Coronary Vein Research Articles

Anatomical Study of Triangle of Brocq and Mouchet in Human Cadaveric Heart

Right and left coronary arteries maintain the nutritional supply of heart. The left coronary artery (LCA) bifurcates into Anterior Interventricular Artery (AIA) and Circumflex Artery (CA). Triangle of Brocq and Mouchet is an arterio-venous triangle formed by AIA and CA of left coronary artery and great cardiac vein (GCV) that lies between conus aretriosus and left auricle. This study aims to determine frequency of Brocq and Mouchet triangle and its anatomical details. This study was conducted in thirty formalin fixed cadaveric hearts collectively available in the Department of Anatomy, Nepal Medical College from November 2019 till April 2020. The incidence of heart showing the triangle was 93.3% with the most common type being closed which is followed by inferiorly opened, superiorly opened, and completely opened. Most frequent content of the triangle was median artery followed by diagonal branches of AIA and CA. the mean area of the triangle was 218.84mm2(527.97 mm2-57.26 mm2). The branches of LCA varied from bifurcation to pentafurcation. Relationship of GCV with AIA and CA was found to be either superficial or deep. The anatomical knowledge of the Brocq and Mouchet triangle regarding arterio-venous relationship will be required for angiographic procedures. Also, the triangle is a potential epicardial access route to mitral valve annulus thus detailed anatomical knowledge of the triangle will help cardiologist to achieve successful cardiological procedures with minimal complications.

Multimodal Ultrasound Model Based on the Left Gastric Vein in B-Viral Cirrhosis: Noninvasive Prediction of Esophageal Varices.

OBJECTIVES:To establish and verify a simple noninvasive model based on the left gastric vein (LGV) to predict the grade of esophageal varices (EV) and high-risk EV (HEV), to facilitate clinical follow-up and timely treatment.METHODS:We enrolled 320 patients with B-viral cirrhosis. All patients underwent endoscopy, laboratory tests, liver and spleen stiffness (SS), and ultrasonography. HEV were analyzed using the χ2 test/t test and logistic regression in the univariate and multivariate analyses, respectively. EV grades were analyzed using the variance/rank-sum test and logistic regression. A prediction model was derived from the multivariate predictors.RESULTS:In the training set, multivariate analysis showed that the independent factors of different EV grades were SS, LGV diameter, and platelet count (PLT). We developed the LGV diameter-SS to PLT ratio index (LSPI) and LGV diameter/PLT models without SS. The area under the receiver operating characteristic curve of the LSPI for diagnosis of small EV, medium EV, large EV, and HEV was 0.897, 0.899, 0.853, and 0.954, respectively, and that of the LGV/PLT was 0.882, 0.890, 0.837, and 0.942, respectively. For the diagnosis of HEV, the negative predictive value was 94.07% when LSPI < 19.8 and the positive predictive value was 91.49% when LSPI > 23.0. The negative predictive value was 95.92% when LGV/PLT < 5.15, and the positive predictive value was 86.27% when LGV/PLT > 7.40. The predicted values showed similar accuracy in the validation set.DISCUSSION:Under appropriate conditions, the LSPI was an accurate method to detect the grade of EV and HEV. Alternatively, the LGV/PLT may also be useful in diagnosing the varices when condition limited.

COVID-19 and its implications on patient selection for TAVI and SAVR: Are we heading into a new era?

COVID-19 and its implications on patient selection for TAVI and SAVR: Are we heading into a new era?

Left coronary cusp ablation to eliminate epicardial substrates – a novel strategy for left ventricular summit ventricular tachycardia ablation

