Congenital Absence of Pericardium:The Largest Systematic Review in the Field on 247 Worldwide Cases(1977-Now)

Background:Congenital absence of pericardium(CAP),also known as pericardial agenesis,represents an uncommon cardiac abnormality and mostly incidental finding.It can be subdivided into complete and partial(left or right-sided)forms.Because of its infrequency,just case reports and a few case series have been released so far.This paper represents the largest systematic review in the field.Nine features(age at diagnosis,type,gender,clinical presentation,electrocardiography,imaging(ultrasounds,CT/MRI),concomitant cardiac defects,and outcome)were analysed.Methods:The electronic database PubMed was investigated from its establishment up to July 15th,2023.Just case reports and case series were included.Animal studies,papers that were not in English,Spanish,and Italian,and those manuscripts not reporting at least seven of the nine analysed features.were ruled out.The analysed data were reported mostly in terms of percentage.Results:One hundred eighty studies were included encompassing 247 patients.More than half of reviewed CAP cases were in males(63.2%).The mean age at diagnosis was 31.8±19.3 years;a range of 32 weeks of gestation-81 years).23.5%of the patients did not report any symptoms.The most common clinical presentations were chest pain(35.2%)and dyspnoea(29.2%).The most commonly seen ECG changes were right axis deviation(28.7%)and right bundle branch block(23.9%).CAP was suspected or diagnosed by echocardiography in 20.1%of cases.The diagnosis was made by CT and/or MRI in 61.9%of cases.CAP was left-sided in 71.2%,complete in 23.1%,and right-sided in 5.7%.A concomitant congenital heart defect was found in 22.7%,especially in the form of atrial septal defect(6.5%)and patency of ductus arteriosus(2.8%).The pericardial repair was required in 12.9% of the incomplete forms of the disease.Never did the complete form require surgical correction.The outcome appeared favourable in the vast majority of cases,with just 18 deaths(7.3%).Discussion:The main limitation of this systematic review is that it is based just on case reports and case series,due to the lack of large studies on CAP.However,it represents the largest analysis in the field.Due to the rarity of CAP establishing an International Registry is recommended.

Insight into congenital absence of the portal vein:Is it rare?

Congenital absence of portal vein （CAPV） was a rare event in the past. However, the number of detected CAPV cases has increased in recent years because of advances in imaging techniques. Patients with CAPV present with portal hypertension （PH） or portosystemic encephalopathy （PSE）, but these conditions rarely occur until the patients grow up or become old. The patients usually visit doctors for the complications of venous shunts, hepatic or cardiac abnormalities detected by ultrasonography （US）, computed tomography （CT） and magnetic resonance imaging （MR1）. The etiology of this disease is not clear, but most investigators consider that it is associated with abnormal embryologic development of the portal vein. Usually, surgical intervention can relieve the symptoms and prevent occurrence of complications in CAPV patients. Moreover, its management should be stressed on a case-by-case basis, depending on the type or anatomy of the disease, as well as the symptoms and clinical conditions of the patient.

Preliminary report on screening IGSF3 gene mutation in families with congenital absence of lacrimal puncta and canaliculi

AIM:To investigate the variation of IGSF3 gene in three families with congenital absence of lacrimal puncta and canaliculi,and to lay a foundation for further research on the pathogenic gene of congenital lacrimal duct agenesis.METHODS:The members of the three families were recruited.The ophthalmologic examinations in details,including slit-lamp biomicroscope,intraocular pressure and fundus examination,etc.were carried out.All patients were checked with paracentesis of puncta membrane and lacrimal duct probing,as well as the computed tomographydacryocystography(CT-DCG).Peripheral blood of 14 participants(3 normal)from three families were collected,4 mL each,for genomic DNA extraction,and 11 exon fragments of IGSF3 gene were amplified and sequenced by polymerase chain reaction(PCR)to determine whether there were IGSF3 genetic variation.RESULTS:A total of 14 members from three families were screened for 4 synonymous variants:c.930 C>T(p.Pro366=),c.1359 T>C(p.Ser709=),c.1797 G>A(p.Ser855=),c.1539 G>A(p.Ser769=),and 6 missense variants:c.l507 G>A(p.Gly759 Ser),c.1783 T>C(p.Trp851 Arg),c.1952 G>T(p.Ser 907 lle),c.3120 C>G(p.Asp1040 Glu),c.3123 C>G(p.Asp1041 Glu),c.3139_3140 insGAC(p.Asp1046_Pro1047 insAsp),and the latter three were only found in two patients with absence of lacrimal puncta and canaliculi combined with congenital osseous nasolacrimal canal obstruction from the first family.CONCLUSION:The same IGSF3 gene mutation c.31393140 insGAC is found in the patients with congenital absence of lacrimal puncta and canaliculi combine with osseous nasolacrimal canal obstruction.

