Fossa Ovalis Research Articles

In vivo study of a reserved atrial septal puncture area patent foramen ovale occluder.

After patent foramen ovale interventional closure, puncture of the interatrial septum through the occluder is difficult but sometimes needed for further interventional treatment. This paper presents findings from an in vivo experimental study of a reserved atrial septal puncture area patent foramen ovale occluder. A patent foramen ovale model was established in canines using trans-septal puncture of the fossa ovale and high-pressure balloon dilation. Then, patent foramen ovale closure was performed with a reserved atrial septal puncture area and all canines were raised for 3 months. Then, the occluder was crossed and left atrial angiography was performed on the septal area with the occluder. Finally, DSA angiography, echocardiography, and histology were used to evaluate the performance and feasibility of the reserved atrial septal puncture area. A patent foramen ovale model was successfully established in 10 canines using the atrial septal puncture method. The average diameter of the patent foramen ovale was 3.77 ±0.19 mm, and the patent foramen ovale was successfully closed in all canines using a reserved atrial septal puncture area. As assessed using transoesophageal echocardiography, the new occluder exhibited an ideal position and was occluded entirely without a residual shunt intraoperatively and postoperatively. A 100% success rate of atrial septum puncture was achieved across the new occluder. The occluders were completely endothelialised 3 months post-implantation. The reserved atrial septal puncture area was effective in patent foramen ovale closure and exhibited positive sealing performance and biological compatibility. Trans-septal puncture was feasible and effective after reserved atrial septal puncture area patent foramen ovale closure.

The first discovery of in situ Pelophylax pueyoi (Amphibia: Anura) from the Late Miocene of Libros Konservat-Lagerstätte (Teruel, Spain)

ABSTRACT For the first time, a specimen of Pelophylax pueyoi Navás, 1922a has been recovered in situ, about 600 meters from the main entrance inside the Libros II mine (Teruel, Spain). The fossil comes from the Libros Gypsum Unit (Late Miocene), and represents a nearly complete articulated adult frog exposed in ventral view, with partial preservation of soft tissues. The only apomorphic character diagnosing the family Ranidae is the presence of cylindrical sacral diapophyses. Other characteristics congruent with that of the family Ranidae can be observed: sphenethmoid fused medially, large and oval orbital fossa, well-developed pterygoids without alar expansion and the inner ramus clearly shorter than the posterolateral ramus, transverse processes of presacral vertebrae and sacral diapophyses of subequal length, sacrum unfused with the urostyle, probable bicondylar sacro-urostylar articulation, transverse processes of the urostyle lacking, absence of ribs, and elongated hind limb. An apomorphic combination of features of the genus Pelophylax can also be recognized, such as the more open sacral diapophysis, and less elongated and more robust femora than usually observed in the genus Rana. Finally, some discrete characteristics permit establishing a close relationship with P. pueyoi, such as the large size of the fossil, the wide proportion of the skull, and the somewhat trapezoidal distal contour of the V4 transverse processes. The carpus of P. pueyoi is described here for the first time, suggesting a similar condition of the adult carpal morphology found in most Neobatrachian species. Presence or absence of a praepollex in P. pueyoi still cannot be resolved.

A STUDY OF FOSSA OVALIS : HOW THE MORPHOMETRY AND LOCATION AFFECTS TRANSSEPTAL APPROACH TO LEFT ATRIUM.

Background- Fossa Ovalis (FO) surrounded by limbus are embryological remnants in inter atrial septum of heart. By Trans-septal approach, towards the left heart chambers, floor of FO is punctured to perform various types of diagnostic and therapeutic procedures. Variable position and morphometry of FO remains main challenge. Materials and Methods– 30 heart specimens were procured from properly embalmed cadavers. FO was Inspected in interior of the right atrium. Shapes, diameters, position of FO were determined by Vernier callipers. Probe patency test was performed in cases of Patent Foramen Ovale (PFO). occurrence of PFO is 23.3% (7 out of 30 hearts). The average Result- transverse diameter of FO was 11.68 mm and average vertical diameter was 13.70 mm. Most of the FOs ware oval with longer vertical diameter. In 26 cases (86.6%) limbus is raised and in 4 it is totally flat with the surface of IAS. In 22 hearts, wall of FO were thinner than rest of inter atrial septum (IAS). In one case Chiari strands are found in the floor of FO. Conclusion– Raised limbus of FO prevents slipping of needle while puncturing. Small FO, Chiari strands or multiple cardiac anomalies are unfavourable for TS puncture. To perform Left atrial pressure measurement, and in different cardiac surgeries proper visualization and knowledge of FO is very important.