Abstract Background Catheter ablation of LV summit VT can be challenging due to possible subepicardial or intramural site of origin and its close proximity to the major coronary vessels. Objective Local electrograms monitoring inside LV summit communicating vein potentially defines arrhythmogenic substrates and facilitates ablation from the adjacent anatomical structures. Results We experienced two cases of LV summit VT with epicardial local abnormal ventricular activities (Epi-LAVA) recorded from distal bipolar electrode of the 2F microcatheter in communicating vein close to the superior portion of LV summit. During sinus rhythm, Epi-LAVA displayed isolated late fractionated potentials in the first case but had initial fractionated potentials fused with terminal portion of far-field ventricular signals and late isolated potentials exhibiting 2:1 conduction in the second case. Epi-LAVA represented earliest ventricular signals during VT in both cases. Pace mapping at Epi-LAVA sites yielded single QRS morphology with excellent pacemap score and induced VT. Our strategy was to perform ablation at the facing site of Epi-LAVA aiming to eliminate the potentials transmurally. Radiofrequency (RF) energy was applied above and under the left coronary cusp opposite to Epi-LAVA sites using 3.5-mm tip open-irrigation catheter with a power of 30–35 W for 60 seconds under real-time intracardiac echocardiograhic guidance. VT was slowed and terminated in 1 second. Repeat ablation delayed and completely abolished Epi-LAVA followed by noninducibility of VT. Anatomical proximity of the left coronary cusp semilunar insertion and subepicardial or intramural site of origin possibly dictates successful ablation. Epi-LAVA from coronary vein mapping serve as a new landmark of the ablation target with a measurable procedural endpoint. Conclusion Elimination of epicardial substrates with RF energy application at the left coronary cusp can be a novel strategy for LV summit VT ablation. Funding Acknowledgement Type of funding source: None

Classification of portosystemic shunts entering the caudal vena cava at the omental foramen in dogs.

To re-evaluate the anatomy and classification of congenital extrahepatic portosystemic shunts entering the caudal vena cava at the level of the omental foramen. A retrospective review of a consecutive series of dogs undergoing CT angiography as part of the diagnostic work-up for a congenital extrahepatic portosystemic shunt. In total, 53 dogs met the inclusion criteria revealing four anatomically distinct omental foramen shunt types; one of which (32 of 53 dogs) showed no shunting blood flow through the right gastric vein and three of which (21 of 53 dogs) involved shunting flow through this vessel. The anatomy of these four distinct shunt types, as defined by CT angiography, was found to be highly consistent. In all cases, regardless of the tributary vessels, the left gastric vein was the final vessel that communicated with the caudal vena cava. Using these findings, a more accurate naming classification for congenital portosystemic shunts entering the caudal vena cava at the level of the omental foramen was proposed. A precise pre-treatment anatomical classification of congenital extrahepatic portosystemic shunts entering the caudal vena cava at the level of the omental foramen is important for a more complete understanding of the severity of clinical signs and prognosis, and for the better communication between clinicians and researchers in this clinical field.

The Correlation between High Sensitive Troponint Level and SYNTAX Score in Type II Diabetic Patients with Chronic Stable Angina

The point of this work was to assess the job of high-affectability troponin T (hsTnT) as an indicator of seriousness of constant stable angina (CSA) in type II diabetic patients. The examination was completed on 70 diabetic patients with likelihood of coronary vein infection and another 30 patients with ordinary coronary angiography will be incorporated as a benchmark group got ready for coronary angiography and (hsTnT) was estimated in all patients. There was solid factually huge positive connection in the middle of troponin level and (number of ailing vessels rs 0.639, number of sores rs 0.650 and SYNTAX score rs 0.970).The cutoff estimation of hs-cTnT acquired by the ROC bend investigation was 8.6 ng/L for the expectation of higher SYNTAX score. Concerning connection among troponin and various boundaries in cases gathering, there was a measurably noteworthy connection in the middle of troponin and (hypertension, smoking and SYNTAX score), anyway there was factually non huge connection in the middle of troponin and (sex, age and hostile to diabetic medications). In spite of low coursing convergences of hs-cTnT Serum level, it was freely connected with coronary vein malady seriousness. There is a measurably huge connection in the middle of hs-cTnT and (hypertension, smoking and SYNTAX score).

The Relationship between Elevated Plasma Homocysteine Level and Isolated Coronary Artery Ectasia

Coronary conduit ectasia speaks to a type of atherosclerotic coronary course sickness found in 3-8 % of patients going through coronary angiography We meant to utilize homocysteine level for ahead of schedule and simple location of coronary vein ectasia to improve the dreariness and mortality in patients with coronary supply route ectasia Subjects and strategies: patients were partitioned into two gatherings: gathering (1) 50 patients with detached CAE and gathering (2) 50 patients with typical coronary corridors. All subjects were oppressed Echocardiography and CRP and Plasma Homocysteine levels. Results : The echocardiographic proof of LVH was altogether higher in bunch 1 and there was no critical contrast between the two gatherings with respect to LVEDD, LVESD and LVEF the methods for Homocysteine and CRP were fundamentally higher in gathering (1) while no huge distinction between the two gatherings in regards to the serum creatinine level.With significance of huge positive connection between's number of ectatic fragments and Homocysteine level.Conclusion: Our discoveries recommend that hyperhomocysteinemia may assume a significant part in early analysis of coronary vein ectasia.

