Multidisciplinary Discussion Research Articles

Pancreatic cancer and long survivors: a survey of Italian society of oncological surgery (SICO).

Long-term survivors after pancreatic resection for PDAC are rare, constituting a specific subset of patients that remains poorly understood. The aim of this survey is to describe the current landscape related to survival in the Italian context and identify factors associated with long-term survival. An online survey, conducted by the Italian Society of Oncological Surgery (SICO) and endorsed by Italian Association of the Study of the Pancreas (AISP) and Italian Association of Hepatobiliary Pancreatic Surgery (AICEP), was distributed to surgeons in July 2023. The survey included 27 multiple-choice questions covering demographics, professional details, clinical practices, and long-term survival data. Responses were analyzed using descriptive statistics and multinomial logistic regression to identify factors related to long-term survival. The majority of surgeons (46.9%) considered LTS as "alive at 5years, regardless of disease-free status". The percentage of patients alive at 5years post-2013 was higher compared to pre-2013. Almost all centers (93.2%) held multidisciplinary discussions. Very high-volume centers (> 100 resections/year) in comparison to very low-volume (< 10 resections/year) showed better long-term survival rates. No difference in survival were observed between centers with low, medium, high, and very high volumes. In addition, centers with multidisciplinary approach showed better survival rates. Centers with more neoadjuvant chemotherapy rates, low-grade and low-stage tumors were also associated with improved survival outcomes. This survey has allowed to understand the Italian scenario regarding survival in patients undergoing surgery for PDAC.

Rectal cancer with situs inversus totalis and previous malignant middle cerebral artery infarction: a case report and review of the literature

BackgroundSitus inversus totalis is a rare congenital condition where there is complete inversion of thoracic and abdominal organs. There is limited information on the laparoscopic treatment of rectal cancer in patients with situs inversus totalis accompanied by other underlying conditions.Case presentationWe report the case of a 61-year-old Chinese male with rectal cancer accompanied by situs inversus totalis, malignant middle cerebral artery infarction, stenosis of the right internal carotid artery and anterior cerebral artery, and diabetes who underwent a successful laparoscopic radical resection of rectal cancer. We discuss the diagnosis, treatment, and considerations for patients with situs inversus totalis accompanied by other underlying conditions. We performed relevant inspections, organized multidisciplinary team discussions, and made sufficient perioperative preparations. The patient had no intraoperative complications and was successfully discharged from the hospital. Pathological stage was T3N0M0, and the patient did not develop tumor recurrence or metastasis in the 24-month follow-up period.ConclusionsWe conclude that patients with rectal cancer with situs inversus totalis, even when accompanied by underlying diseases, can undergo surgical treatment with adequate preparation, and surgical treatment is the most effective treatment method.

Hybrid stenting through ventricular access for Severe Stenosis of the Pulmonary Venous Baffle after atrial switch operation for Transposition of the Great Arteries: Case Report

Abstract Background Atrial switch repair was the first surgical intervention to result in long-term survival in patients with ventriculo-arterial discordance or transposition of the great arteries. However, the natural history after atrial switch is not uneventful with frequent atrial arrhythmia, development of baffle stenosis and eventually heart failure. For this, new interventions might be necessary but are often associated with increased risk. Case Presentation We present the case of a 49-year-old woman born with ventriculo-arterial discordance or D-TGA who underwent atrial switch repair according to Mustard at the age of one year. She presented with shortness of breath and reduced exercise capacity. The echocardiography revealed prominent turbulent flow at the level of the pulmonary venous baffle (PVB). This was confirmed on cardiac computed tomography. After multi-disciplinary discussion, a hybrid approach was considered as the preferred strategy. In this, the cardiac surgeon provided apical access by left lateral thoracotomy. The PVB was accessed retrograde through right ventricular apical access and stenting with a covered stent with subsequent balloon dilatation up to 13 mm was performed. This reduced the peak gradient on echocardiography from 18 to 11 mmHg. Clinical follow-up was uneventful with improved functional capacity six months after discharge. Discussion This case provides an alternative access to the pulmonary venous baffle by left lateral mini-thoracotomy and apical ventricular access. Furthermore, we highlight the challenges in decision-making and the importance of the multidisciplinary collaboration between adult congenital cardiologist, the echocardiographer and cardiac surgeon as well as the flexibility in interventional techniques to individualise the management of such cases.

Decreasing Perceived Moral Distress in Pediatrics Residents: A Pilot Study.

