Posterior Septum Research Articles

Sinonasal Hamartoma and Chronic Laryngeal Edema Causing Severe Dyspnea.

Sinonasal hamartomas, according to the 5th edition of the World Health Organisation classification of head and neck tumours are divided into respiratory epithelial adenomatoid hamartoma (REAH), seromucinous hamartoma and chondromesenchymal hamartoma. Seromucinous hamartoma are benign proliferations of small eosinophilic glands surrounded by fibrous stroma and cuboidal cells. Hamartomas of the nasal cavity and paranasal sinuses are rare entities, clinically presenting as sinonasal polyposis. A 79- year-old female patient was referred to our emergency room due to severe dyspnea. Anterior rhinoscopy revealed unilateral greyish polypoid mass obstructing the middle, inferior and common nasal meatus. Systemic corticosteroids and oxygen therapy were administered under observation. Computerized tomographic imaging of the paranasal sinuses with contrast on all three planes showed an opacified polypoid mass in all meatus and the maxillary, anterior ethmoidal and sphenoidal sinus posteriorly extending to the choanae. On the coronal plane a widening of the olfactory clefts about 12mm was described. FESS visualized that the polypoid mass originated from the posterior septum and extended to all meatus anteriorly and to the choanae posteriorly. The polypoid lesion was endoscopically completely excised. Histopathological analysis revealed a seromucinous hamartoma. Seromucinous hamartoma are rare benign tumors of the sinonasal region with potential of malignant alteration. Unfortunately, they share symptoms and clinical appearance with other benign conditions of the sinonasal region. Therefore, it is even more important to consider them as a differential diagnose.

The precise midline myelotomy through anatomical posterior median septum by dissecting dorsal column in microsurgical resection of ependymoma (2-dimensional operative video).

Although resection is the gold standard treatment for spinal ependymoma, permanent neurological deterioration has been reported postoperatively in 20%-27% of patients. Despite thorough dissection of the tumor from its surroundings, conventional longitudinally directed midline myelotomy can lead to injury to the dorsal column, possibly due to deformation of the posterior median septum as the tumor grows. To address this issue, the authors have been performing precise midline myelotomy through the anatomical posterior median septum by directly dissecting the dorsal column. This video presents the principles and application of this technique.

Complete Resolution of Fungal Ball Sinusitis with Medical Management Only: Case Series with Literature Review

Abstract Fungal ball (FB) is non-invasive type of fungal sinusitis. It might present with facial pain or pressure, nasal obstruction, secretions, or decreased sense of smell, depending on the size and location of the sinus that is involved. In this series, we aim to share our experience in treating cases of FB with medical treatment only. Medical records data collected from three different centers for four patients diagnosed with FB were discussed in this case series. Four cases, with two males and two females, were reported in this series. Patient ages ranged from 19 to 51 years old. The most common complaint was nasal obstruction and nasal discharge. Computed tomography (CT) showed a heterogenous mass in the maxillary sinus for three cases with one of them involved the concha bullosa. Also, in one case the mass involved sphenoid sinus with expansion over the posterior sphenoidal septum. Two patients received intranasal steroids, one received additional oral steroids, and one received only intranasal decongestant drops. Within one to six months, all patients reported the complete resolution of their symptoms. Repeated CT showed the complete resolution of the FB in all four cases. Surgical resection of FB remains the mainstay of management. However, trials using medical treatment can be used to waive the surgical option in some cases where there is no urgent indication for surgical intervention.

Optimizing fibrosis detection: a comparison of electroanatomical mapping and late enhancement gadolinium magnetic resonance imaging.

Fibrotic atrial cardiomyopathy plays an important role in determining the outcome of ablation in patients with atrial fibrillation (AF). Two main methods are being used for the evaluation of fibrosis: voltage-based high-density (HD) electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI). The comparability between both methods in detecting fibrosis has not been systematically investigated. LGE-MRIs of the left atrium (LA) were performed in 21 patients. LA-fibrosis was evaluated using a custom-designed software generating a 3D-model of the LA. HD-electroanatomical maps were recorded in each patient. After processing the maps and the MRI models by excluding the mitral valve, pulmonary veins, and the left atrial appendage, the LGE areas were measured and compared to the low voltage areas (LVA) in the HD maps using three different cutoff values of 0.5 mV, 0.7 mV, and 1.0 mV. The analysis revealed significant differences between EAM and LGE-MRI in assessing LA-fibrosis at 0.5-mV (for anterior and posterior walls) and 1.0-mV cutoffs (for anterior and posterior wall and septum). However, no significant differences were found between EAM and LGE-MRI when using a 0.7-mV cutoff for all the investigated areas. A voltage cutoff of 0.7 mV provided the best correlation between EAM and LGE MRI for detecting left atrial fibrosis. It supports the idea that a 0.5-mV cutoff may underestimate fibrosis, as areas with local signal voltages between 0.6 and 0.8 mV could also show LGE on MRI. Further research is needed to determine the ideal voltage cutoff for detecting left atrial fibrosis.

