Entire Posterior Wall Research Articles

Bone Mineral Density Distribution in the Posterior Wall of the Lateral Mass Evaluated by Computed Tomography Osteoabsorptiometry

Abstract Objective Cervical open-door laminoplasty using plates and miniscrews is gaining popularity. One of the complications of this procedure is the loosening or back-out of the miniscrews inserted in the lateral mass (LM). Bone mineral density (BMD) measured by computed tomography (CT) has been used as a predictor of bone strength. However, bone density distribution in the LM remains unclear. Materials and Methods We investigated bone density distribution in the posterior wall of the LM. A total of 120 LMs were analyzed from the patients who underwent laminoplasty. The distribution of BMD defined by Hounsfield unit (HU) in the posterior wall of the LM was measured by CT osteoabsorptiometry. The posterior wall was divided into nine zones, which consisted of three columns (lateral, center, and medial) and three rows (cranial, center, and caudal). BMD in each zone was averaged and compared by zones and cervical levels. Results Overall mean ± standard deviation BMD was 1,092 ± 433 HU. Averaged BMD in the entire posterior wall was highest at C4 (1,365 ± 459 HU), second highest at C3 (1,239 ± 435 HU), and lower in the lower levels. BMD in the medial–center zone (1,357 ± 443 HU) was the highest in all zones. BMD in the medial–caudal region at C7 was only 59% of the highest BMD in the medial–center region at C4. Conclusion The medial–center to the cranial region was most suitable for miniscrew fixation for laminoplasty. These biomechanical findings would be useful in the preoperative planning of laminoplasty especially for the determination of the LM screw entry points and in the design of laminoplasty implants.

Abstract 12943: Long-Term Ablation Outcome in Patients With Coexistent Metabolic Syndrome and Long-Standing Persistent Atrial Fibrillation Undergoing First Catheter Ablation: Results From a Propensity-Matched Population

Introduction: Procedure-outcome after catheter ablation in long-standing persistent atrial fibrillation (LSPAF) is reported to be highly variable with different ablation approaches. Metabolic syndrome (MS), a pro-inflammatory state, is also considered to be closely associated with recurrent AF. Purpose: We evaluated the long-term outcome with different ablation strategies in patients with coexistent MS and LSPAF Methods: Consecutive patients with LSPAF and MS undergoing their first catheter ablation were classified into two groups; group 1: standard ablation: PVAI extended to the entire posterior wall (PW) plus empirical isolation of superior vena cava (SVC) and group 2: standard ablation+ ablation of non-PV (NPV) triggers. Ablation strategy was based on operators’ discretion. In order to attenuate the between-group imbalance of the baseline covariates, a propensity score-matching technique was used resulting in 108 and 432 (1: 4) patients in gr 1 and 2 respectively. Arrhythmia-monitoring was performed quarterly for 1 year and biannually afterwards. Ablation success was assessed off-antiarrhythmic drugs (AAD). Results: All patients received PVAI plus isolation of left atrial PW and SVC (standard ablation). Following the standard ablation, high-dose isoproterenol challenge (25-30 μg/min for 10-15 min) was performed in group 2 (n=432) patients to identify non-PV triggers. These were detected in LAA (294, 68%), CS (315, 73%), inter-atrial septum (125, 29%) and crista terminalis (76, 17.6%). These sites were ablated using additional radiofrequency energy. Isoproterenol challenge to reveal non-PV triggers was not performed in group 1 (n=108) patients. Procedural complications included 3 (2.7%) and 6 (1.4%) groin hematomas in group 1 and 2 respectively (p=0.31). At 6 years of follow-up, the single-procedure off-AAD success rate was 19 (17.6%) in group 1 and 231 (53.4%) in group 2 (p<0.001) Conclusion: In our study patients with LSPAF and metabolic syndrome, standard ablation plus ablation of all detectable non-PV triggers during the first procedure was demonstrated to be significantly more effective in achieving long-term arrhythmia-free survival compared to standard ablation alone.