S2192 Over-the-Scope Clip as Rescue Treatment for Bleeding Gastric Varices

INTRODUCTION: We present a case of gastrointestinal bleeding in a patient with pancreatitis-induced splenic vein thrombus. This case highlights an important etiology of gastric varices, a known complication of treating them, as well as a method for treating refractory bleeding. CASE DESCRIPTION/METHODS: An 18-year-old male with ALL s/p post allogeneic HSCT, chronic pancreatitis, bowel perforations s/p ileostomy presented with gastrointestinal bleeding. The patient had hospitalizations at other institutions with intermittent melena and occasional hematemesis. After multiple upper endoscopies that did not identify the etiology of bleeding, he was referred to our hospital for double balloon enteroscopy. His hemoglobin was down to 5.9 g/dL (baseline 9-10 g/dL). EGD was performed with plan for double balloon enteroscopy, but a large blood clot was seen in the stomach. A nodular area in the fundus was actively bleeding. Given concern for an isolated gastric varix (IGV-1), EUS-guidance was used to inject coils and N-butyl-2-cyanoacrylate into the gastric varices with adequate hemostasis. Follow-up imaging noted extensive portal and splenic vein embolization from the glue. The patient developed recurrent melena and an emergent TIPS placement with coronary vein coil embolization was performed. Recurrent gastrointestinal bleeding was again noted. CT angiography was obtained and revealed a splenic vein thrombus. The patient underwent a balloon-occluded antegrade transvenous obliteration with glue/coil embolization of a smaller vessel feeding the gastric varix. However, GI bleeding was again noted. A repeat endoscopy was subsequently performed with placement of three over the scope clips (OTSC) on the varix for successful hemostasis. DISCUSSION: Gastric varices are often associated with cirrhosis but can occur in patients with non-cirrhotic portal hypertension (i.e., splenic vein thrombosis). Cyanoacrylate glue injection is recommended for acute bleeding from IGV. A known complication of glue injection is the risk of embolization (approximately 1–2%). Endoscopic ultrasound guided coil deployment can act as a scaffold at the time of glue injection to reduce this risk. OTSC have been used successfully in esophageal variceal bleeding. We report the first successful use of OTSC for gastric varices which should be considered as salvage therapy.Figure 1.: Gastric varices with hemostasis after endoscopic ultrasound-guided coil and glue injection.Figure 2.: Portal vein embolization after endoscopic ultrasound-guided coil and N-butyl-2-cyanoacrylate injection.Figure 3.: Recurrent gastric variceal bleeding with hemostasis after successful over the scope clip deployment.

Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias: Outcomes of a Multicenter Experience.

The aim of this study was to assess the long-term efficacy and outcomes of retrograde venous ethanol ablation in treating ventricular arrhythmias (VAs). Retrograde coronary venous ethanol ablation (RCVEA) can be effective for radiofrequency ablation (RFA)-refractory VAs, particularly those arising in the LV summit (LVS). Patients with drug and RFA-refractory VAs were considered for RCVEA after RF failure attempts. Intramural coronary veins (tributaries of the great cardiac, anterior interventricular, lateral cardiac, posterolateral, and middle cardiac) were mapped using an angioplasty wire. Ethanol infusion was delivered in veins with appropriate signals. Of 63 patients (age 63 ± 14 years; 60% men) with VAs (71% extrasystole, 29% ventricular tachycardia, 76% LVS origin), RCVEA was performed in 56 patients who had suitable vein branches. These were defined as those amenable to cannulation and with intramural signals that preceded those mapped in the epicardium or endocardium and had better matching pace maps or entrainment responses. Seven patients had no suitable veins and underwent RFA. In 38 of 56 (68%) patients, the VAs were successfully terminated exclusively with ethanol infusion. In 17 of 56 (30%) patients, successful ablation was achieved using ethanol with adjunctive RFA in the vicinity of the infused vein due to acute recurrence or ethanol-induced change in VA morphology. Overall, isolated or adjuvant RCVEA was successful in 55 of 56 (98%) patients. At 1-year follow-up, 77% of patients were free of recurrent arrhythmias. Procedural complications included 2 venous dissections that led to pericardial effusions. RCVEA offers a significant long-term effective treatment for patients with drug and RF-refractory VAs.

