Uterine leiomyosarcoma is a rare and aggressive tumour with a poor prognosis. Its metastases to the heart are even rarer, especially to the epicardium. The majority of reported cardiac metastases of ...uterine leiomyosarcoma were in the cardiac chambers or intramyocardial. Surgical resection of the uterine leiomyosarcoma in the early stages is the only definitive treatment for this disease. However, in the cases of cardiac metastasis, surgery is recommended only in emergencies and patients with expected beneficial outcomes.
Our patient was a 49-year-old female referred to the Department of Cardiac Surgery for scheduled surgery of pericardial neoplasia. The patient underwent a hysterectomy and adnexectomy three years prior owing to the uterine leiomyosarcoma. A regular follow-up magnetic resonance imaging of the abdomen and pelvis discovered neoplasia in the diaphragmic portion of the pericardium. No other signs of primary disease relapse or metastases were found. The patient was asymptomatic. The multidisciplinary team concluded that the patient is a candidate for surgery. Surgery included diastolic cardiac arrest achievement and resection of the tumour. Macroscopically, a parietal layer of the pericardium was completely free from the tumour that invaded only the apical myocardium of the left ventricle. Completed histopathology confirmed the diagnosis of leiomyosarcoma of the uterine origin. Three months after surgery, the patient received adjuvant chemotherapy with doxorubicin and dacarbazine. One year after surgery, there are no signs of new metastases.
Strict surveillance of patients with uterine leiomyosarcoma after successful treatment of the early stage of the disease is of utmost importance to reveal metastatic disease to the heart in a timely manner and to treat it with beneficial outcomes. Surgery with adjuvant chemotherapy might be a good approach in patients with a beneficial prognosis. From a surgical point of view, it is challenging to assess the appropriate width of the resection edges to be radical enough and, at the same time, sufficiently conservative to ensure the satisfactory postoperative function of the remaining myocardium and avoid repetitive tumour growth. Therefore, intraoperative histopathology should always be performed.
A 47‐year old male with ischaemic cardiomyopathy was referred to us for durable left ventricular assist device placement. He was found to have prohibitively elevated pulmonary vascular resistance for ...heart transplantation. He underwent HeartMate 3 left ventricular assist device implantation, with additional temporary right ventricular assist device (RVAD) placement. Following a 2‐week period of unweanable temporary right ventricular support, the patient was switched to durable biventricular support with two Heartmate 3 pumps. The patient was placed on a transplant waiting list but was not offered a heart for over 4 years. While on Heartmate 3 biventricular support (BiVAD), he returned to full activity and enjoyed an excellent quality of life. He underwent laparoscopic cholecystectomy 7 months after the BIVAD implant. After 52 months of uneventful BiVAD support, he presented with a combination of adverse events that occurred over a short period. These included subarachnoidal haemorrhage and a new motor deficit, followed by RVAD infection and RVAD low‐flow alarms. After over 4 years of unimpeded RVAD flows, new imaging revealed an outflow graft twist with subsequent flow reduction. The patient underwent heart transplantation after a total of 1655 days of Heartmate 3 BiVAD support and continues to do well on latest follow‐up.
Observational studies have indicated potential benefits of CYP2C9- and VKORC1-guided dosing of warfarin but randomized clinical trials have resulted in contradictory findings. One of the reasons for ...contradiction may be the negligence of possible differences between warfarin indications. This study aims to determine efficacy and safety of genotype-guided and clinically guided dosing of warfarin in atrial fibrillation (AF), deep-vein thrombosis (DVT), and pulmonary embolism (PE) within the first 5 days after the introduction of therapy.
In this single-center, single-blinded, randomized, controlled trial including patients of both sexes, ≥18 years of age, and diagnosed with AF, DVT, or PE, a total of 205 consecutive patients were allocated into the group where warfarin therapy was genotype-guided pharmacogenetics guided (PHG), and where it was adjusted according to the clinical parameters non pharmacogenetics guided (NPHG). Genotyping of CYP2C9*2, *3, and VKORC1 was performed using the real-time polymerase chain reaction method. The primary outcomes were the percentage of time in the therapeutic international normalized ratio (INR) (2.0-3.0) range and the percentage of patients who achieved a stable anticoagulation defined as the INR (2.0-3.0) range in at least 2 consecutive measurements.