Initial experience and early outcomes of posterior wall ablation using pulsed-field ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background The success rate of pulmonary vein isolation (PVI) is lower in patients with persistent compared to paroxysmal atrial fibrillation (AF). In patients with persistent AF, additional isolation of the posterior wall is under investigation to improve ablation success. Pulsed field ablation (PFA) might be superior to conventional methods for posterior wall isolation due to its safety profile and might allow for posterior wall ablation (PWA) rather than posterior wall isolation (PWI) based on its efficiency. Purpose To report our initial experience with PWA using a multipolar PFA catheter. Methods Consecutive patients with PWA during their first PFA procedure for AF between May 2021 and October 2022 at our institution were included. For PWA, the multipolar PFA ablation catheter was used in flower configuration only. With the wire in each of the pulmonary veins and the sheath angulated posteriorly, we first performed 2 x 2 sets of anchor lesions with the catheter rotated by ~30° between sets. Next, with the wire retracted back into the device, single sets of two applications were delivered in an overlapping fashion and without catheter rotation between lesion sets to cover the entire posterior wall between the superior and inferior pulmonary veins. Finally, completeness of PWA was verified by 3D electro-anatomical mapping. Results PWA using PFA was performed in 163 patients (mean age 67 years, 71% male). In 55 patients (34%), PWA was added to PVI during the first AF ablation procedure and the remaining 108 patients (66%) had undergone a median of two (interquartile range 1-3) previous AF ablation procedures using either cryoablation and/or radiofrequency ablation. Of all patients, 45 (28%) had paroxysmal, 93 (57%) persistent AF, and 22 patients (15%) left atrial reentry tachycardia. Median procedure duration and fluoroscopy time were 120 (70-190) min, and 18 (9-36) min, respectively. 3D-EAM showed no residual electrical signal (>0.05 mV) on the posterior wall at the end of the procedure in any patient. No cardiac tamponade, stroke, phrenic nerve injuries, atrio-esophageal fistula, or clinically manifest coronary spasm occurred. A repeat ablation was performed in seven patients (4%) and 3D-EAM showed persisting posterior wall isolation in six (86%) and recurrent roof dependent atrial flutter in one patient. Despite PWA, low-voltage signals were found in four (67%) cases on the superior aspect of the posterior wall. Conclusions Left atrial PWA can be performed safely and efficiently using PFA. Early data on the durability of PWA are promising. The impact of PWA on arrhythmia-free outcome needs to be evaluated in larger, prospective randomized trials.

S3659 Primary Gastric Squamous Cell Carcinoma With Concurrent H. pylori Infection and Colonic Metastasis

Introduction: Primary gastric squamous cell carcinoma (PGSCC) is a rare, aggressive, malignancy that cannot be distinguished from other gastric malignancies clinically and therefore, requires EGD with biopsy and pathology. H. pylori infection is a known risk factor for gastric malignancies but, only one case has been reported with an association between the two. Case Description/Methods: 66-year-old Hispanic male, with no significant medical, family, or social history presented to the hospital with syncope. Further history revealed three weeks of melena, fatigue, exertional dyspnea, and 50 lb weight loss. Upon evaluation, the patient was found to have HGB of 3.2. CT abdomen with contrast showed a mass in the antrum of the stomach, most prominent posteriorly and around the greater curvature. EGD revealed normal esophagus and a 15 cm, oozing, fungating, and partially circumferential gastric mass. It was located in the antrum, involving the entire posterior wall with extension into the greater curvature. The gastric mass was 5 cm below the GE junction, without evidence of esophageal involvement. Biopsy of the mass revealed poorly differentiated squamous cell carcinoma and Helicobacter pylori infection. Colonoscopy then revealed a 4 cm lesion near the splenic flexure which was confirmed to also be poorly differentiated squamous cell carcinoma. The patient was placed on triple therapy for his H. pylori infection. PET scan showed known gastric and colonic mass with multiple enlarged and hypermetabolic perigastric and retroperitoneal lymph nodes consistent with metastasis. He was seen by oncology and started on systemic chemotherapy (Figure 1). Discussion: PGSCC is a rare form of gastric malignancy accounting for roughly 0.2% of primary gastric cancer reported. Compared to the more common gastric adenocarcinoma, SCC tends to be more aggressive with poorer outcomes. Unfortunately, the pathogenesis remains obscure, making early detection difficult. Our case was associated with H. pylori infection which is one of the most significant risk factors for the development of gastric cancer due to the chronic inflammation caused by infection. Additionally, metastasis to the colon is exceptionally rare with most cases metastasizing to liver, peritoneum, lung and bone. Further investigation and studies are needed to understand this rare disease.Figure 1.: Primary gastric tumor (left panel), submucosal colonic mass (right panel).