CT angiography identifies collaterals in dogs with splenic vein obstruction and presumed regional splenic vein hypertension

Occlusion of the splenic vein, without occlusion of the portal vein, can lead to a localized, regional splenic hypertension, referred as sinistral or left-sided portal hypertension in the human radiology literature. In people, may cause gastrointestinal hemorrhages from the esophageal and gastric varices and the primary pathology usually includes pancreatitis and pancreatic neoplasms. The final diagnosis of localized splenic hypertension necessitates accompanying normal liver functions and a patent extrahepatic portal vein. Following obstruction, the resultant elevated splenic bed venous pressure causes formation of collateral routes, the extent of which depends upon the level and degree of obstruction. In this retrospective descriptive study, authors assessed the collateral pathways in dogs with isolated splenic vein occlusion and possible regional splenic vein hypertension. Out of the 46 patients initially recruited, 25 were excluded due to the presence of concomitant portal thrombosis and direct/indirect CT signs of portal hypertension. The remaining 21 dogs had clinicopathological tests suggesting normal liver function. The causes of obstruction identified included splenic pedicle torsion, tumoral splenic vein invasion, and splenic vein thrombosis. Four of 21 dogs with isolated splenic vein obstruction showed collateral pathways through the left gastroepiploic vein (4/4), left gastric vein (2/4), and splenogonadal vein (1/4). The diagnosis of isolated, regional splenic hypertension should be based on clinical, biochemical, and radiological evaluation. Computed tomography is an excellent tool to assess the collateral patterns and to determine the underlying cause.

Anatomy of the Atrioventricular Junction, Atrioventricular Grooves, and Accessory Pathways.

Accessory pathways that bypass all or part of the normal atrioventricular conduction system traverse the atrioventricular junction. The atrioventricular junction comprises of a limited septal component and much more extensive right and left parietal components. Its composition forms a plane of insulation between atrial and ventricular myocardium, preventing direct continuity between them. Typical accessory atrioventricular pathways located anywhere along the atrioventricular junction are muscle bundles or may involve muscle around the walls of coronary sinus aneurysms or coronary veins. Increasingly, variants or unusual accessory pathways, some involving an accessory node, are reported in clinical studies.

Quantitative change of perfusion in gastric tube reconstruction by sidestream dark field microscopy (SDF) after esophagectomy, a prospective in-vivo cohort study

BackgroundAnastomotic leakage is one of the most severe complications in patients undergoing esophagectomy with gastric tube reconstruction. Transection of the left gastric and gastro-epiploic artery and vein results in compromised perfusion which is seen as the major contributing factor for anastomotic dehiscence. The main objective of this prospective, observational, in-vivo pilot study is to microscopically evaluate gastric tube perfusion with Sidestream Darkfield Microscopy (SDF). MethodsIntra-operative microscopic images of gastric-microcirculation were obtained with SDF directly after reconstruction in 22 patients. Quantitative perfusion related parameters were: velocity, Microvascular Flow Index(MFI), Total Vessel Density(TVD), Perfusion Vessel Density(PVD), Proportion of Perfused Vessels(PPV) and De Backer Score(DBS). Dedicated software was used to assess parameters predictive for compromised perfusion. ResultsSDF was feasible to accurately visualize and evaluate microcirculation in all patients. Velocity(μm/sec) was significantly decreased towards the fundus (p = 0.001). MFI, PVD and PVD were decreased distal of the watershed – between the right and left gastro-epiploic artery and vein – and in the fundus, compared to the base of the gastric tube(p = 0.0002). No differences in TVD and DBS were observed; because of vessel-dilation in the fundus-area. This suggests that venous congestion results in comprised inflow of oxygen rich blood and plays a role in the development of ischaemia. ConclusionWe present quantitative perfusion imaging with SDF of the gastric tube. Velocity, MFI, TVD and PPV are accurate parameters to observe perfusion decrease. Also, venous congestion is visible in the fundus, suggesting an important role in the development of ischaemia. These parameters could allow early risk stratification, and, potentially, can accomplish a reduction in anastomotic leakage.