Surgical and Electrical Anatomy of the Inter-Nodal and Intra-Atrial Conduction System in the Heart.

An anatomical understanding of the atrial myocardium is crucial for surgeons and interventionists who treat atrial arrhythmias. We reviewed the anatomy of the inter-nodal and intra-atrial conduction systems. The anterior inter-nodal route (#1) arises from the sinus node and runs through the ventral wall of the atrial chambers. The major branch of route #1 approaches the atrioventricular node from the anterior aspect. Other branches of route #1 are Bachmann’s bundle and a vestibular branch around the tricuspid valve. The middle inter-nodal route (#2) begins with a broad span of fibers at the sinus venarum and extends to the superior limbus of the oval fossa. The major branch of route #2 joins with the branch of route #1 at the anterior part of the atrioventricular node. The posterior inter-nodal route (#3) is at the terminal crest and gives rise to many branches at the pectinate muscles of the right atrium and then approaches the posterior atrioventricular node after joining with the vestibular branch of route #1. The branches of the left part of Bachmann’s bundle and the branches of the second inter-nodal route form a thin myocardial network at the posterior wall of the left atrium. These anatomical structures could be categorized into major routes and side branches. There are 9 or more anatomical circles in the atrial chambers that could be structural sites for macro re-entry. The implications of normal and abnormal structures of the myocardium for the pathogenesis and treatment of atrial arrhythmias are discussed.

The safety and efficiency of fluoroless site-specific transseptal puncture guided by three-dimensional intracardiac echocardiography.

Although fluoroless transseptal puncture (TSP) guided by intracardiac echocardiography (ICE) has been used for many years, there are no reports of an accurate site-specific method for TSP in detail, especially about the safety and efficiency of the method. This study aimed to compare the efficacy and safety of TSP guided by three-dimensional ICE using a fluoroless site-specific method with that of the conventional fluoroless method in patients with atrial fibrillation (AF). This prospective study included 60 patients with AF scheduled for radiofrequency ablation who were assigned to undergo modified fluoroless site-specific TSP (SS-ICE group, n = 30) or conventional fluoroless TSP (C-ICE group, n = 30). TSP was guided by three-dimensional ICE in both study groups. All fluoroless TSP were performed successfully in both groups. There were no significant differences in patient characteristics, Pre-TSP time (11.3 ± 1.7min vs. 11.1 ± 1.6min, P = 0.822) and TSP time (3.4 ± 0.9min vs. 3.5 ± 1.1min, P = 0.772) between the SS-ICE group and the C-ICE group. The distance between the actual traversing point and the presetting point in the fossa ovalis was less than 5mm in 87% of patients (26/30, 3.1 ± 1.2mm) in the SS-ICE group. There were no TSP-related complications in either group. SS-ICE method is a simple, safe, and effective approach for fluoroless site-specific TSP.

A technique for inserting a large sheath through the fossa ovalis.

A 64-year-old man underwent catheter ablation of paroxysmal atrial fibrillation by using a cryoballoon catheter. A transseptal puncture was performed, and an 8.5-F SL-1 sheath (Abbott Medical, Polymouth, MN) was placed in the left atrium (LA). The 8.5-F sheath was exchanged for a 12-F steerable sheath (FlexCath, Medtronic, Minneapolis, MN) over a 0.032-in superstiff guidewire. Although the inner dilator was easily advanced into the LA, the 12-F sheath would not pass through the septum for several minutes because of the poor transition between the inner dilator and the sheath and the septum having become aneurysmal.