Intraoperative ultrasound assessment of ureteral patency during pelvic surgery.

Ureteral injuries probably represent the most feared complication of benign hysterectomies. Lack of proper intraoperative detection causes diagnostic delay, which results in additional hospitalization, prolonged catheterization, and multiple additional procedures. However, the policy of universal cystoscopy is still under debate, owing to costs, increased operative time, lack of proper training, and risk of trauma. Intraoperative ultrasound assessment can offer a valid alternative for evaluating ureteral patency. After intravenous administration of 300ml of saline solution and 10mg of furosemide, the bladder is filled with 300ml of saline solution. Transabdominal ultrasound bladder scans are obtained with a convex 3.5-MHz probe in transverse planes. The power Doppler field size is set to include the entire posterior wall of the bladder, at the level of the ureterovesical junctions. Ureteral patency test is considered normal if jets are present on both sides. It is considered abnormal when either absent or comparatively diminished on one side. It is considered nondiagnostic when neither side is visualized. Cystoscopy should be performed in the case of abnormal or nondiagnostic sonographic findings. Intraoperative transabdominal power Doppler ultrasound represents a feasible, non-invasive, and inexpensive diagnostic tool for assessing ureteral patency during gynecological surgery.

Determinants of inferolateral basal hypertrophy in patients with Marfan syndrome

Marfan syndrome (MFS) is responsible for cardiovascular disease such as aortic aneurysm and mitral valve prolapse (MVP). A recent study found an enlargement of the inferolateral basal segment (ILBH) in more than 20% of MFS FBN1 patients. The aim of this study is to describe the clinical, electrical and morphological cardiac abnormalities in a cohort of MFS patients carrying FBN1 mutations in connection with the presence of an absolute hypertrophy (AH) (> 11 mm thick) or relative hypertrophy (RH) (Basal/average segment > 1.5). All patients who came for a multidisciplinary consultation at the National Reference Centre for Marfan Syndrome were evaluated prospectively by a clinical examination, a 12-lead electrocardiogram, a standard transthoracic echocardiography and molecular genetic screening. In total, 250 consecutive patients were included from April 2015 to October 2016. AH was found in 54 patients (22.31%) and RH in 30 patients (12%). Patients with AH had more MVP [67.4% of HA + SV 32.62% AH− ( P = 0.001)] as did patients with RH [60% of RH + vs. 35.78% RH− ( P = 0.0111)]. Patients with AH had fewer positive T waves in lower territory and a significant QTc prolongation ( P = 0.0221) compared to patients without AH. Patients with RH had more often abnormal mitral ring kinetics evidenced by a delta of the diastole-systole negative mitral ring ( P = 0.0286) compared to patients without RH. AH and RH are frequent anomalies in MFS. AH being linked to repolarisation disorders as well as a tendency to abnormal kinetics of the mitral ring and RH being linked to abnormal kinetics of the mitral ring. The combination of the two criteria seems to allow the isolation of patients who present with a disease of the entire posterior wall (abnormal kinetics of the mitral ring, bivalvular MVP and ILBH).

SINGLE PROCEDURE SUCCESS RATE OF RADIOFREQUENCY CATHETER ABLATION OF PERSISTENT ATRIAL FIBRILLATION RESULTS FROM A PROSPECTIVE, MULTICENTRE, OBSERVATIONAL REGISTRY

We prospectively evaluated the electrophysiological features and ablation outcomes in a large cohort of Persistent AF patients. All patients (n=1803) underwent pulmonary vein antrum isolation (PVAI) extended to the entire posterior wall (PW). A standardized protocol was performed to elicit any AF

A novel approach for posterior acetabular fractures: Surgical technique.

