation was performed at the posterior left atrium and around the pulmonary veins. Subsequently, through an transseptal approach, endocardial lesions were created at the posterior antrum of the left superior pulmonary vein. Bidirectional block was confirmed across all four veins and a right-sided cavotricuspid isthmus line was created. Amiodarone was continued for 3 months. Four months after the procedure, she complained of constant bloating. Physical examination and routine laboratories were normal. Echocardiography showed an echogenic mass anterior to her heart. Computed tomography of her chest confirmed a diaphragmatic hernia with portions of greater omentum and transverse colon extending into the pericardium (Fig. 1). Laparoscopic hernia repair was performed. Diaphragmatic and pericardial openings were closed with figure of eight sutures and her abdominal symptoms resolved. Figure 1: CT chest showing diaphragmatic hernia with portions of greater omentum and transverse colon extending into the pericardium. Diaphragmatic hernia is rare and usually congenital or traumatic [1]. There are few case reports documenting diaphragmatic hernias following a pericardial window, pacemaker placement [2] and coronary artery bypass graft [3]. Being a minimally invasive procedure, the convergent ablation has minimal complications [4]. We have modified our technique to create a more posterior pericardial access site and we have not had any further cases of intrapericardial hernia. Alternatively, routine closure of the diaphragmatic access with a suture may also reduce the possibility of hernia formation.

Notes on surgical pathology in the dog

A French poodle, fully grown and bred to extreme fineness, was noticed by his owner, a highly trained observer, to “save himself” in play and for this reason was suspected of having heart-disease. Except for these periods of rest. taken at unexpected and unusual times, the animal appeared physically perfect. On January 12, 1915, the dog developed general convulsions which lasted one half hour, at the end of which he died. The autopsy, performed the following morning, revealed the following: “Heart.—Pericardial sac large. Right heart compressed by three lobes of liver, gall bladder, and great omentum, 7 by 15 cm. Liver and omentum congested. Gall bladder empty and connected with liver remaining within the abdomen by elongated adhesive band. Deficiency in pericardium measured 3 cm. in diameter and reinforced by fibrous tissue. Deficiency of equal size in central tendon of diaphragm. No hernial sac found. 2. “Liver.—Portion within pericardial sac shows extreme passive congestion and fibrosis, indicating that the circulatory obstruction caused by its position has been of long duration. Free portion shows moderate fat infiltration. “Edge of Diaphragmatic Opening.—Appears well rounded and is covered by endothelium,—evidently a congenital defect.” Many phrenic hernias in man have been reported to date. Grosser and Thoma, alone, have collected 433 cases. Learning's radiograms of Freeman's case showed ante-mortem practically the entire colon in the chest. It entered the mediastinum in front of the heart curving backward over that organ. The liver was transposed. The hernia was through the right side. Besides the true and the false varieties, there is the analogous condition of eventration of the diaphragm. This is defined, as a dislocation cephalad of the abdominal viscera, particularly of the stomach, on the left side under an abdominally high position of the left vault of the diaphragm.