Pediatric residents experience ethical dilemmas and moral distress during training. Few studies have identified meaningful methods in reducing moral distress in pediatric trainees. The authors aimed to determine how residents perceive ethics case discussions, whether such a program affects trainee ethics knowledge and perceived moral distress, and if residents' perceived moral distress changes before, during, and after a discussion series. Participants included pediatric residents in a single residency program. Five separate 1-hour sessions were presented over a 5-month period. Each session consisted of a case presentation by a resident developed under the guidance of an ethicist. Multidisciplinary services and content experts were present during sessions. Baseline, postsession, and final surveys were distributed to resident attendees. Open-ended responses were recorded. When comparing baseline and final responses, the only significance was increased preparedness to navigate ethical decisions (p = 0.004). A 10.2% decline was observed in perceived moral distress. An increase in ethics knowledge was observed. Residents favored case-based, multidisciplinary discussions. Residents desire more sessions, time for small-group discussions, and legal insight. Satisfaction was high with 90.7% of respondents feeling better prepared to address ethical concerns. Pediatric trainees desire case-based ethics training that incorporates small-group discussions and insight from multidisciplinary topic experts.

Left-sided portal hypertension: what an interventional radiologist can offer?

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

Broadening indications: A descriptive and comparative in-depth analysis of venovenous extracorporeal membrane oxygenation outcomes in trauma and nontrauma patients.

Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used for medical etiologies of acute respiratory distress syndrome refractory to conventional management. More recently, VV ECMO has been used to stabilize trauma patients with acute lung injury. We hypothesize that patients with traumatic injuries requiring VV ECMO have similar survival outcomes and describe the characteristics between the two populations. This single-center, retrospective cohort study included all trauma and nontrauma patients in an 8-year period who were placed on VV ECMO. Cannulation decisions were made via multidisciplinary discussions between two intensivists and a trauma surgeon. Data were analyzed with descriptive statistics and regression analysis. After testing for normality, significance was defined as a p < 0.05. A total of 516 patients were identified (438 nontrauma and 78 trauma VV ECMO patients). The trauma patient, defined as undergoing cannulation during initial trauma admission, had a median age of 29 years with 81% of patients being male, while the nontrauma patient had a median age of 41 years with 64% being males. Trauma VV ECMO patients had shorter ECMO courses (216 hours vs. 372 hours, p < 0.001), earlier cannulation (8 hours vs. 120 hours, p < 0.001), higher lactic acid levels precannulation (4.2 mmol/L vs. 2.3 mmol/L, p < 0.001), higher Sequential Organ Failure Assessment scores (13 vs. 11, p = 0.001), and higher Simplified Acute Physiology Scores II (63 vs. 48, p < 0.001). There was no difference in bleeding complications. Survival to discharge rates were similar between trauma and nontrauma VV ECMO groups (69% vs. 71%, p = 0.81). This study demonstrates that trauma VV ECMO patients have higher markers of severe illness/injury when compared with their nontrauma VV ECMO counterparts yet have similar survival rates and shorter ECMO runs. Venovenous extracorporeal membrane oxygenation in trauma patients is a useful treatment modality for refractory hypoxemia, respiratory acidosis, and stabilization because of acute lung and thoracic injury. Therapeutic/Care Management; Level IV.

Three-year survival follow-up of patients with gastrointestinal cancer treated during the COVID-19 pandemic in Spain: data from the PANDORA-TTD20 study.

The initial SARS-CoV-2 pandemic wave in Spain in 2020 precipitated significant paradigm shifts in gastrointestinal oncology patient management. This study captures the "Zeitgeist" of this period by analyzing adaptive strategies, treatment modifications, and survival outcomes, leveraging a 3-year follow-up perspective to extract insights from this unprecedented experience. We conducted a multicenter, retrospective cohort study utilizing the RETUD-TTD registry, encompassing 703 patients across 19 Spanish centers in April 2020. We evaluated alterations in clinical practice, therapeutic approaches, coronavirus disease 2019 (COVID-19)-related impacts, and patient survival. A Bayesian hierarchical model was employed to identify potential regional-specific frailties. The peak of the pandemic in April 2020 catalyzed substantial shifts in oncological care delivery. Outpatient consultations decreased by 13%, with a notable selection bias toward cases with more favorable prognostic indicators. Multidisciplinary tumor board discussions were significantly curtailed (eg, mean monthly colorectal cancer cases discussed was reduced from 40 to 23), compromising qualitative care measures. This occurred concurrently with an average of over 3 oncologists per center on medical leave. Contrary to initial concerns, the healthcare system demonstrated remarkable resilience. The majority of patients received standard-of-care therapies with regulatory approval, albeit with regimen modifications in 15% of cases. These adaptations included extended dosing intervals, dose intensity modulations, and transitions to oral formulations while maintaining unexpectedly stable long-term survival outcomes. The Bayesian frailty model detected minimal unmeasured prognostic factors related to geographic location, and the type of pandemic-induced adaptation did not significantly impact survival. The model revealed that coronavirus disease 2019's impact was less pronounced than other core prognostic variables. The decentralized Spanish healthcare system exhibited substantial robustness in managing pre-pandemic diagnosed gastrointestinal malignancies, despite asymmetrical, and occasionally severe organizational disruptions. The insights gleaned from this experience could inform future crisis preparedness strategies and optimize care provision during subsequent public health emergencies.