First Dedicated Minimally Invasive Right Atrial Retractor.

The importance of correcting tricuspid valve insufficiency in patients with left-sided valve disease is clear. In the United States, up to 30% of mitral valve operations are minimally invasive, while the data for isolated tricuspid valve is not known. A minimally invasive approach to the tricuspid valve provides faster recovery with lower transfusion rates and lower length of stay. There are no dedicated right atrial (RA) retractors for minimally invasive tricuspid valve (TV) operations. TV exposure is different from mitral given the proximity of the tricuspid anterior annulus to the cut edge of the atrium. An RA retractor should be shallow while preventing slippage of the RA roof and should be quick to deploy and remove. We created a dedicated minimally invasive RA retractor to expose the TV and RA structures (fossa ovalis and coronary sinus). The retractor is a fenestrated shallow and wide retractor with bilateral articulating "wings" to expose left and right of the atrium. This retractor is compatible with the left atrial system by USB Medical Limited (Hatboro, Pennsylvania) and has tilting capability. A three-dimensional (3D)-printed prototype was modified after evaluation by two experienced minimally invasive surgeons (MCS and RKV). Once modifications were finalized, the retractor was then deployed in surgery. The RA retractor was used in isolated TV repairs, RA myxoma resection, RA clot removal, removal of RA migrated stents, select mitral valve operations, and closure of atrial septal defects. The retractor proved effective, safe, and fast to deploy and remove and allowed for full visualization of the tricuspid valve, interatrial septum, ostia of both vena cavas, and coronary sinus. The retractor was useful in mitral valve operations with existing aortic valve prosthesis and in the small left atria. The minimally invasive RA retractor affords excellent, stable exposure of the right atrial structures with fast deployment and removal.

P106 A LEFT GIANT MYXOMA WITH A NOTABLE NEOVASCULARIZATION

Abstract A 73–year–old asymptomatic woman came to our observation to perform a routine echocardiographic examination. The patient suffered from arterial hypertension, dyslipidemia, hypothyroidism, paroxysmal atrial fibrillation. She underwent a bilateral mastectomy for breast cancer about 5 years ago, and she was undergoing chemotherapy and radiation therapy for a stage IV lung adenocarcinoma. The clinical evaluation was normal, as was the electrocardiogram. Transthoracic echocardiographic evaluation showed the presence of a rounded formation with variable echogenicity, with an irregular surface (4 x 3 cm), adherent to the interatrial septum at the level of the fossa ovalis, which did not hinder the excursion of the mitral valve. No other significant cardiac abnormalities were detected. Tansesophageal echocardiography confirmed the presence of atrial mass adhered to the oval fossa (panels A, B). of coarsely rounded shape, and variable echogenicity, in the absence of interference with the movement of the valve leaflets and of anomalies of the interatrial septum (panel C). Coronary angiography showed a right–dominant coronary circulation (panel D) and a mild stenosis of the mid left anterior descending artery. An abundant arterial perfusion of the atrial mass, with several vessels originating from the circumflex artery was also evident at the coronary angiography (panels E, F). The patient underwent cardiac surgery; the surgical exeresis of the left atrial mass was performed through right mini thoracotomy. Because the neo–formation was adherent not only to the atrial septum but also to the left atrial roof, to obtain a radical excision, a large portion of the atrial wall and the septum were removed and totally reconstructed with the pericardium. The main artery supplied the mass related vascular network was ligated. The post–operative course was uneventful, and the patient was discharged at home on day six. The pre–discharge echocardiography showed absence of any residual mass in left atrium that appear anatomically reshaped, no shunt at level of interatrial septum, preserved ventricular function of both ventricles. Histological analysis confirmed the diagnosis of atrial myxoma. At six–month follow–up the patient was asymptomatic and the echocardiography was superimposable to discharge.