In patients with AF, the percentage of time spent in the therapeutic range of INR was higher in the PHG group mean = 26% (SD 25.0) than in the NPHG group mean = 14% (SD 18.6), Δ = 12; 95% confidence interval, 0-23; P = 0.040. There was no significant difference in other 2 indications for warfarin treatment. A stable dose of warfarin was achieved in a statistically higher number of patients in the PHG group 14/30 (47%) than in the NPHG group 7/32 (22%) (odds ratio = 3.13, 95% confidence interval, 0.92-10.98; P = 0.039).
CYP2C9 and VKORC1 genotype-guided dosing of warfarin may be beneficial in patients diagnosed with AF. There is no evidence for such conclusion in patients with DVT and PE.
Between 0.1% and 0.3% of all aortic dissections occur during pregnancy. Arterial hypertension, connective tissue disorders, and congenital cardiovascular anomalies-including bicuspid aortic ...valves-are well-known risk factors. The causality between pregnancy and aortic dissection is unclear, but there have been some observations that COVID-19 illness may increase the risk. This report describes a pregnant woman at 34 weeks of gestation who had a bicuspid aortic valve and experienced an acute aortic dissection while ill with COVID-19 pneumonia. Computed tomography confirmed a type A aortic dissection and bilateral patchy pulmonary opacities. Cesarean delivery was performed, followed by replacement of the aortic valve with a mechanical aortic prosthesis and reconstruction of the ascending aorta and hemiarch. The intraoperative course was uneventful, and the patient was successfully weaned from mechanical ventilation after 51 hours. COVID-19 during pregnancy seems to increase the risk for aortic dissection, although there is no evidence base for an association. Because guidelines for diagnosis and treatment in such complex cases are lacking, care from a multidisciplinary team is crucial for successful outcomes.
Abstract
Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, ...including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest.
Background: Observational studies have indicated potential benefits of CY2C9 and VKORC1 guided dosing of warfarin. However, randomized clinical trials resulted in contradictory findings. One of the ...reasons for contradiction may be the negligence of possible differences between warfarin indications. The goal of this study was to determine efficacy and safety of genotiype- and clinically- guided dosing of warfarin in atrial fibrillation (AF), deep-vein thrombosis (DVT) and pulmonary embolism (PE) within the first five days after the introduction of therapy. Methods:In this single-center, single-blinded, randomized, controlled trial including patients of both sexes, 18 years of age or older, diagnosed with AF, DVT or PE a total of 205 consecutive patients were allocated into 2 groups: genotype-guided (PHG) warfarin therapy, and 2) warfarin therapy guided by clinical parameters (NPHG). Genotyping of CYP2C9*2*3 and VKORC1 was performed by RealTimePCR method. The primary outcomes were the percentage of time in the therapeutic international normalized ratio (INR 2.0-3.0) range, and the percentage of patients whoachieved a stable anticoagulation defined as the INR 2.0-3.0 range in at lest two consecutive measurements. Results: In patients with AF percentage of time spent in the therapeutic range of INR was higher in PHG group (mean=26%; SD25.0), than in NPHG group (mean=14%; SD18.-6) (delta=12;95%CI 0-23; p=0.040). There was no significant difference in other two evaluated indications for warfarin treatment. Overall, stable dose of warfarin was achieved in statistically higher number of patients in PHG group 14/30 (47%), than in NPHG group 7/32 (22%) (OR=3.13, 95%CI 0.92-10.98;P=0.039). Conclusion: CYP2C9 and VKORC1 genotype guided dosing of warfarin may be beneficial in patients diagnosed with AF. However, we found no evidence to support such conclusion i patients with DVT and PE.
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