Initiating Prognostic Talk During Hospice Multidisciplinary Team Meetings: A Conversation Analytic Study.

Objective: Guidelines recommend that patients' prognoses should be discussed by the palliative care multidisciplinary team. However, there is a lack of evidence on how multidisciplinary teams carry out prognostic discussions, and especially how prognostic talk is initiated during team meetings. This study explored how prognostic talk is initiated and responded to during meetings of a hospice multidisciplinary team. Methods: Video-recordings of 24 inpatient multidisciplinary team meetings in a UK hospice were collected from May to December 2021. A total of 65 multidisciplinary team members participated in the meetings. Recordings were transcribed and analysed using Conversation Analysis. Results: Prognostic talk was initiated during multidisciplinary team members' patient case presentations. Case presentations followed a certain template, and prognoses could be initiated as responses to template items such as the patient's Phase of Illness and Karnofsky's Performance Status score and the patient's main diagnosis and issues. Prognoses also occurred as accounts for a lack of template item responses. Beyond the patient case presentation, prognostic talk was initiated in relation to discharge planning. Prognoses appeared with sequences of assessments that accounted for them. When a prognosis was provided, it received confirming minimal responses from other team members. Conclusions: Patients' prognoses were embedded into other care discussions during meetings of a hospice multidisciplinary team. These findings can be used to inform the development of clinical guidelines and interventions aiming at improving multidisciplinary team discussions around prognosis in the future.

EGS SO04 - Gastrodoudenal Artery Pseudoaneurysm Secondary to blunt abdominal trauma: A rare case report

Abstract Background Visceral artery pseudoaneurysms (VAPAs) are rare, potentially life-threatning aneurysms found in the celiac, superior, or inferior mesenteric arteries. They are most common in the splenic artery (60-70%), followed by hepatic arteries (20%) and celiac or mesenteric arteries (10%). Usually asymptomatic, VAPAs are often discovered incidentally during abdominal imaging. They pose a high risk of rupture and haemorrhage. Risk factors include iatrogenic injury and abdominal trauma. Traumatic VAPAs are extremely rare with unclear management guidelines. Treatment options vary from observation to endovascular therapy or surgical repair. This report presents a case of a gastoduodenal artery psuedoaneurysm due to blunt abdominal trauma. Method A case report: a 68-year-old male with a high BMI and atrial fibrillation managed with edoxaban, presented with severe upper abdominal pain following a fall. Initial examination and laboratory results suggested acute pancreatitis or cholecystitis, but a CT angiography revealed a GDA pseudoaneurysm with active extravasation. The patient was referred for urgent therapeutic embolization; however, the pseudoaneurysm had spontaneously thrombosed, precluding the need for embolization. The patient was managed conservatively, with close monitoring in the high dependency unit (HDU), analgesics, proton pump inhibitors, and mechanical venous thromboembolism prophylaxis. He remained hemodynamically stable and was discharged with instructions for follow-up care. Results GDA pseudoaneurysms are rare, accounting for 0.01-1% of all visceral artery aneurysms, with trauma being an exceptionally infrequent cause. The management of VAPAs, particularly in hemodynamically stable patients, can range from conservative observation to endovascular interventions. This case underscores the importance of a multidisciplinary approach involving surgery, interventional radiology, and vascular teams for optimal management. Conclusion Gastroduodenal artery pseudoaneurysms secondary to blunt abdominal trauma can be effectively managed conservatively in stable patients. Comprehensive history-taking, appropriate imaging, and multidisciplinary discussions are crucial for successful outcomes. Continued monitoring is essential to ensure patient safety and address potential complications.