Immunohistochemical characteristics of the gray matter of the human spinal cord in the late prenatal period

The study is dedicated to the relevant problem of studying the patterns of age-related (prenatal) restructuring in the brain and spinal cord and provides opportunities for predicting and correcting the occurrence of congenital defects. The aim of the research was to establish the nature of immunohistochemical marker expression in the gray matter structures of the human spinal cord during the late prenatal period. The material for the study consisted of spinal cord preparations from 27 human fetuses at gestational age 35-40 weeks. The following methods were used during the research: anatomical, general histological, special histological, immunohistochemical, morphometric, and statistical analysis of the obtained data. It was found that at 35-36 weeks of the gestational period, the proliferation of neural stem cells (NSCs) occurs more intensively in the ventral neuroepithelium of spinal cord segments compared to the dorsal neuroepithelium. In the ventral neuroepithelium, there are 5-6 mitotic or post-mitotic NSCs, while in the dorsal part, there are only 2-3 cells. In fetuses at 39-40 weeks, the proliferative activity of neural stem cells in the dorsal neuroepithelium is higher in cervical and lumbar segments, where Ki-67 expression is detected in 6 % of cells (reactive in 7-8 cells), and in thoracic and sacral segments, it is 4 % (reactive in 3-4 cells). In contrast to the dorsal neuroepithelium, in the ventral part of the neuroepithelium of the segments, the proliferative activity of neural stem cells is slightly less intense. In cervical and lumbar segments, Ki-67 expression occurred in 4 % of cells (reactive in 3-4 cells), and in thoracic and sacral segments, it was 2 % (reactive in 1-2 cells). At 35-36 weeks of gestation, high vimentin expression was observed around the neuroepithelium, at the base of the posterior horns, and along the posterior median septum. Vimentin expression in the mantle layer was relatively weak and persisted along blood vessels and in the area of spinal cord root formation. Before birth, relatively weak vimentin expression was detected in the remnants of radial glia surrounding the neuroepithelial layer. Vimentin expression was absent in the neuroepithelium proper, but focal vimentin expression was observed around blood vessels. The absence of vimentin expression in the neuroepithelium indicates the disappearance of radial cells. At 35-40 weeks of the gestational period, relatively strong synaptophysin expression was observed in the mantle layer of spinal cord segments, indicating the intensity of neuronal connectivity establishment and myelination of nerve fibers. These processes continue after birth. Synaptophysin expression was absent in the neuroepithelium proper.

Evaluation of a New Method of Sciatic Nerve Block: A Prospective Pilot Study.

The location of the sciatic nerve deep within the thigh tissue makes it challenging to locate while the patient is in a supine position. The posterior intermuscular septum of the thigh, which encircles the posterior surface of the adductor magnus muscle (AMM), is where the sciatic nerve is located. Our hypothesis was that administering local anesthetic injections into this area could block the sciatic nerve. Therefore, our aim was to evaluate the effectiveness of sciatic nerve block achieved by injecting local anesthetic into the posterior intermuscular septum of the thigh, named the AMM approach. Twenty-six patients undergoing total knee arthroplasty were included in the study. We performed an ultrasound-guided sciatic nerve block by injecting 20 mL of 0.25% ropivacaine into the posterior surface of the adductor magnus muscle, using the AMM approach. Additionally, we administered a femoral nerve block with 20 mL of 0.4% ropivacaine. We assessed the sensory and motor effects of the blockade in the operated lower limb and recorded postoperative pain scores at 0, 4, 8, 12, 24, and 48 hours after the operation. The AMM approach successfully block the sciatic nerve in all 26 patients. The onset of the sensory and motor blockades was achieved within 5.4 ± 1.9 min and 8.7 ± 3.5 min, respectively. We achieved a satisfactory position with the first puncture in 19 of 26 patients (73.1%). The muscle strength of the tibialis anterior immediately after surgery was 4 (ranging from 2 to 5). Additional rescue analgesics were required in 5 of the 26 patients (19.2%) during the first 24 hours postoperatively. The AMM approach is an innovative and effective method for sciatic nerve block. When combined with simultaneous femoral nerve block in patients undergoing total knee arthroplasty, it provides a useful analgesic treatment option.