P110 ACCIDENTAL FINDING OF COR TRIATRIUM SINISTER IN AN ADULT: DIAGNOSIS MANAGMENT

Abstract A 45–year old woman presented at the emergency department for palpitations and fever. The EKG, thoracic x–ray and troponins were normal, only a neutrophil leucocytosis was found. The echocardiography showed a normal bi–ventricular and valvular function and a mobile, linear, mass in the left atrium. In order to exclude an infective vegetation the patient underwent to a 2D and 3D transesophageal echocardiography (Figure 1 and 2) which showed a left ventricle concentric remodelling (iLVmass 62 g/m2; RWT 0.45), preserved left and right ventricle function (LVEF according to Simpson 70%; FAC 50%) and valves function; inter–atrial septum defects were excluded, too. The mass was described as a mobile membrane in the left atrium at 2.11 cm from the mitral valve anular plane, which divided the atrium into two separate chambers with a large fenestration without trans–mitralic flow obstruction, supporting a cor triatrium sinister. We excluded endocarditis (the blood cultures were negative, too) and supra–valvular mitral ring (since the left appendage position in the antero–inferior side of the left atrium). The cardiac MRI showed (Figure 3) (SSFP–FIESTA, IR–GRE T1, STIR T2) confirmed the finding of a left atrium divided in two chamber by a iso–intense membraine from the coumadin ridge between the left upper pulmonary vein and the left appendage to the inter–atrial septum fossa ovalis, incomplete in the infero–lateral part. Venous drenaige and other congenital abnormalities were excluded. Miocarditis was excluded since no fibrosis in IR–GRE T1 and no edema in Triple T2 sequences. Since the non–obstructive cor triatrium sinister, grading IA according the Lucas classification, was confirmed, no surgical treatment was proposed and the patient was discharged without complications.

18F-FDG PET/CT helps rule out malignancy in lipomatous hypertrophy of the interatrial septum with atypical MRI manifestations, to avoid unnecessary surgical treatment.

Lipomatous hypertrophy of the interatrial septum (LHIS) is a rare benign heart disease characterized by excessive deposition of adipose tissue in the atrial septum with sparing fossa ovalis, which demonstrates a characteristic hourglass/dumbbell configuration. We reported a case of LHIS with inhomogenous characteristic on CMR and persistently no FDG uptake on 18F-FDG PET-CT, which is contrary to a few previous cases. This single case report suggests that in case LHIS present in-homogenous characteristic on CMR, metabolic PET imaging could be used as a complementary imaging model to decrease the concern of lipomatous neoplasms, thereby avoid unnecessary surgical therapy.

Automated MSCT Analysis for Planning Left Atrial Appendage Occlusion Using Artificial Intelligence.

Background The number of multislice computed tomography (MSCT) analyses performed for planning structural heart interventions is rapidly increasing. Further automation is required to save time, increase standardization, and reduce the learning curve. Objective The purpose of this study was to investigate the feasibility of a fully automated artificial intelligence (AI)-based MSCT analysis for planning structural heart interventions, focusing on left atrial appendage occlusion (LAAO) as the selected use case. Methods Different deep learning models were trained, validated, and tested using a cohort of 583 patients for which manually annotated data were available. These models were used independently or in combination to detect the anatomical ostium, the landing zone, the mitral valve annulus, and the fossa ovalis and to segment the left atrium (LA) and left atrial appendage (LAA). The accuracy of the models was evaluated through comparison with the manually annotated data. Results The automated analysis was performed on 25 randomly selected patients of the test cohort. The results were compared to the manually identified landmarks. The predicted segmentation of the LA(A) was similar to the manual segmentation (dice score of 0.94 ± 0.02). The difference between the automatically predicted and manually measured perimeter-based diameter was −0.8 ± 1.3 mm (anatomical ostium), −1.0 ± 1.5 mm (Amulet landing zone), and −0.1 ± 1.3 mm (Watchman FLX landing zone), which is similar to the operator variability on these measurements. Finally, the detected mitral valve annulus and fossa ovalis were close to the manual detection of these landmarks, as shown by the Hausdorff distance (3.9 ± 1.2 mm and 4.8 ± 1.8 mm, respectively). The average runtime of the complete workflow, including data pre- and postprocessing, was 57.5 ± 34.5 seconds. Conclusions A fast and accurate AI-based workflow is proposed to automatically analyze MSCT images for planning LAAO. The approach, which can be easily extended toward other structural heart interventions, may help to handle the rapidly increasing volumes of patients.