HPB SO73 - Histopathological Patterns in Emergency and Elective Cholecystectomy

Abstract Background Laparoscopic cholecystectomy (LC) is one of the most frequently performed general surgical procedures. In the United Kingdom, gallbladder specimens are routinely submitted for histopathological analysis to detect occult pathologies, such as carcinoma in situ and early-stage carcinomas. This study aims to assess the results of routine histopathological examination of LC specimens. Method A prospectively collected database of all LCs and laparoscopic common bile duct exploration (LCBDE) performed between August 2022 and June 2024 was analysed. The database was populated from a single benign biliary center by two specialized biliary surgeons. Electronic case notes were analysed for the demographics, indication(s), operative findings and the histopathological results. All gallbladder specimens were sent for histopathology analysis, irrespective of their gross appearance. Results Of the 201 eligible patients, 164 patients had histopathology results available. Median age was 56 years (IQR 41-66) and 100 (61%) were female. 72 (43.9%) were emergency cases. 48 (29.3%) had cholecystectomy, 70 (42.7%) also had intraoperative cholangiogram and 46 (28%) had LCBDE. Conclusion Chronic calculus cholecystitis was the most frequent histopathological finding, followed by acute on chronic cholecystitis and gangrenous acute cholecystitis. Dysplasia was identified in 1.8% of patients, warranting multidisciplinary team discussion. This study underscores the significance of routine histopathological examination after cholecystectomy, as early incidental detection of dysplasia and carcinoma can modify postoperative management and improve patient outcomes.

HPB SO02 - Cutting surgical site infection rates in perihilar cholangiocarcinoma with informed changes to perioperative antibiotic prophylaxis: A quality improvement project in a UK hepatopancreatobiliary tertiary centre

Abstract Background Perihilar cholangiocarcinoma (pCCA) is the most common cancer of biliary epithelia. While potentially curative, surgical resection is associated with high morbidity and mortality. Surgical site infections (SSIs) are common and pernicious. Preoperative biliary instrumentation is universal: to confirm histological diagnosis and deploy stents to relieve jaundice. Patients receive multiple antibiotic courses as periprocedural prophylaxis and to treat cholangitis. They are at high risk of harbouring bacteria not quelled by perioperative prophylactic antibiotics given for other general surgical procedures. Studying the biliary microbiome, this quality improvement project sought to reduce SSIs through informed changes to local guidelines on perioperative antibiotic prophylaxis. Method Health records of all patients undergoing resection for pCCA in a UK hepatopancreatobiliary centre from February 2009 to January 2024 were analysed retrospectively (n=118). For all patients, we routinely sent intraoperative bile swabs for culture and sensitivity. Informed by these microbiology results, multidisciplinary discussion led to changes to local guidelines in March 2019. Formerly, cefuroxime and metronidazole were given on anaesthetic induction, with subsequent antibiotic choice and duration according to surgeon preference. New guidance stipulated teicoplanin and piperacillin/tazobactam be given on induction and for 72 hours postoperatively. We studied the impact of these changes on SSIs within 30 days. Results 75 patients received cefuroxime and metronidazole; 43 patients were given teicoplanin and piperacillin/tazobactam after the policy change. Proportions of patients who developed any SSI substantially fell following the guideline change (55% v 28%; p=0.0049), primarily owing to reductions in intraperitoneal collections (39% v 21%; p=0.047). Rates of deep (8% v 2%; p=0.21) and superficial incisional infections (8% v 5%; p=0.49) were not significantly affected. Associated secondary outcomes were drops in post-hepatectomy liver failure (17% v 5%; p=0.047), and 90-day mortality (16% v 5%; p=0.067), albeit the latter was not statistically significant. Conclusion Invasive investigative work-up, disease complications and exposure to multiple courses of antibiotics prior to resection of pCCA subject patients’ biliary systems to colonisation with antimicrobial-resistant bacteria. We urge centres that undertake these operations to introduce intraoperative bile cultures as a part of routine practice to inform local guidance on perioperative antimicrobial prophylaxis. We demonstrated effective antibiotics in the perioperative period can have enormous benefits to patient outcomes.