Optimal method for ablation of atypical AVNRT

BackgroundConsidering that ablation of atypical AVNRT may be unsuccessful after ablation at the right posterior septum, in this study, we aimed to present an optimal method for ablation of atypical AVNRT. Also, we evaluated the efficacy of this technique for preventing recurrences.MethodsThis is a prospective, double-center study. It was conducted on 62 patients with atypical AVNRT referred for radiofrequency ablation. The patients were randomly divided into two groups before ablation: 1-Group A (n = 30): treated with conventional ablation at the anatomic area of the slow pathway; 2-Group B (n = 32): ablation was done 2 mm higher in the septum during fluoroscopy.ResultsThe mean age of patients in groups A and B were 54 ± 11.7 and 55 ± 12.2, respectively (P = 0.43). In group A, ablation was successful in 24 (80%) patients following right-sided slow pathway ablation, and the remaining patients required further treatment with either a left-side approach (N = 4, 13.3%) or ablation of additional regions (N = 2, 6.7%). In group B, ablation was successful in all patients. After a 48-month follow-up, recurrence of symptomatic atypical AVNRT was detected in 4 (13.3%) patients of group A and none of group B patients (p < 0.001).ConclusionIn patients with atypical AVNRT, ablation 2 mm above the conventional area is more promising regarding success rate and recurrence of the arrhythmia.

The role of contractile dyssynchrony in pacing-induced cardiomyopathy: detailed assessment using index of contractile asymmetry

AimsThe pathophysiological effects of chronic right ventricular pacing and the role of right ventricular lead position are not well understood. Therefore, we investigated the association between left ventricular contractile dyssynchrony and pacing-induced cardiomyopathy (PICM) in patients with chronic right ventricular pacing. Furthermore, we assessed the association between right ventricular lead location and left ventricular contractile dyssynchrony.MethodsThis was a retrospective study using data from 153 pacemaker patients with normal (≥ 50%) pre-implant left ventricular ejection fraction (LVEF). Baseline and follow-up echocardiograms were analyzed, and PICM was defined as LVEF < 50% with ≥ 10% decrease in LVEF after pacemaker implantation. Relative index of contractile asymmetry (rICA), a novel strain rate-based method, was calculated to quantify left ventricular contractile dyssynchrony between opposing walls in the three apical views. Right ventricular lead position was categorized into anterior septum, posterior septum, free wall, and apex based on contrast-enhanced cardiac computed tomography.ResultsForty-seven (31%) developed PICM. Overall contractile dyssynchrony, measured by mean rICA, was higher in the PICM group compared with the non-PICM group (1.19 ± 0.21 vs. 1.03 ± 0.19, p < 0.001). Left ventricular anterior-inferior dyssynchrony, assessed in the apical two-chamber view, was independently associated with PICM (p < 0.001). Thirty-seven (24%) leads were implanted anterior septal, 11 (7.2%) posterior septal, 74 (48.4%) apical, and 31 (20.3%) free wall. Left ventricular anterior-inferior dyssynchrony was significantly different between the four pacing lead locations (p < 0.01) with the highest rICA observed in the posterior septal group (1.30 ± 0.37).ConclusionsPICM is significantly associated increased contractile dyssynchrony assessed by rICA. This study suggests that especially left ventricular dyssynchrony in the anterior-inferior direction is associated with PICM, and pacing the right ventricular posterior septum resulted in the highest degree of anterior-inferior dyssynchrony. Quantification of left ventricular dyssynchrony by rICA provides important insights to the potential pathophysiology of PICM and the impact of right ventricular lead position.Graphical

Rhinoethmoidal mixt cavernous-capillary hemangioma – endoscopic transnasal resection. Case report

Hemangiomas are benign vascular tumors which originate in the skin, mucosae and deep structures such as bones, muscles or glands. Hemangiomas have capillary, cavernous, mixed, and hypertrophic subtypes. These neoplasms rarely arise in the nasal cavity, and when they appear here, they are predominantly capillary and are found attached to the nasal septum. Cavernous hemangiomas, on the other hand, are more likely to be found on the lateral wall of the nasal cavity. This article presents a case of a mixt cavernous-capillary hemangioma, arising from the mucosa of the posterior and superior nasal septum, in a 62-year-old female, successfully treated by the transnasal endoscopic excision technique.