FECHAMENTO PERCUTÂNEO VERSUS CIRÚRGICO DA COMUNICAÇÃO ATRIAL DO TIPO OSTIUM SECUNDUM: UMA REVISÃO INTEGRATIVA

Atrial septal defect (ASD) represents about 5% to 10% of all diagnosed congenital heart diseases, it is more common in women, with a prevalence of 1.5 to 3.5 women for each man. Changes in the interatrial septum in the oval fossa are called ostium secundum interatrial communication, which correspond to 75% of all ASD cases. Half of the defects are resolved spontaneously while the other half requires surgical of percutaneous intervention. Although the surgical approach has been used for many years, the development of percutaneous techniques has allowed the transcatheter closure of the ASD ostium secundum with excellent results in short and long terms. However, the wide anatomical variation of ASD can compromise the results of percutaneous treatment. Therefore, an integrative review was carried out in order to compare the surgical and percutaneous closure of ASD ostium secundum pointing out the benefits and complications of both techniques. The results showed that as for effectiveness, safety and mortality, both techniques are equally comparable but the complication rates and reduced hospitalization of percutaneous treatment justifies its indication as the method of choice for the treatment of ASD ostium secundum.

Cardiac myxoma originating from mitral valve leaflet

Primary heart tumors are an extremely rare disease, with a prevalence of 0.0017%0.03% in the population according to various data.
 Heart tumors are benign in most cases, and more than half of such formations are represented by cardiac myxomas. Myxoma is the most common primary cardiac tumor; however, its number is extremely small among the general population. Myxoma that affects the cardiac valves is a rare pathology. For the first time, such variance of changes was described in 1934. Most often, cardiac myxomas are localized at the atrial septum level near the oval fossa. One of the typical signs of myxoma is a narrow leg and an uneven surface, which causes the risk of embolism. Echocardiographic examination and magnetic resonance imaging are currently the methods of choice when suspecting the presence of volumetric heart formation. With such atypical tumor localization, conducting a mandatory differential diagnosis with heart valve vegetations and papillary fibroelastoma is necessary.
 Herein, presented an elderly patient with complaints of shortness of breath, stabbing pains in the left half of the chest, and arrhythmias with a history of aspiration pneumonia and esophageal extirpation with stomach esophagogastroplasty. During the examination, the patient revealed a paroxysmal form of atrial fibrillation (outside of paroxysm), chronic heart failure, and arterial hypertension. The clinical data of the patient were not characteristic enough for the possibility of infectious endocarditis with valvular vegetations. The echocardiographic examination and multispiral computed tomography with bolus contrast enhancement on the atrial surface of the posterior flap of the mitral valve revealed an additional volume formation of 59 mm in size, rounded shape, with clear uneven contours, together with the valve flap into the left ventricular cavity into the atrial systole. The formation was optimally visualized using the Fiesta-CINE mode in modified two- and four-chamber projections. The formation was removed with suture plasty of the mitral valve in artificial blood circulation conditions. The histological examination of the formation revealed a morphological characteristic of myxoma. The postoperative period proceeded without complications.

Computed tomography-based selection of transseptal puncture site for percutaneous left atrial appendage closure.