Abstract 4138268: The Use of Mavacamten for Management of Post TAVR Obstruction: A Novel Approach to Treatment

Background: Treatment of left ventricular outflow tract (LVOT) obstruction involves a combination of negative inotropic agents. However, these therapies have limitations which may result in insufficient control of symptoms, leading to more invasive options such as surgical septal myectomy or septal alcohol ablation. Mavacamten, a cardiac myosin inhibitor, is currently approved for the treatment of patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM). We present a case of a patient treated with mavacamten in addition to β-blockers (BB) for management of post-TAVR LVOT obstruction. Case: A 76 year old female with a past medical history of hypertension, severe aortic stenosis, and coronary artery disease underwent a Medtronic Evolut TAVR in March 2022. Her TTE post TAVR showed LVOT peak gradient greater than 100 mm Hg, LVEF 75% and severe eccentric mitral regurgitation secondary to systolic anterior motion (SAM) of the mitral valve (MV). After multidisciplinary discussion, the patient was discharged on maximally tolerated BB therapy. Follow up TTE showed persistent obstruction and gradients, so diltiazem was added to her regimen. Her subsequent TTE showed a peak LVOT &gt; 100 mmHg at rest, and severe MR. Given persistent findings, she was started on mavacamten, continued on metoprolol, and tapered off of diltiazem. Her TTE two months after initiation of mavacamten revealed resolution of LVOT gradients, reduction of MR to mild and normal LV and TAVR function. She tolerated the therapy well and endorsed ongoing symptomatic improvement on subsequent follow up. Discussion: With the increasing use of TAVR therapy, there has been a corresponding rise in cases of post-TAVR obstruction that must be managed. As demonstrated by this case, management with BB therapy alone may be suboptimal. Although mavacamten is currently approved in patients with HCM, the obstruction in post-TAVR patients is functionally similar. Thus, this medication was trialed as a supplemental treatment in this patient and yielded positive results. This case highlights the potential benefit of extending use of mavacamten alongside β-blocker therapy for this patient population and suggests the need for future studies.

Abstract 4138310: Successful Endovascular Closure of Ascending Aortic Pseudoaneurysm Using Atrial Septal Defect Occluder

Introduction: Ascending aortic pseudoaneurysms are mostly related to either surgery or non-surgical trauma. Any pseudoaneurysm arising from graft anastomoses, regardless of size or location, must be repaired due to the potential for catastrophic rupture. Traditional surgical intervention has a high mortality rate, but percutaneous treatment has emerged as an alternative. We present such a case of pseudoaneurysm treated by percutaneous intervention using a 6-mm Amplatzer device. Case: A 77-year-old female with a history of type A aortic dissection s/p emergent repair with a 32 mm tube graft one year ago presented with chest pain radiating to her back. Initial vital signs showed a BP of 185/105, SaO2 98% on RA, 98.3 F, HR 98 bpm, and RR 24/min. A chest CT scan suggested a pseudoaneurysm at the proximal anastomotic site of the aortic graft (Figs. 1A and B). Serial troponin and EKGs were unremarkable for acute ischemia. Multiple quaternary centers declined intervention due to the high risk of redo sternotomy for open repair and patient frailty. After multidisciplinary discussions, it was felt that percutaneous closure with an Amplatzer device was possible without coronary obstruction. In the catheterization lab, a TEE probe was placed to visualize the pseudoaneurysm of the ascending aorta (Fig. 1C). Angiography showed the aneurysm coming off the posterior aorta just above the noncoronary cusp, with the neck measuring ~6 mm (Fig. 1D). The aneurysm was successfully engaged using an 8-French sheath and an 8-French AL1. Based on measurements from the TEE and the angiogram, a 6 mm ASO device was used. After device deployment and release, aortograms showed that the pseudoaneurysm was excluded (Fig. 1H). Assessment with TEE and CTA showed no residual flow in the pseudoaneurysm (Fig. 1 E–G). Conclusion: Using an atrial septal occluder, endovascular intervention may be a safe and effective alternative to surgery for treating the ascending aortic pseudoaneurysm, especially in patients with a high prohibitive surgical risk. Longitudinal follow-ups are needed to comment on long-term mortality benefits for these individuals.

Abstract 4136566: Primary Pericardial Mesothelioma: Diagnostic dilemma and rapid decline