Morphometric Characteristics of the Glands of the Mucous Membrane of All the Walls of the Human Frontal Sinus in a Norme

The purpose of the work was to study the microscopic structure of the mucous membrane of all the walls of the frontal sinus of a person in order to obtain morphometric data on its structural components – glands and the submucosal base. Materials and methods. The material for the study was the mucous membrane of the frontal sinus of 110 people who died at the age of 22–86 years from causes not related to the pathology of the paranasal sinuses. Results and discussion. The results of the study showed that the glands in the mucous membranes of all the walls of the frontal sinus are alveolar-tubular in structure. In a morphometric study of such a structural component of the mucous membrane of all the walls of the frontal sinus, as the thickness of the submucosal base, it was shown that the thickest submucosal base is located on the inferior wall (on the left – 423.67 ± 21.33 μm; on the right – 426.45 ± 16.77 μm (p&lt;0.05)) and is four times higher than the average values of thickness on the posterior wall and septum. The outer diameter of the end sections of the glands of septum of the human frontal sinus in a morphometric study averaged 25.42 ± 1.68 μm on the left and 25.89 ± 1.38 μm on the right (p&lt;0.05), that is, the smallest compared to other walls. The values of the average diameter of the end sections of the glands of the mucous membranes of the anterior, inferior, and posterior walls of the frontal sinus probably did not differ between themselves. Conclusion. From the obtained data, it can be clearly seen that the mucous membrane of the inferior wall of the frontal sinus has the greatest functional load, since it has a connection with the nasal cavity in the middle nasal passage. The information obtained in the course of the study significantly expands knowledge about the structure of the human frontal sinus. Digital morphometric (metric) material with statistical processing confirms and complements the differences in the microstructure of the glands of the mucous membrane of the human frontal sinus in general, and separately on each wall, and in comparison with other paranasal sinuses. This is of great importance for modern otorhinolaryngology, since the glands of the mucous membranes of the paranasal sinuses are links of the mucociliary system, and such a process as mucociliary clearance depends on their quality work.

Outcome Analysis of External Neurolysis in Posture-Induced Compressive Peroneal Neuropathy and the Utility of Magnetic Resonance Imaging in the Treatment Process.

We aimed to analyze the effectiveness of external neurolysis on the common peroneal nerve (CPN) in patients with posture-induced compressive peroneal neuropathy (PICPNe). Further, we aimed to examine the utility of magnetic resonance imaging (MRI) in assessing the severity of denervation status and predicting the postoperative prognosis. We included 13 patients (eight males and five females) with foot drop who underwent CPN decompression between 2018 and 2020. We designed a grading system for assessing the postoperative functional outcome. Additionally, we performed MRI to evaluate the denervation status of the affected musculature and its effect on postoperative recovery. The median time to surgery was 3 months. The median preoperative ankle dorsiflexion and eversion grades were both 3, while the average functional grade was 1. Posterior crural intermuscular septum was the most common cause of nerve compression, followed by deep tendinous fascia and anterior crural intermuscular septum. There was a significant postoperative improvement in the median postoperative ankle dorsiflexion and eversion grades and average postoperative functional (4, 5, and 2.38, respectively). Preoperative ankle eversion was significantly correlated with denervation status. Additionally, the devernation status on MRI was positively correlated with the outcome favorability. However, denervation atrophy led to a less favorable outcome. Among patients with intractable PICPNe despite conservative management, surgical intervention could clinically improve motor function and functional ability. Additionally, MRI examination of the affected muscle could help diagnose CPNe and assess the postoperative prognosis.