Electrode Model and Simulation of His- Bundle Pacing for Cardiac Resynchronization Therapy

Abstract A disturbed synchronization of the ventricular contraction can cause a highly developed systolic heart failure in affected patients with reduction of the left ventricular ejection fraction, which can often be explained by a diseased left bundle branch block (LBBB). If medication remains unresponsive, the concerned patients will be treated with a cardiac resynchronization therapy (CRT) system. The aim of this study was to integrate His-bundle pacing into the Offenburg heart rhythm model in order to visualize the electrical pacing field generated by His-Bundle-Pacing. Modelling and electrical field simulation activities were performed with the software CST (Computer Simulation Technology) from Dessault Systèms. CRT with biventricular pacing is to be achieved by an apical right ventricular electrode and an additional left ventricular electrode, which is floated into the coronary vein sinus. The non-responder rate of the CRT therapy is about one third of the CRT patients. His- Bundle-Pacing represents a physiological alternative to conventional cardiac pacing and cardiac resynchronization. An electrode implanted in the His-bundle emits a stronger electrical pacing field than the electrical pacing field of conventional cardiac pacemakers. The pacing of the Hisbundle was performed by the Medtronic Select Secure 3830 electrode with pacing voltage amplitudes of 3 V, 2 V and 1,5 V in combination with a pacing pulse duration of 1 ms. Compared to conventional pacemaker pacing, His-bundle pacing is capable of bridging LBBB conduction disorders in the left ventricle. The His-bundle pacing electrical field is able to spread via the physiological pathway in the right and left ventricles for CRT with a narrow QRS-complex in the surface ECG.

LIVER TRANSPLANTATION FOR PORTAL VEIN THROMBOSIS: SINGLE CENTER EXPERIENCE

Introduction: Portal vein thrombosis (PVT) is a common complication of liver cirrhosis. The presence of portal thrombosis leads to the progression of portal hypertension and potentially complicate the liver transplantation. The most common classification (Yerdel) is based on the prevalence of thrombosis of the portal system (IV stages). For a long time, severe PVT (III-IV) was considered as a contraindication to liver transplantation due to the complexity of portal revascularisation. However, the current development of vascular surgery suggests a few effective surgical options for these patients. Purpose: Analysis of deceased donor liver transplantation in patients with the presence of PVT. Materials and Methods: The study included the period from January 2016 to February 2020. During this period at the National Medical Research Center of Transplantology and Artificial Organs were performed 241 deceased donor liver transplantation for adult patients. Of these, 25 recipients (10,3%) obtained PVT before transplantation. Fifteen patients had PVT stage I-II, ten patients had severe thrombosis of III and IV stage (six and four respectively). To revascularization of portal flow in the patients with local thrombosis, thrombectomy was performed in 15 cases, in 6 cases (with PVT III stage) an eversion thrombectomy technique was used to remove the thrombus. In four cases (PVT stage IV) were performed various techniques of portal flow bypass. One case was applied by rent portal transposition witch was supplemented by jump-graft between superior mesenteric vein (SMV) and graft’s portal vein (PV). In another case, just a jump-graft technique using donor IVC graft was applied. In two cases, portal supply was carried out from the varicose left gastric vein. When comparing with the control group (n = 216), there were no statistically significant differences in-hospital mortality rates or the length of hospital stay, however, in the group of patients with severe portal vein thrombosis (stages III-IV), early postoperative bleeding was more common. Conclusions: Portal vein thrombosis, including severe thrombosis (Yardel III-IV stages) is not a contraindication for liver transplantation. In a high-volume centers, the presence of PVT is not impact on the results of transplantation.