Description of case: A 33-year-old man with no medical history or environment exposures, presented with dyspnea, nausea, and vomiting. He was tachycardic, with jugular venous distension, pulsus paradoxus, low voltage QRS and echocardiogram (TTE) showed a large pericardial effusion with ventricular interdependence. He underwent pericardiocentesis with negative fluid studies, including cytology. Two months later he represented with dyspnea and pleuritic chest pain, was diagnosed with pericarditis, and found to have recurrent pericardial effusion without tamponade. He was treated with aspirin and colchicine and discharged, with surveillance TTE showing a stable pericardial effusion but with significant adhesions and constrictive physiology (confirmed on right heart catheterization). Negative QuantiFERON was obtained and Anakinra started. Two months later he remained symptomatic with new pleural effusions and was sent for positron emission tomography scan which revealed diffuse intensely hypermetabolic pericardial thickening/fluid, up to 3.8 cm in maximal thickness and increased uptake in mediastinal nodes. Next, a cardiac MRI showed extensive circumferential thickening of the pericardial space approximately 2.5 cm in thickness. Both the visceral and parietal pericardium exhibited extensive scattered delayed hyperenhancement. Subsequent pericardial biopsy showed markedly fibrotic pericardium and pathology showed biphasic malignant pericardial mesothelioma. Immunosuppressive medications were stopped, and he underwent thoracentesis. After multidisciplinary discussions, he was started on nivolumab every two weeks and ipilimumab with a plan for surgery based on response to therapy. However, progressive symptoms and worsening constriction physiology led to palliative consultation and comfort care transition, with him dying shortly after. Discussion: Recurrent pericarditis and pericardial effusion, along with negative typical pericardial fluid studies, raised suspicion for a non-benign etiology. Multimodality imaging was employed and led to a pericardial biopsy. Constrictive pericarditis is an uncommon presentation of primary pericardial mesothelioma. Biphasic mesotheliomas from pleural or peritoneal origins are normally treated with systemic therapy with preference for combined immunotherapy. Primary pericardial mesothelioma is associated with a late presentation and high mortality rate, with surgery, if able to be done early appearing to be the recommended approach.

Abstract 4137919: Electrical Storm Caused by Chagasic Cardiomyopathy Successfully Treated with Ventricular Aneurysmectomy

Introduction: Chronic Chagasic cardiomyopathy (CCC) is a serious complication of Chagas disease that can manifest as LV dysfunction, ventricular aneurysms, and ventricular arrhythmias. Management of the electrical storm in CCC is challenging, especially when it is refractory to catheter ablation. Case Presentation: A 59-year-old woman from southern Peru presented to the ED with palpitations and dyspnea for 1 week. Physical exam was normal. ECG showed Q waves in III and AVF leads. TTE revealed an LVEF of 45% with an inferolateral LV aneurysm. Coronary angiography showed no lesions. CCC was suspected and serology was ordered, which was positive for T. cruzi . Cardiac MRI confirmed the presence of a 32x22mm basal inferolateral LV aneurysm. During hospitalization, she experienced 4 episodes of unstable monomorphic ventricular tachycardia (VT) within 24 hours, requiring defibrillation with 200J, vasopressor support, and invasive mechanical ventilation. The diagnosis of electrical storm secondary to CCC was proposed, for which amiodarone infusion was started until complete impregnation was achieved. Additionally, support was provided with IABP and specific antiparasitic treatment with benznidazole. Electrophysiology determined that the probable focus of the VT was situated at the level of the LV aneurysm. Therefore, ablation with endocardial-epicardial mapping was performed. However, the patient continued to experience recurrent episodes of VT. Consequently, in a multidisciplinary discussion, it was decided to perform a ventricular aneurysmectomy, which was successful. The patient's clinical progress was favorable, with initiation of GDMT and placement of a single-chamber ICD for secondary prevention. After one year of outpatient follow-up, the patient remains free of VT recurrences. Conclusion: Ventricular aneurysmectomy is a successful management approach for patients with CCC who present with electrical storm refractory to antiarrhythmic drugs and catheter ablation, and whose VT is believed to originate from the aneurysm. The diagnosis of CCC is highly arrhythmogenic and should be suspected at an early stage, given the patient's demographics and the presence of LV aneurysm in the absence of coronary artery disease.

Abstract 4138424: Ring of Power: Unraveling a Rare Diagnosis in a Young Male with Palpitations