1112 DOUBLE RUPTURE OF INTERVENTRICULAR SEPTUM AFTER MYOCARDIAL INFARCTION

Abstract Ventricular septal rupture (VSR) is a mechanical complication of acute myocardial infarction (MI). VSR and early surgical repair is associated with a high mortality rate and suboptimal results with frequent postoperative residual shunt. Rapid diagnosis and proper management are critical. We present the case of a 73-year-old patient who came to our Emercency Room (ER) reporting oppressive chest pain and profuse sweating . The physical examination showed a 4/6 L rude holosystolic murmur in right parasternal location. Electrocardiogram (ECG) showed inferior MI. Hematochemicals tests detected an increase of myocardial necrosis markers. Two-dimensional and three-dimensional transthoracic echocardiography (TTE) showed normal-sized left ventricle with akinesia of inferior and posterolateral walls and akinesia of posterior basal septum with ventricular septal rupture at this level. Coronary angiography showed total occlusion in mid right coronary artery (RCA). An intra-aortic balloon pump (IABP) was inserted to promote hemodynamic stability of the patient and as a bridge. Afterload was reduced using vasodilatators. A preoperative transesophageal echocardiography (TOE) showed the presence of an additional septal rupture into middle posterior interventricular septum. The role of echocardiographic assessment in VSR, therapeutic management, IABP use and timing of surgery are discussed.

1029 FABRY DISEASE: A RARE CAUSE TO REMEMBER WHEN FACING ACUTE KIDNEY INJURY IN YOUNG

Abstract Introduction Anderson-Fabry disease (FD) is a rare X-linked hereditary disease caused by mutations in the alpha-galactosidase A (GLA) gene, a lysosomal hydrolase that catabolizes lipids. GLA deficency leads to a progressive accumulation of undegraded glycosphingolipids, mainly Globotriaosylceramide (GB3), within lysosomes of cells (epithelial and endothelial cells, neurons, cardiomyocytes and renal cells), leading to cellular dysfunction. The incidence of FD is 1:117.000 but in patients with end stage renal disease (ESRD), incidence is higher, ranging from 0.04% up to 1.16% in male dialysis patients. Classical form of the disease shows renal, cardiac and cerebrovascular involvements usually. Cardiac involvement includes hypertrophic cardiomyopathy, arrhythmias such as complete heart block, valve dysfunction and myocardial infarction. Renal manifestations include proteinuria, progressive loss of renal function with chronic kidney disease (CKD) that leads to ESRD. The diagnosis of FD can be very difficult and often is delayed due to subtle clinical manifestations, but an early diagnosis is crucial to start enzyme replacement therapy (ERT), based on recombinant human GLA, as soon as possible. Clinical Case we describe the case of a 36-years-old male admitted to the Emergency Room of our hospital due to asthenia, nausea, dysphagia, anuria and loss of weight. At physical examination, apical systolic murmur and a bilateral ankle edema. Blood pressure was 195/100 mmHg, heart rate 125 beats per minute, peripheral oxygen saturation 100%. Blood test showed Hemoglobin 8 g/dL, Blood Urea 422 mg/dL, Creatinine 20 mg/dL, Na+ 135 mEq/L, K+ 4 mEq/L, Phosphorus 9 mg/dL. Arterial blood gas analysis showed metabolic and lactic acidosis. The diagnosis of acute kidney injury (AKI) was made, and a dialytic treatment was scheduled. During dialytic session, the patient had a syncope. EKG showed a complete left bundle branch block (LBBB) with advanced atrio-ventricular block (2:1, complete). An echocardiogram highlighted a severe myocardial hypertrophy (septal wall 25 mm) involving also the right ventricle with “ground glass” aspect of the posterolateral, posterior and inferior septum, with minimal pericardial effusion. Heart MRI scan confirmed LV myocardial hypertrophy with circumferential aspect (interventricular septum 26.6 mm), mild decrease in left ventricular ejection fraction (47%) and myocardial hypointensity area in the FSE sequences. Renal ultrasound showed bilateral cortical hyperecogenity, small cortico-medullary border, initial reduction of kidney volume and diffuse perirenal edema. In consideration of the high probability of a storage disease, we performed genetic testing for FD and Gaucher disease, peri-umbilical fat biopsy for Amyloid Disease and a renal biopsy. The genetic test resulted positive for typical mutation of FD and renal biopsy documented ESRD secondary to glycosphingolipid storage disease ceramid type from FD. Conclusion Differential diagnosis of AKI in a young male should include FD, as suggested by the clinical case reported, and nephrologist should screen young patients for α-GLA enzyme deficiency (diagnostic for FD) possibly coupled with renal biopsy in uncertain cases.

Hajek and Hirsch: Otolaryngology Pioneers of Endonasal Transsphenoidal Pituitary Surgery.