LIVER TRANSPLANTATION IN THE UNITED ARAB EMIRATES: INITIAL TWO-YEAR EXPERIENCE

Background: Passage of the landmark brain death law in the United Arab Emirates (UAE) in May 2017 enabled the establishment of solid organ transplantation, including liver transplant (LT). The shortage of deceased donor (DD) organs mandated the development of living donor LT (LDLT) as well. We report our initial experience following the formal establishment of LT in the UAE. Materials and Methods: The first DDLT and LDLT in the UAE were performed on Feb 1 and July 29, 2018 respectively.Since inception, a total of 11 DDLTs and 12 LDLTs have been performed – 8 left-lobe and 4 right-lobe LDLTs. Five (22%) recipients were expatriates (four of whom underwent DDLT), while the remainder were UAE nationals. Primary indication for LT was NAFLD (48%). All four (17%) recipients with HCC had cirrhosis from NAFLD. Two recipients (9%) each underwent LT for PSC, Wilson’s disease, HBV and AIH. Two emergent LTs were performed - one for fulminant Wilson’s disease (left lobe LDLT), and the other for early graft dysfunction following LDLT. Mean graft to recipient weight ratio (GRWR) for LDLTs was 0.92 (range: 0.64 – 1.30). GRWR for left and right lobe grafts were 0.83 and 1.1 respectively. All but one of the left lobe recipients underwent splenectomy. All recipients underwent duct to duct biliary reconstruction. Results: All living donors recovered uneventfully with a median duration of hospitalization of 6.5 days (6 and 8 days respectively for left and right lobe donors). Two recipients underwent unplanned re-operation within 30 days of LT. Four (17%) recipients developed acute cellular rejection. All episodes were mild-moderate and responded to either escalation of immunotherapy or pulse steroids, with the exception of one severe episode due to non-compliance. CMV viremia was noted in 11, with invasive disease (retinitis) occurring only in one recipient. Four DDLT and 6 LDLT recipients developed biliary strictures, all of which were anastomotic in nature and responded promptly to endoscopic therapy, with the exception of four post-LDLT strictures that required more than 3 ERCPs. 14 recipients have completed at least a year of follow up, with one-year actual graft and patient survival of 100% and 100% respectively. The overall patient and graft survival for the 22 patients and 23 grafts were 100% and 96% respectively. The solitary graft loss occurred due to portal vein steal syndrome via coronary vein shunt following left lobe LDLT causing graft dysfunction, necessitating emergent DDLT. Conclusions: We report the successful establishment of LT from living and deceased donors in the UAE and our results after the first two years. Ongoing efforts to overcome shortage of deceased donor organs include creation of a national digital donor registry, regional organ sharing agreements for critically ill patients and establishment of donation after circulatory death. These initiatives will enable us to build on our early success and meet the anticipated increase in demand for LT related to the growing burden of NAFLD in the region.

Association of abnormal coronary sinus reflux with coronary slow flow and importance of the Thebesian valve

BackgroundThe relationship between coronary slow flow (CSF) and coronary sinus (CS) reflux has not been previously studied. This study aimed to investigate the relationship between CSF and CS reflux and Thebesian valve presence as well as the relationship between CS reflux and serum annexin-V and ICAM-1 levels. MethodsIn this case–control study, patients were divided into two groups: CSF (n = 13) and control (n = 7) groups. CS flow parameters and Thebesian valve presence were evaluated by cardiac magnetic resonance (CMR). Moreover, serum ICAM-1 and annexin-V levels were measured. ResultsRegurgitation volume and regurgitation fraction, indicators of reflux flow in CS, were higher in the CSF group than in the control group (p = 0.039 and p = 0.019). Fewer Thebesian valves were observed in the CSF group than in the control group (p = 0.022). Furthermore, a positive correlation was found between regurgitation volume and regurgitation fraction and serum annexin-V and ICAM-1 levels (r = 0.813, p < 0.001 and r = 0.996, p < 0.001; r = 0.817, p < 0.001 and r = 0.993, p < 0.001, respectively). ConclusionsThis study revealed the significant relationship between CSF and reflux flow in CS. The fact that the patients in the CSF group have fewer Thebesian valves suggests the importance of the valve in preventing backward flow from the coronary vein. A positive correlation between serum ICAM-1 and annexin-V levels with regurgitation volume and regurgitation fraction indicates that after a certain threshold, CS reflux should be considered an abnormal condition.

Pseudo-loss of left ventricular capture due to interventricular crosstalk.