This article describes a novel approach, the Direct Posterior Approach (DPA) for the treatment of posterior acetabular fractures (posterior column, posterior wall, or both posterior column and wall). This technique allows direct visualization of the entire posterior wall, part of the hip capsule and the posterior column between the space of the gluteus medius and the piriformis superiorly. The approach spares the division of short external rotators, abductors, and hip capsule, thus preventing iatrogenic damage to the medial femoral circumflex artery, sciatic nerve, and superior and inferior gluteal neurovascular bundles, as well as protecting the vascularity of the fracture fragments. In addition to the low blood loss, short operative time and low risk of iatrogenic injury, patients who are treated by the DPA approach exhibit positive functional recovery in follow-up. DPA is an effective, safe and minimally-invasive technique for the treatment of posterior acetabular fractures.

Novel Transabdominal Preperitoneal Hernioplasty Technique for Recurrent Inguinal Hernia: Overlapping of Whole Posterior Wall with Newly Added Mesh and Pre-Existing Mesh by Closing Hernia Defect.

Purpose: In some patients with recurrent inguinal hernias who have undergone previous laparoscopic herniorrhaphy, dissecting the entire posterior wall is difficult due to mesh adhesion. We applied a novel transabdominal preperitoneal (TAPP) hernioplasty technique that involves closing of the hernia defect and implantation of a newly added mesh while preserving the pre-existing mesh for inguinal hernia recurrence after laparoscopic herniorrhaphy. This study was performed to evaluate this novel technique for treatment of recurrent inguinal hernias. Methods: We evaluated 24 adult patients (23 male, 1 female; mean age, 55.8 ± 14.0 years; range, 26-77 years) with recurring inguinal hernias. A modified TAPP (mTAPP) procedure involving closing of the defect and implantation of an 8 × 6-cm2 newly added mesh was performed. The new technique covered the whole posterior wall with pre-existing mesh. Results: Among the 24 patients, there were 12 direct hernias and 12 indirect hernias. The mean postoperative pain scores after 1 week were 2.5 and 2.0 in patients with direct and indirect hernias, respectively, and the mean duration until return to normal activities was 8.5 and 7.5 days in patients with direct and indirect hernias, respectively. The mean follow-up period was 21.0 ± 17.0 (range, 2-56) months. No chronic inguinodynia or rerecurrence was observed. Conclusions: In this novel mTAPP procedure for recurring inguinal hernias, closing sutures prevented mesh migration, and complete posterior wall overlap was possible using the pre-existing mesh and newly added mesh. The mTAPP procedure was an effective operation with few recurrences and complications.

Ablation of Advanced Subtypes of Atrial Fibrillation: Highlighting the Art of When and When Not to Perform Additional Ablation

The purpose of this review is to determine the role of pulmonary vein (PV) triggers in different types of atrial fibrillation (AF) as well as to determine based on prospective randomized data which other approaches may increase the success rate of radiofrequency ablation of persistent AF. Special attention must be paid to detect, diagnose, and optimize management of reversible or treatable causes of persistent AF such as obesity, obstructive sleep apnea, hypertension, hypo- or hyperthyroidism, inflammatory and infectious diseases, and stress. Though the role of PVs is more pronounced in paroxysmal AF than in persistent AF, performing an adequate PV isolation is still a key part in treating persistent AF. There are now numerous techniques to obtain long-lasting pulmonary vein isolation and avoid esophageal damage. Patients with persistent AF will frequently require a more aggressive mapping and ablative approach. Ablation of sites associated with non-PV triggers such as the entire posterior wall, the roof, the anterior part of the left atrial (LA) septum, the left atrial appendage (LAA), the coronary sinus, and the superior vena cava has been shown to improve the freedom from AF at follow-up when combined with PV isolation. We do not encourage the use of empiric lines or complex fractionated atrial electrograms. Several studies have shown the role of empirical LAA electrical isolation in persistent AF. When focal ectopic atrial activity is observed after PV isolation, its activation sequence is compared to that of sinus rhythm, allowing quick identification of its origin. For significant non-PV triggers (repetitive isolated beats, focal atrial tachycardias or beats triggering AF/atrial flutter), a more detailed activation mapping is performed in the area of origin. They are subsequently targeted with focal ablation, except for triggers originating from the superior vena cava (SVC), LAA, or coronary sinus, for which complete isolation of these structures is the ablation strategy of choice. We truly believe the LAA and the posterior LA wall deserve special consideration when managing patients with persistent AF.