An inferoposterior transseptal puncture (TSP) is generally recommended for percutaneous left atrial appendage (LAA) closure. However, the LAA is a highly variable anatomical structure. This may have an impact on the preferred TSP site. This study aimed to determine the optimal TSP site for percutaneous LAA closure in different LAA morphologies. In this prospective study, 182 patients undergoing percutaneous LAA closure were included. The spatial relationship of the LAA to the fossa ovalis and its consequence for TSP was assessed at preprocedural cardiac computed tomography (CCT). Based on CCT analysis, it was predicted that coaxial alignment between the delivery sheath and the LAA would be obtained by an inferoposterior, inferocentral, or inferoanterior TSP in 75%, 16% and 8% of cases, respectively. This was also confirmed by procedural LAA angiogram in 175 cases (96%) with <30° angle between the delivery sheath and the LAA central axis. Multivariate logistic regression analysis identified reverse chicken wing LAA (odds ratio [OR] 6.36 [1.85-29.3]; p=0.005) and posterior bending of the proximal LAA (OR 17.2 [3.3-96.2]; p<0.001) as independent predictors of a central or anterior TSP - this to increase the chance of obtaining coaxial alignment between the delivery sheath and the LAA. An inferoposterior TSP is recommended in the majority of percutaneous LAA closure procedures in order to obtain coaxial alignment between the delivery sheath and the LAA. An inferior but more central/anterior TSP should be recommended in case of a reverse chicken wing LAA or posterior bending of the proximal LAA, which occurs in 20-25% of cases.

Syntopy of Pulmonary Vein Orifices in the Left Atrium of the Human Heart

INTRODUCTION: The syntopy of the left atrial (LA) structures is the least studied aspect of the normal heart anatomy. The morphometric data on the position of orifices of the pulmonary veins in the LA walls relative to the adjacent heart structures and heart vessels are important as reference parameters of heart morphology and are needed in the endovascular treatment of atrial fibrillations.&#x0D; AIM: To establish the general patterns and topospecific peculiarities of the location of the pulmonary vein orifices relative to the oval fossa and orifices of the venae cavae using morphometric methods of anatomical preparations of conventionally normal adult human heart.&#x0D; MATERIALS AND METHODS: Fiftyfour wet anatomical preparations of the heart without macroscopic signs of hemodynamically significant cardiac pathology were studied. The preparations were obtained from patients aged 3589 years who died from diseases not related to heart pathology. LA diastole was modeled by filling its cavity with silicone; after it hardened, the distances from the oval fossa and orifices of the venae cavae to the orifices of the pulmonary veins were measured using sliding calipers.&#x0D; RESULTS: The article presents variation, medians, and extreme values of distances from the oval fossa and orifices of the venae cavae to the orifices of the pulmonary veins at the site of their opening to LA. The significance of differences of morphometric parameters of the topography was evaluated, and their correlation and oneway regression analyses were implemented. The strongest regression dependence was found for LA width and distance from the orifice of the superior vena cava to the orifice of the left inferior pulmonary vein (Y) r2 = 0.45; Х = 19.94 + 0.545Y). The heart dimensions and LA length were not significant predictors for the studied parameters.&#x0D; CONCLUSION: The right pulmonary veins were located expectedly closer to the orifices of the venae cavae and the oval fossa than the left pulmonary veins. The narrowest was the space between the orifices of the superior vena cava and the right superior pulmonary vein. The farthest from the orifices of both venae cavae was the orifice of the left inferior pulmonary artery. The strongest correlation relationships were characteristic of the distances from the orifices of both venae cavae to the orifices of the homolateral pulmonary veins, which we propose to consider as one of the criteria of the harmoniousness of the structure of the atrial complex.

Transhepatic device closure of atrial septal defect in children associated with interrupted inferior vena cava.

Percutaneous transcatheter closure of fossa ovalis atrial septal defect (FOASD) is an established procedure. When femoral venous approach is unfeasible due to interrupted inferior vena cava (IVC) or occluded femoral veins, other interventional methods through transjugular, transhepatic approach, or surgical closure can be performed. We report two cases of transhepatic device closure of FOASD associated with IVC interruption successfully performed without any complications.

How to do it? Transcatheter correction of superior sinus venosus defects.