An 82-year-old man was admitted to our clinic for evaluation of chronic heart failure (CHF) often punctuated by acute exacerbations. The patient had undergone placement of a biventricular implantable cardioverter-defibrillator (ICD) capable of cardiac resynchronization therapy (CRT-D; Unify Quadra 3251-40Q; St. Jude Medical, St Paul, MN) six years ago in a tertiary centre due to nonischemic cardiomyopathy, left bundle branch block (LBBB) QRS pattern of QRS duration 250 ms and drug refractory congestive heart failure with left ventricular ejection fraction (LVEF) of 25%. St. Jude Medical leads had been implanted using an Durata™ 7120Q passive right ventricular (RV) lead in the apex, an Tendril™ 1888 bipolar screw-in lead in the right atrium (RA) and an Quartet™ 1458Q quadripolar LV lead in an anterolateral coronary vein. Follow-up in-person outpatient visits occurred regularly at another hospital. Overall, the non-pacemaker dependent patient had unchanged NYHA functional class III-IV symptomatology and similar LVEF. This article is protected by copyright. All rights reserved.

Obliteration of a Portosystemic Shunt by Hybrid Interventional Radiology Using a Transmesenteric Approach Under Minilaparotomy After Liver Transplantation: A Case Report

Hepatic encephalopathy that occurs long after liver transplantation (LT) is an uncommon condition. Here, we describe the successful case of a 65-year-old patient who underwent interventional radiology (IVR) using a transmesenteric approach under minilaparotomy for hepatic encephalopathy because of a portosystemic shunt 11 years after ABO-incompatible living donor LT with splenectomy. Enhanced computed tomography confirmed a huge portosystemic shunt and left gastric vein (LGV)-esophageal-azygos vein, which was not treated during LT. Liver stiffness measurements based on transient elastography did not show severe fibrosis in the liver graft. Since the hyperammonemia could not be managed with conventional medical treatment, balloon-occluded retrograde transvenous obliteration (BRTO) was indicated. However, it was difficult to perform because the drainage vein could not be approached from the inferior vena cava (IVC). Surgical shunt ligation was also difficult because of the history of multiple laparotomies. Although intraperitoneal adhesion was severe, the portosystemic shunt was successfully embolized with metallic coils and a plug by IVR using a transmesenteric approach under minilaparotomy. No complications occurred during the operation. His symptoms improved after the operation. The ammonia level and portal flow by ultrasound also improved. He was discharged 14 days after surgery without any complications.

Color Doppler Ultrasound in Portal Hypertension: A Closer Look at Left Gastric Vein Hemodynamics.

Portal hypertension is one of the most important causes of morbidity and mortality in cirrhotic patients. A color Doppler evaluation of the left gastric vein (LGV) has proven utility in the prediction of esophageal varices and variceal bleeding in patients with portal hypertension. The purpose of this review is to discuss the ultrasound evaluation, imaging findings, and clinical application of Doppler ultrasound in the assessment of the LGV. Knowledge of the color Doppler technique and imaging findings of the LGV may help clinicians improve the monitoring of portal hypertension and predict patients with a high risk of esophageal varices.

Antithrombin III treatment for portal vein thrombosis after living donor liver transplantation: a case report

BackgroundThere have been no reports on the effectiveness of the administration of antithrombin III (AT III) for post-transplant portal vein thrombosis (PVT). We herein report a case of post-transplant PVT that was resolved by AT III treatment after living donor liver transplantation (LDLT).Case presentationThe patient was a 57-year-old man who had been diagnosed with decompensate liver cirrhosis by hepatitis C virus infection. He presented with repeated hepatic coma and refractory ascites. Computed tomography (CT) revealed PVT of Yerdel classification grade II before LDLT. He underwent ABO-identical LDLT using a right lobe graft. A liver function test revealed elevated liver enzyme levels on post-operative day (POD) 14. The CT examination on POD 15 revealed PVT in the left side of the main portal vein at the side of left gastric vein ligation. AT III treatment from POD 15 to POD 24 was performed. Magnetic resonance imaging revealed that the PVT had decreased 10% on POD 27. Furthermore, AT III treatment from POD 28 to POD 32 was performed. The CT examination demonstrated the disappearance of PVT on POD 69 and thereafter, he had no recurrence of PVT on 10 post-operative month (POM).ConclusionsThe present case suggests that the administration of AT III is safe and suitable for the treatment of post-transplant PVT.