What Is the Appropriate Lesion Set for Ablation in Patients with Persistent Atrial Fibrillation?

Special attention must be paid to detect, diagnose, and optimize management of reversible or treatable causes of long-standing persistent atrial fibrillation (LSPAF) such as obesity, obstructive sleep apnea (OSA), hypertension, hypo or hyperthyroidism, inflammatory and infectious diseases, and stress. Though, we strongly believe that the role of the pulmonary veins (PVs) is more pronounced in paroxysmal atrial fibrillation (AF) than in persistent AF, performing an adequate pulmonary vein isolation is still key in LSPAF. Patients with LSPAF will frequently require a more aggressive mapping and ablative approach. We do not encourage the use of empiric lines or complex fractionated atrial electrograms. Ablation of sites associated with non-PV triggers such as the entire posterior wall, the roof, the anterior part of the left atrium septum, left atrial appendage (LAA), the CS and SVC has been shown to improve the freedom from AF at follow-up when combined with PVs isolation. During the isoproterenol challenge, non-PV triggers are detected in most patients with AF. Mapping non-PV triggers is guided by multiple catheters positioned along both the right and left atriums: a 10-pole circular mapping catheter in the left superior PV recording the far-field LAA activity, the ablation catheter in the right superior PV that records the far-field interatrial septum and a 20-pole catheter with electrodes spanning from the SVC to the CS. With this simple catheter setup, when focal ectopic atrial activity is observed (a single ectopic beat is enough) their activation sequence is compared to that of sinus rhythm, allowing to quickly identify their area of origin. For significant non-PV triggers (repetitive isolated beats, focal atrial tachycardias or beats triggering AF/atrial flutter, a more detailed activation mapping is performed in the area of origin. They are subsequently targeted with focal ablation, exception being the triggers originating from the SVC, LAA or CS, in which cases complete isolation of these structures is the ablation strategy of choice. We truly believe the LAA deserves special consideration when managing patients with persistent AF and LSPAF.

Entire posterior wall isolation in an unusual case of common ostium between the right inferior and left inferior pulmonary veins

A 47-year-old male patient was referred for pulmonary vein (PV) isolation. The pre-procedural cardiac computed tomography (CT) scan showed an unusual common ostium between the right inferior and left inferior PVs, on the mid-postero-inferior wall of the left …

Sudden death as presenting symptom caused by cardiac primary multicentric left ventricle rhabdomyoma, in an 11-month-old baby. An immunohistochemical study

This case report describes a sudden cardiac death in an apparent healthy 11-month-old infant caused by a multifocal cardiac rhabdomyoma. Parents reported that a few days before the child had fallen to the ground getting a little superficial injury to the scalp. The authors hypothesize that it may have been a transient loss of consciousness episode caused by the cardiac tumour. After the gross examination, histological investigation supported by immunohistochemical analysis using antibody anti- Myoglobin, Actin, Vimentin, Desmin, CD34, S-100, Ki-67 was carried out for the diagnosis. Death was attributed to a multifocal cardiac rhabdomyoma, a benign tumour of striated muscle, which has been completely asymptomatic. In particular, one mass filled the entire posterior wall of the left ventricle. The insidious development of benign cardiac tumours also in infants and children is outlined, focusing on the responsible mechanisms of sudden death in such cases and providing a reference for additional study on these subjects.Virtual slidesThe virtual slide(s) for this article can be found here:http://www.diagnosticpathology.diagnomx.eu/vs/7163626988365078

Management of acquired tracheoesophageal fistula with various clinical presentations