Superior sinus venosus defect is characterized by varying degrees of override of the atrial septum by the superior vena cava and anomalous right upper pulmonary vein (RUPV) drainage. The defect is seen posterosuperior to the oval fossa and is traditionally corrected by a surgical patch that routes the anomalously draining RUPV to the left atrium. A few postoperative patients develop stenosis or occlusion of the caval or pulmonary vein and/or sick sinus syndrome secondary to vascular injury. This has kindled a recent interest in nonsurgical correction of these defects by the use of a covered stent to reroof the defect. The complex anatomy of this defect often necessitates the use of advanced imaging tools and postprocessing. Countries with restricted resources do not have easy access to technologies such as three-dimensional printed models and advanced processing like virtual reality or holography. This “How to do it?” article, applicable in these countries, explains the current understanding of this intervention, patient selection, step-by-step explanation of the evaluation, and stent implantation.

Cardiac Myxomas Resembling Malignant Neoplasia: Incidentally Diagnosed vs. Cerebral Embolized Myxomas.

Simple SummaryCardiac tumors are relatively rare. Cardiac Myxomas (CM) are considered one of the most common benign cardiac tumors. They are usually distinct from soft tissue myxoma, most often occurring as a solitary, sporadic, pedunculated mass in the left atrium, and approximately 10% are associated with Carney syndrome with a high recurrence rate. They may cause sudden death, usually due to mitral valve obstruction or congestive heart failure. Malignant changes are known to occur but are extremely rare. They may mimic malignant neoplasia because of frequent embolism and can cause neurological deficits before theirsurgical removal. The current study analyzed the outcomes after operative myxoma excision in patients with or without cerebral embolic events prior to excision.Background: Cardiac myxomas (CM) are the most common primary cardiac tumors in adults. They are usually benign; however, malignant changes are known to occur but are extremely rare. Embolization is a common complication of cardiac myxomas and can cause neurological deficits before their surgical removal. The current study analyzed the outcomes after operative myxoma excision in patients, with and without cerebral embolic events prior to excision. Methods: All 66 consecutive patients who underwent a surgical excision of CM between 2005 and 2019 at our department were analyzed retrospectively. Patients with (n = 14) and without (n = 52) preoperative strokes caused by cerebral tumor embolization were compared. Results: The mean age was 58.4 ± 12.7 years in the stroke group (SG) and 62.8 ± 11.7 years in the non-stroke group (N-SG) (p = 0.226). Gender (35.7% vs. 61.5% female; p = 0.084) did not differ significantly, and comorbidities were comparable in both groups. The left hemisphere in the territory of the middle cerebral artery was affected by preoperative cerebral infarction most commonly (28.6%). The time from diagnosis to cardiac surgery procedure was 7 (3–24) days in the SG and 23 (5–55) days in the N-SG (p = 0.120). Cardiac myxomas were localized in the left atrium in both groups more frequently (SG: 92.9% vs. N-SG: 78.8%; p = 0.436). In the SG, 57.1% of CM had a non-solid surface, were localized in the left heart, and had a pedunculated attachment away from the fossa ovalis. In the N-SG, 92.3% of CM did not meet all these criteria (p < 0.001). The maximal diameters of CM were comparable (SG: 3.4 ± 1.5 cm vs. N-SG: 3.8 ± 2.1 cm; p = 0.538). The operation times (192.5 (139.3–244.5) min vs. 215.5 (184.5–273.3) min; p = 0.046) and the cross-clamp times (54.5 (33.3–86.5) min vs. 78.5 (55–106.8) min; p = 0.035) were significantly shorter in the SG. Only in the N-SG were reconstructions of the endocardium with bovine pericardium required after resection (51.9% vs 0%; p < 0.001). In the N-SG, CM were explored via the right atrium more often (57.7% vs. 14.3%; p = 0.007). Patients in the N-SG required significantly shorter ICU care after surgery (p = 0.020). Other postoperative courses did not differ significantly. After tumor removal, 1.9% of the N-SG suffered their first stroke and 14.3% of the SG had a cerebral re-infarction (p = 0.111). The 30-day mortality rates were 1.9% in the N-SG and 7.1% in the SG (p = 0.382). In one case in the N-SG, a tumor recurrence was diagnosed. The Kaplan–Meiercurves showed a significantly better long-term prognosis for patients in the N-SG (p = 0.043). Conclusions: After the surgical removal of CM, the outcome is compromised if preoperative cerebral embolization occurs. Surgical treatment is therefore indicated as soon as possible, especially when CM have a non-solid surface, are localized in the left heart, and have a pedunculated attachment away from the fossa ovalis.