Case Description: A 36-year-old male presented for an outpatient treadmill ECG stress test for further evaluation of palpitations exacerbated by exercise. He had no ischemic ECG changes, but developed a sustained episode of polymorphic VT at 13 minutes (Figure 1a). The test was stopped and the VT self-terminated after 43 seconds. The patient was admitted for further workup. Lab workup was unremarkable; baseline ECG demonstrated no ST-T wave changes and displayed normal QT and QRS duration. TTE showed mild biventricular dysfunction. Coronary CT angiogram showed type 3 subtype of Vieussens’ arterial ring (VAR), with an absent left main and super-dominant RCA supplying both LAD and LCx. FFR-CT showed non-hemodynamically significant stenosis in the mid-distal LAD (Figure 1b). Left heart catheterization confirmed presence of VAR and mild diffuse disease in a small-caliber mid-distal LAD (Figures 1c&amp;d). No malignant course or dynamic coronary compression was present. Cardiac MRI revealed normal biventricular function and the absence of late gadolinium enhancement. An exercise stress test, now with myocardial perfusion, was performed and was entirely normal without evidence of myocardial ischemia. Genetic testing for catecholaminergic polymorphic VT was negative. After a multidisciplinary discussion, it was decided not to pursue CABG in the absence of demonstrable ischemia at peak exercise. He underwent an ICD placement for secondary prevention and was discharged on beta blockers. Discussion: Three distinct subtypes of VAR have been described, with type 3 being the rarest. The coronary anomaly was first described by Raymond de Vieussens in 1706, and represents an embryologic remnant of the conotruncal circle. It may be diagnosed incidentally in asymptomatic patients or present with angina especially if underlying CAD, aneurysms or fistulae are present. We report the first case of exercise-induced polymorphic VT in a type 3 VAR patient, theorizing that intermittent myocardial ischemia at peak exercise may induce VT in these patients. Surgical revascularization may be considered if myocardial ischemia is demonstrated on stress testing, although its benefit in patients without such evidence of ischemia is unknown.

Abstract 4124120: Rare but Deadly - Eosinophilic Myocarditis in a Patient with Eosinophilic Granulomatosis Polyangiitis

Eosinophilic myocarditis (EM) is a rare inflammatory myocarditis characterized by eosinophilic infiltration of myocardial tissue. Despite the high mortality rate, EM is frequently underdiagnosed and is often first identified in postmortem studies. We share a case of EM as an early manifestation of newly diagnosed eosinophilic granulomatosis polyangiitis (EGPA). The patient is a 46-year-old female with a past medical history of ulcerative colitis and adult-onset asthma who presented to the emergency department with a 2–3-week history of worsening positional chest pain radiating to the left upper extremity. Associated symptoms include 3 months of fatigue, headaches, right foot neuropathy, urticaria, and B-symptoms. Prior to admission, the patient was started on empiric prednisone for presumed EGPA. Initial lab work on admission was notable for elevated troponin (602 ng/L), hyper-eosinophilia (19.5%), thrombocytosis (680K/uL), and elevated ESR (42 mm/h) that have improved since initiation of prednisone. Transthoracic echocardiogram revealed a newly reduced LVEF of 40% with basal and mid-septal wall motion abnormalities. Cardiac catheterization showed normal coronaries confirming the diagnosis of non-ischemic cardiomyopathy. Late gadolinium enhancement in cardiac MRI was seen in basal to mid segments with patchy pericardial enhancement, meeting the Lake Louise criteria for myocarditis. An endomyocardial biopsy showed substantial myocardial infiltration with lymphocytes, histiocytes and eosinophils, confirming the diagnosis of EM. After multidisciplinary team discussion with cardiology and rheumatology, the patient was started on guideline-directed medical therapy for her HFrEF and pulse dose steroids with a prolonged taper and cyclophosphamide. She is tolerating her treatment well. This case highlights the importance of early recognition, comprehensive assessment and targeted treatment for EM depending on its underlying etiology. In the case of autoimmune dysfunction, it involves a combination of immunosuppressive and symptomatic therapy. Ongoing research is crucial to enhance our understanding and improve clinical outcomes, like arrhythmias and cardiogenic shock, for this complex condition.

Abstract 4120140: Catastrophic Bioprosthetic Aortic Valve Thrombosis: An Unappreciated Complication of Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock

Description of Case: A 56-year-old male with a history of cardiac sarcoidosis with biventricular systolic heart failure (HF) and a bioprosthetic aortic valve presented with acute decompensated HF. Progressive cardiogenic shock and hemodynamic instability ensued, requiring urgent bedside placement of an intra-aortic balloon pump (IABP) which provided only marginal hemodynamic support. After extensive multidisciplinary discussion, emergent cannulation for veno-arterial ECMO (VA-ECMO) was performed at the bedside as a bridge-to-decision for advanced HF therapies. The IABP was left in place for LV venting. Within 72 hours, extensive bilateral pulmonary opacities had developed. It was later realized that true LV ejection (as evidenced by aortic pulsatility on the arterial line) was not present and had been masked by pseudo-pulsatility provided by IABP inflations and deflations. Compared to an echocardiogram done 7 days prior to VA-ECMO cannulation, the bioprosthetic leaflets were no longer opening, thrombosis of the AV had occurred, and thrombus formation along the ECMO venous drainage cannula was noted. Failure to achieve LV venting culminated in complete thrombosis of the entire LV and LA and the patient ultimately expired. Discussion: Bioprosthetic valve thrombosis is a lesser-known complication of VA-ECMO support, with most reports involving bioprosthetic valves in the mitral position. Indeed, bioprosthetic valve thrombosis occurs at a higher rate than native valve thrombosis during VA-ECMO support. However, bioprosthetic AV thrombosis is an extremely rare complication of VA-ECMO support and arguably results in a more catastrophic scenario as most traditional approaches to LV unloading are contraindicated. The optimal LV unloading strategy for these patients (IABP, Impella, surgical apical unloading, etc) is unknown. Data from large retrospective analyses have demonstrated extremely poor outcomes when prosthetic valve thrombosis occurs, and it is thus critical to prevent this complication from developing. In contrast to IABP counter-pulsation, the benefit of upfront transvalvular LV venting with an Impella device safeguards the presence of a direct LV vent in the event of bioprosthetic AV thrombosis and eliminates the false reassurance of IABP pseudo-pulsatility. Further studies are needed to better elucidate the optimal LV unloading strategy in patients with bioprosthetic valves, particularly in the aortic position.

Update of prognosis and characteristics of chronic obstructive pulmonary disease in a real-world setting: a 5-year follow-up analysis of a multi-institutional registry

BackgroundWe conducted a prospective observational study to elucidate the long-term prognosis and management of chronic obstructive pulmonary disease (COPD) in clinical practice in Japan in the mid-2010s.MethodsThis prospective cohort study included 29 facilities. Data from 427 patients clinically diagnosed with COPD, enrolled between September 2013 and April 2016, were analyzed. Interstitial pneumonia was excluded through a central multidisciplinary discussion. Follow-up data were collected for up to 5 years after patient registration.ResultsAt the time of registration, 53 patients clinically diagnosed with COPD did not have airflow limitation (AFL). In the cohort with AFL (n = 374), 232 patients completed a 5-year follow-up, while 49 patients died during the 1576.6 person-years of observation. The mean age was 71.7 years with an overall 5-year survival rate of 85.4%. Stratified by % forced expiratory volume in one second (FEV1), survival rates were 93.6% in the mild and moderate AFL group, 82.5% in the severe AFL group, and 66.1% in the very severe AFL group. The prognosis of the subpopulation without AFL was poor with a 5-year survival of 81.6%. This subpopulation exhibited respiratory symptoms, low vital capacity and total lung capacity, and emphysematous changes.ConclusionsOur study presents the 5-year survival and real-world clinical practice scenario of a prospective cohort of patients clinically diagnosed with COPD in Japan in the mid-2010s. The survival rates of our cohort were numerically better than the Japanese cohort in the 1990s, regardless of the high median age of this cohort. Overall, 12.4% of the patients in this cohort with no AFL at registration exhibited respiratory symptoms and distinct spirometric patterns, and had a poor prognosis.

Imaging of peritoneal metastases of ovarian and colorectal cancer: joint recommendations of ESGAR, ESUR, PSOGI, and EANM.

Diagnostic imaging of peritoneal metastases in ovarian and colorectal cancer remains pivotal in selecting the most appropriate treatment and balancing clinical benefit with treatment-related morbidity and mortality. To address the challenges related to diagnostic imaging and detecting and reporting peritoneal metastatic spread, a joint guideline was created by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Society of Urogenital Radiology (ESUR), Peritoneal Surface Oncology Group International (PSOGI), and European Association of Nuclear Medicine (EANM). A targeted literature search was performed and consensus recommendations were proposed using Delphi questionnaires and a five-point Likert scale. A total of three Delphi rounds were performed. Consensus was reached on the position of diagnostic imaging for assessment of operability, treatment response monitoring, and follow-up of peritoneal metastases, optimal imaging modality and their technical imaging requirements depending on the indication and how to optimise communication of imaging results by the report and multidisciplinary board discussion. The complete list of recommendations is provided. These expert consensus statements aim to guide appropriate indications, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients. Question Staging peritoneal metastases (PM) helps toguide clinical decision-making for colorectal and ovarian cancer patients. How can we optimise the use of imaging techniques to assess PM? Findings Imaging plays a crucial role in the detection, operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in colorectal and ovarian cancer patients. Clinical relevance These expert consensus statements aim to guide appropriate indication, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients.