Case report of Takotsubo syndrome following seizures in a patient with pyruvate carboxylase deficiency

Abstract Background  Takotsubo syndrome (TS) is defined as transient left ventricular dysfunction, which is often related to an emotional or physically stressful event. We describe a case of TS in a lady with pyruvate carboxylase deficiency (PCD). Pyruvate carboxylase deficiency is rare condition with the majority of those affected demonstrating signs of failure to thrive, recurrent seizures, and metabolic acidosis. To our knowledge, this is the first documented case of TS in an individual with PCD. Case summary  This 28-year-old female presented to the emergency department after a tonic-clonic seizure. For 4 days prior to the presentation, she had been suffering from cough and pyrexia. On Day 2, she developed abdominal pain associated with tachycardia and hypotension, and an elevated troponin (791 ng/L). The echocardiogram showed a severely impaired left ventricular systolic function, regional wall motion abnormalities (RWMAs), and a visually estimated left ventricular ejection fraction of 25–30%. Eight days following admission her clinical state significantly improved, with a reduction troponin to 60 ng/L. A repeat echocardiogram on Day 9 showed complete resolution of cardiac function with no RWMAs. Following this, she was discharged from hospital the next day with a diagnosis of TS. Discussion  This is the first case report of TS in a patient with PCD. In this case, multiple aetiologies of TS such as emotional and physical stress, seizures, and acute infection were considered. This case also highlights that TS should be an important differential diagnosis in patients presenting with cardiac symptoms. </jats:sec

Tophaceous gout in the sternoclavicular joint

Abstract Gouty arthritis commonly occurs in peripheral synovial joints and involvement in the thoracic cage is extremely rare. We report a case of a 52-year-old presenting with a painful bony mass in her sternal notch. Imaging demonstrated a lobulated calcified and necrotic lesion causing mass effect on adjacent structures. Excision biopsy confirmed a benign cystic lesion with amorphous material containing needle-shaped refractile crystals suggestive of uric acid. Tophaceous gout was diagnosed. Presence of a periarticular mass with characteristics of gout should warrant investigation with biopsy and imaging. This can prevent misdiagnosis of malignancy and avoid unnecessary surgery in asymptomatic lesions.</jats:p

Uniportal subxiphoid bilateral removal of self-introduced thoracic foreign bodies

Abstract This is a report of a 31-year-old male refugee, who was admitted to Intensive Therapy Unit after being found in severe chest pain after escaping extreme torture from his home country. He was found to have four nails in his thorax. These were removed using a subxiphoid video-assisted thorascopic surgery (VATS) technique. This technique allowed excellent visualization of the right, left and anterior mediastinal part of the chest and therefore preventing damage or injury to surrounding structures. This was particularly useful in a complex case such as this. By avoiding an intercoastal incision and intercostal manipulation, our patient had limited pain post-procedure facilitating an earlier aggressive mobilization program with potential benefit in terms of improved lung expansion, reduction of atelectasis and lung infections. With the right training, the technical challenges of using the technique should be overcome and thus the benefits of subxiphoid VATS will be offered to a larger portion of thoracic surgical patients.</jats:p

Posterior left pericardiotomy reduces postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting surgery

Objective: Atrial fibrillation (AF) is a common postoperative complication with an incidence of up to 10% to 33% after coronary artery bypass grafting surgery and is associated with worse morbidity and mortality. At present, studies have shown a promising reduction in postoperative AF (POAF) with posterior pericardiotomy (PP). However, there are limited data on the widespread use of PP amongst cardiac surgeons. This retrospective analysis assesses the influence of a real-world adoption of PP on the incidence and cumulative burden of POAF. Methods: Patients who underwent coronary artery bypass grafting surgery between 2015 and 2022 were analyzed. One group had PP as part of their surgical procedure whilst the control group did not. For both groups, the incidence of POAF was analyzed. PP was performed via a 5-cm incision between the left inferior pulmonary vein and the phrenic nerve. Results: Two thousand four hundred eighty patients were included in the analysis; 806 patients underwent PP and 1674 formed the control group. PP was associated with a 27.4% reduction in the odds of developing POAF (odds ratio, 0.73; 95% CI, 0.55-0.95; P = .023). Age was significantly associated with POAF, with a 4.3% increase in odds per additional year (odds ratio, 1.04; 95% CI, 1.03-1.06; P < .001). In the multivariate model for AF, PP remained significantly protective, reducing the odds of POAF by 26.9% (odds ratio, 0.73; 95% CI, 0.55-0.96; P = .028). Patients who underwent PP had significantly reduced cumulative POAF duration, with a 5.3% average reduction (P = .002). Conclusions: Posterior left pericardiotomy is associated with reduced odds and duration of POAF. A large, multicenter trial is indicated to confirm this finding as well as the influence of PP and POAF on postdischarge clinical outcomes