Morphometric topography of the left atrial appendage in human adult heart

Topography of the left atrial appendage is of importance for supraventricular arrhythmias surgery and sealing of the appendage orifice to prevent thromboembolism in cryptogenic strokes. The aim was to explore the common position of the appendage and delineate variants of its adjacent anatomy in human adults by means cadaveric morphometrics. Material and methods . We studied 54 silicone-filled heart specimens of 200–400 g. With the caliper, we measured the distances from the base of the left atrial appendage to the cardiac apex, to the structures of the atrial complex, nearest large blood vessels, as well as to the left coronary artery. Results. The base of the appendage was 87 ± 13.1 mm from the cardiac apex and 49.7 ± 7.0 mm from the right appendage. The distance from the appendage to the superior caval vein (36.4 ± 8.1 mm) was 16 % longer than the distance to the ascending aorta (30.4 ± 6.4 mm), 1.25 times less than the distance to the oval fossa (45.2 ± 6.0 mm), 1.5 times less than the distance to the inferior caval vein (55.5 ± 8.7). The smallest median value (9.6 mm) and the largest variation (1.4–15.2 mm) were found for the distance to the pulmonary trunk. Four pulmonary veins inflowed to the atrium at different distances from the appendage opening. In 59.6 %, we revealed the left upper pulmonary vein to be closest to the auricle. The mouth of that was 43 % higher and 57 % at the same level with the appendage opening ( p = 0.07). The left coronary artery ran 2.63–18.74 mm inferiorly to the appendage. Interrelations of average strength were found for the parameters of atrial complex. The study showed the length of the ventricular complex as being an unpredictable parameter for determining the adjacent anatomy of left atrial appendage. Conclusions. The morphometric parameters and their interrelations are proposed to use as reference values and criteria for determining the normal atrial complex.

Cardiac masses and contrast echocardiography

Abstract Funding Acknowledgements Type of funding sources: None. Introduction echocardiography may be the first imaging modality detecting a cardiac mass. Although echocardiography cannot give the histopathology, certain imaging features and adjunctive tools such as contrast echocardiography may aid in the differential diagnosis. Methods: we describe five cardiac masses in which echo-contrast helped to assess the presence or not of vascularization. Panel A shows a left atrial mass attached to the fossa ovalis with a large stalk prolapsing to the mitral inflow. Contrast echocardiography showed late but homogeneous opacification of the mass. Gross pathology confirmed an atrial mixoma. Panel B shows two masses in a patient with non-small cell lung cancer one embedded in the inferior left ventricular wall and the other floating in the left atrium. Administration of echo-contrast showed late and inhomogeneous enhancement of the myocardial mass and absent opacification of the atrial mass suggesting a metastatic infiltration of the myocardium together with an avascular neoplastic thrombus in the left atrium. Panel C shows a multi-lobulated and mobile mass in the right atrium straddling the tricuspid valve. Contrast echocardiography highlighted an inhomogeneous diffusion of the contrast within the mass with a rapid opacification only of its atrial portion. Gross pathology confirmed a recurrent thymoma. Panel D shows an intraventricular mass arising from the interventricular septum with multiple hypoechoic areas in a patient with metastatic carcinoid. Contrast administration showed a very late and mild degree of inhomogeneous enhancement. Conclusion: the echo-contrast allows a good differentiation between vascularized and non-vascularized cardiac masses, providing an important indication to differentiate thrombus from tumor. In those hypervascularized masses the homogeneous or inhomogeneous distribution of the contrast could be an interesting clue that orientates between primary or secondary cardiac tumors. Abstract Figure.