To evaluate the historical descriptive origins of the extracranial transnasal transsphenoidal route to the sphenoid sinus and sella turcica focusing on the works of two otolaryngologists: Markus Hajek (1861-1941) and Oskar Hirsch (1877-1965). A collection of primary references of author publications, and contemporary references and textbooks. Primary references were reviewed with specific focus on surgical routes to the sphenoid sinus and sella turcica. Chronology was cross-referenced with contemporary publications by contemporaries. Translations from German were conducted by author AM when necessary. Markus Hajek elegantly described the surgical approach to the posterior ethmoids and sphenoid sinus in 1904 using a transnasal route. Building on this foundation, Oskar Hirsch described the fully extracranial endonasal transethmoid transsphenoidal approach in 1909. He was first to describe surgical entrance to the sella using this exclusively unilateral endonasal route, which he demonstrated on a cadaver. He reports performing this procedure on a live patient in April, 1910, under local anesthesia in stages over 5 weeks. For better exposure, Hirsch consolidated his method with Killian's submucosal window resection of the posterior nasal septum allowing for bilateral access to the sphenoid sinus and sella, and completed a single stage procedure on a patient in June 1910. Oskar Hirsch was the first to describe and perform a stepwise surgical approach to the sella using an exclusively extracranial, endonasal, transethmoid, and transsphenoidal approach. He built upon his mentor Markus Hajek's approaches to the posterior ethmoid cells and sphenoid sinus. NA: Background information, synthesis from multiple sources emphasizing factual information Laryngoscope, 133:807-813, 2023.

Endoscopic Management of Ethmoidal Schwannoma: A Case Report.

Schwannomas of sinonasal origin are rare tumours with an incidence as low as 4% and may present with a wide range of clinical features. Due to non-specific endoscopic and radiological findings, diagnosis becomes difficult. We present a case of an ethmoidal schwannoma with nasal and nasopharyngeal extension in an elderly female patient who had a slow course of the long-standing disease. Her main complaints were nasal obstruction, nasal discharge, mouth breathing, snoring and recurrent nasal bleed. Nasal endoscopy showed a pale, firm, polypoidal mass with dilated vessels on the surface which bled on probing. It was a non-enhancing sinonasal mass with scalloping of adjacent paranasal sinuses and erosion of posterior nasal septum on contrast-enhanced computed tomography. Endoscopic excision of the mass was done in toto and histopathology report confirmed it as schwannoma. Long standing sinonasal masses especially in the elderly age group with an indolent medical history should arise suspicion of benign neoplasm especially schwannomas due to their high rate of incidence amongst benign sinonasal neoplasms.

Abstract 15782: A Rare Case of Septal Atrial Flutter

Background: Isthmus-dependent counterclockwise or clockwise flutter is well defined and responsive to radiofrequency ablation (RFA) of the cavotricuspidisthmus (CTI). However, inter-atrial septal (IAS) flutter is rare and occurs with IAS substrate abnormalities and prior cardiac surgery. Case: A 62-year-old female with paroxysmal AF on rivaroxaban, hypertension and diabetes mellitus presented with palpitations refractory to propafenone and metoprolol. She underwent successful isolation of all four pulmonary veins (PVs) and RFA of the CTI with demonstration of bidirectional block. A year later, she presented with atypical AFL (Fig 1A) failing cardioversion. During redo ablation, bipolar voltage map of the left atrium (LA) demonstrated durable isolation of all four PVs. Burst pacing (BP) from the coronary sinus (CS) up to 220ms did not induce AFL. The LA posterior box was isolated by creating a roof line and a line connecting the inferior veins (Fig 1B). No extra-PV triggers were noted on high dose isoproterenol. However, during the washout period, BP from the CS induced AFL with a tachycardia cycle length of 237ms, concentric CS activation and almost simultaneous activation along the crista in the right atrium (RA). High-density activation and coherent mapping of LA and RA suggested a micro-reentrant circuit over the posterior IAS with wavefront collision across the CTI (Fig 1C, D). Concealed entrainment was observed over the LA posterior septum near the transseptal puncture site. RFA successfully terminated the AFL. RFA was performed in a sequential unipolar fashion on both sides of the septum over areas of fractionation. No atrial arrhythmias were inducible with BP on or off isoproterenol. Patient remained in sinus rhythm at 9 month follow up. Conclusion: IAS flutter post AF ablation or cardiac surgery is rare, and management is challenging. While RFA has a 93% success rate, larger studies are required to further delineate this condition.