Purpose To determine the best therapeutic approach for acquired tracheoesophageal fistulae in childhood by evaluation of distinct clinical presentations requiring different surgical management based on our clinical experience. Patients and Methods Seven patients with acquired tracheoesophageal fistula seen between 1999 and 2010 were retrospectively studied with regard to the presenting findings, diagnostic evaluation, therapeutic approach, and outcomes. Results Five girls and two boys with a median age of 36 months (range, 2-156 months) were treated for acquired tracheoesophageal fistula. The presenting symptoms were respiratory difficulty (n = 3), coughing (n = 2), and dysphagia with coughing (n = 2), with a median duration of 30 days (range, 1-730 days). The etiologies were disc battery ingestion (n = 3), placement of endoesophageal prosthesis for caustic esophageal stricture (n = 2), corrosive ingestion with extensive burn (n = 1), and blunt chest trauma with subsequent emergency tracheotomy (n = 1). The site of the fistulae were proximal (n = 3) and middle (n = 1) trachea, left main bronchus (n = 1), and nearly the entire posterior wall of the trachea (n = 2). The patients were variously managed: conservatively with eventual spontaneous closure (n = 1), primary repair (n = 2), and colon interposition after cervical esophagostomy (n = 4) based on the clinical evaluation on admission and the follow-up status. Stenosis of the proximal esophagus (n = 2) and esophagocolonic anastomosis (n = 2) were the only complications encountered after treatment and were successfully managed with dilatation. Conclusions The best therapeutic approach for acquired tracheoesophageal fistula can be determined with careful consideration of relevant parameters on admission, including medical history, presenting findings, etiology, and characteristics of the fistula, in addition to the clinical evaluation in the follow-up period. In general, conservative management should precede definitive surgical intervention both to allow for possible spontaneous closure and also to achieve optimal preoperative status. Primary repair or a staged surgical approach can be best selected by giving priority to the patient's airway security.

Sudden Death After Myocardial Infarction in a High‐School Athlete

This is an unusual case of ischemic heart disease occurring in a young female athlete, aged 14 years, in whom almost the entire posterior wall of the left ventricle was affected. The patient collapsed and died suddenly after a vigorous physical activity while resting at home. The ischemic lesion was apparently owing to right orifice stenosis in association with a small hypoplastic right coronary artery.

Reconstruction of fractures of the posterior acetabular wall

Fractures of the posterior wall of the acetabulum are frequently associated with simultaneous posterior dislocations of the hip and are the most common type of acetabular injury treated today. A wide spectrum of injuries to the posterior acetabular wall can occur from simple nondisplaced fractures of the posterior lip to markedly comminuted, impacted fractures of the entire posterior wall. Most of the fractures of the posterior acetabular wall require open reduction and internal fixation to restore articular congruency, maintain stability of the hip, and provide early mobilization of the patient. A standard posterolateral Kocher-Langenbach approach provides adequate exposure for operative fixation of most posterior wall acetabular fractures. This can be extended by trochanteric osteotomy or triradiate approach, if necessary, to provide fixation of complex posterior wall fractures that involve the posterior or anterior column. This article describes an approach to the operative management of fractures of the posterior acetabular wall when appropriately indicated. Radiographic evaluation, surgical indications, preoperative planning, and surgical technique are discussed.

A CASE OF LARGE NONMALIGNANT GASTRIC ULCER AND A CASE OF LARGE DUODENAL ULCER WITH FATAL HEMORRHAGE

Crohn 1 states that average size of a gastric ulcer is 2-3 centimeters in diameter, although it is not unusual to find an ulcer 4-6 centimeters in width. He describes an ulcer which eroded nearly the entire posterior wall of the stomach so the palm of the hand laid on it covered it with difficulty. Alvarez and MacCarty 2 state from their own data that on the basis of size alone if an ulcer is larger than a dollar, it is almost certainly a cancer. Peabody 3 described a gastric ulcer measuring 19 by 10 cm. Duodenal ulcers, according to Crohn, average 0.5 by 1 cm. in diameter. He describes a duodenal ulcer measuring 8 by 3.5 cm. in diameter which had penetrated through the base of the duodenum in its entire length, exposing the pancreas and causing a fatal erosion of the superior pancreaticoduodenal artery. We report a