Low Grade Chondrosarcoma of the Posterior Nasal Septum.

Chondrosarcoma originating from the nasal septum is extremely rare. CT, MRI and biopsy are standard in diagnosis. Although wide surgical excision of chondrosarcoma is used in the treatment, endoscopic excision can be recommended in appropriate cases. In this case report, we have presented a case of chondrosarcoma that was excised endoscopically and no recurrence or distant metastasis was observed in the 5-year follow-up.

The characteristics of pre-excitation syndrome concomitant with atrial tachyarrhythmia and the effect of radiofrequency ablation.

Wolff-Parkinson-White (WPW) concomitant with atrial tachyarrhythmia (ATA) has not been systemically characterized. Detailed electroanatomical mapping of the right atrium (RA) and/or left atrium (LA) was performed using three-dimensional mapping and the accessory pathway (AP) was mapped. WPW syndrome with ATA was diagnosed in 11 patients (median age 60 years). The characteristic of unidirectional anterograde conduction over the AP was displayed in nine patients, six of whom were intermittent. Sustained atrial tachycardia, that is, counterclockwise atrial flutter (AFL) with a median tachycardia cycle length (TCL) of 225 (220-275) ms, was mapped in eight patients; furthermore, "figure 8" right atrial reentry was mapped with TCL 250ms in one patient with a surgical history of ventricular septal defect repair. The remaining two patients underwent mitral annulus-dependent AT after paroxysmal atrial fibrillation (PAF) ablation and LA micro-reentry AT, respectively. In four patients, the location of the APs was left posterior. Left-lateral APs were identified in four patients. The locations of the APs in the remaining three patients were the right posterior and middle septum. All ATAs and APs were successfully ablated. After a median follow-up of 37 (15-72) months, no anterograde conduction over the AP was recorded, new onset of PAF was recorded in three patients, and all of them underwent circumferential pulmonary vein isolation. WPW with concomitant ATA frequently had continuous anterograde conduction over the AP with a rapid ventricular rate. Most WPWs displayed the characteristic of unidirectional anterograde conduction.

Comparative study of feline arterial thromboembolism treated with the combination of atenolol-clopidogrel and single clopidogrel

Feline Arterial Thromboembolism (FATE) is one of the most devastating consequences of cardiac disease in cats, characterized by a thrombosis that leads to an obstruction in the blood vessel. This disease predominantly occurs with Hypertrophic Cardiomyopathy (HCM) condition. The purpose of this case study is to corroborate the comparison of therapy between two FATE cases treated with a combination of atenolol and clopidogrel compared to clopidogrel only. Two cats were brought by the owner to the clinic with the same conditions including paraparesis, hypothermia, and pale hind paws. Physical examination revealed that both cats got hypothermic, had no femoral pulse, and pale hind legs. The blood test result showed an increase in lactate from the femoral vein and hyperkalemia in the body. Echocardiographic found HCM characterized by thickening of the left ventricular posterior wall and interventricular septum. The first cat was given the combination of atenolol (beta-blocker) and clopidogrel (antiplatelet), with supportive medications such as analgesic, omega 3, and diuretic. On the other hand, the second cat was given the same exact medications, but without atenolol (beta-blocker). After 9 days of treatment and hospitalization, the first cat that was administered a combination of atenolol and clopidogrel died after got hypotension and dyspnea. While the second cat that was given single clopidogrel survived with good clinical conditions and recovered from the lameness

Unusual Choanal Atresia in Children

Highlights: Unusual CA in a 5-year-old boy with paranasal sinuses malformation in the ORL-HNS. Transnasal endoscopy posterior septectomy was successfully done. Abstract: Choanal atresia is a developmental failure of the nasal cavity to connect with the nasopharynx. The cause is either unilateral or bilateral nasal obstruction. Bilateral choanal atresia is a very rare condition and diagnosed soon after birth because neonates are obligate nasal breathers. Delayed diagnosis can cause death due to respiratory distress. The objective of this study was to report bilateral choanal atresia in 5-year-old boy who survived by breathing through his mouth using a simple tool made by his parent. It was a very rare condition because the posterior nasal cavity was covered by medial wall malformations of both maxillary sinuses which fused with the posterior nasal septum. The surgery method for this patient was posterior septectomy with transnasal endoscopic to create a neochoanae. The post-operative patient could breathe normally through his nose. Six weeks later, the nasal endoscopic evaluation indicated the patient’s patent neochoana.