CFTR mutations causing congenital unilateral absence of the vas deferens(CUAVD)and congenital absence of the uterus(CAU)in a consanguineous family

Cystic fibrosis(CF)is one of the most common recessive genetic diseases,with a wide spectrum of phenotypes,ranging from infertility to severe pulmonary disease.Mutations in the cystic fibrosis transmembrane conductance regulator(CFTR)gene are considered the main genetic cause for CF.In this study,we recruited a consanguineous Iranian pedigree with four male patients diagnosed with congenital unilateral absence of the vas deferens(CUAVD),and one female patient diagnosed with congenital absence of the uterus(CAU).Testicular biopsy of one patient was performed,and hematoxylin and eosin(H and E)staining of testis sections displayed the presence of germ cell types ranging from spermatogonia to mature spermatids,indicating obstructive azoospermia.To explore the underlying genetic factor in this familial disorder,we therefore performed whole-exome sequencing(WES)on all available family members.WES data filtration and CFTR haplotype analysis identified compound heterozygous mutations in CFTR among four patients(two CUAVD patients carried p.H949Y and p.L997F,and one CUAVD and the female CAU patient carried p.H949Y and p.I148T).All these mutations were predicted to be deleterious by at least half of the prediction software programs and were confirmed by Sanger sequencing.Our study reported that CFTR compound heterozygous mutations in a consanguineous Iranian family cause infertility in both sexes.

The CFTR polymorphisms poly-T, TG-repeats and M470V in Chinese males with congenital bilateral absence of the vas deferens

Congenital bilateral absence of the vas deferens （CBAVD） is a frequent cause of obstructive azoospermia, and mutations of the cystic fibrosis transmembrane conductance regulator （CFTR） gene have also been frequently identified in patients with CBAVD. However, the distribution of the CFTR polymorphisms M470V, poly-T, TG-repeats and F508del mutation in the Chinese CBAVD population with presumed low cystic fibrosis （CF） frequency remains to be evaluated. Samples obtained from 109 Chinese infertile males with CBAVD and 104 normal controls were analyzed for the presence of CFTR （TG）m（T）n, M470V and F508del by PCR amplification followed by direct sequencing. Our study showed that the F5OSdel mutation was not found in our patients. The 5T mutation was present with high frequency in Chinese CBAVD patients and IVS8-5T linked to either 12 or 13 TG repeats was highly prevalent among CBAVD patients （97.22% of 72 cases and 96.91% of 97 alleles with IVS8-5T）. Moreover, a statistically significant relationship between TG 12-5T-V470 haplotype and CBAVD was detected. This study indicated that the CFTR polymorphisms poly-T, TG-repeats and M470V might affect the process of CBAVD in the Chinese population.

Identification of the second CFTR mutation in patients with congenital bilateral absence of vas deferens undergoing ART protocols

Congenital bilateral absence of vas deferens （CBAVD） is a manifestation of the mildest form of cystic fibrosis （CF） and is characterized by obstructive azoospermia in otherwise healthy patients. Owing to the availability of assisted reproductive technology, CBAVD patients can father children. These fathers are at risk of transmitting a mutated allele of the CF transmembrane conductance regulator （CFTR） gene, responsible for CF, to their offspring. The identification of mutations in both CFTR alleles in CBAVD patients is a crucial requirement for calculating the risk of producing a child with full-blown CF if the female partner is a healthy CF carrier. However, in the majority of CBAVD patients, conventional mutation screening is not able to detect mutations in both CFTR alleles, and this difficulty hampers the execution of correct genetic counselling. To obtain information about the most represented CFTR mutations in CBAVD patients, we analysed 23 CBAVD patients, 15 of whom had a single CFTR mutation after screening for 36 mutations and the 5T allele. The search for the second CFTR mutation in these cases was performed by using a triplex approach： （i） first, a reverse dot-blot analysis was performed to detect mutations with regional impact; （ii） next, multiple ligation-dependent probe amplification assays were conducted to search for large rearrangements; and （iii） finally, denaturing high-performance liquid chromatography was used to search for point mutations in the entire coding region. Using these approaches, the second CFTR mutation was detected in six patients, which increased the final detection rate to 60.8%.

Congenital extrahepatic portosystemic shunt complicated by the development of hepatocellular carcinoma

Congenital extrahepatic portosystemic shunt,also known as Abernethy malformation, is a rare congenital malformation. It causes shunting of blood through a communication between the portal and systemic veins such as a patent ductus venous. We report 3 cases of Abernethy malformation complicated by the development of hepatocellular carcinoma. Additionally, we comprehensively reviewed all previously reported cases and highlighted common features that may help in early diagnosis and appropriate management.Patients with Abernethy malformation may have an increased propensity to develop hepatocellular carcinoma. All 5 previously reported cases, plus the three of our patients, have a type 1（complete） shunt suggesting a role for absent portal blood flow in the pathogenesis of hepatocellular carcinoma. Congenital extrahepatic portosystemic shunt should be sought for in cases with raised serum ammonia, hepatic encephalopathy or hepatocellular carcinoma in the absence of cirrhosis.

Rare portal hypertension caused by Abernethy malformation(Type IIC):A case report

BACKGROUND Abernethy malformation is a rare congenital vascular malformation with a portosystemic shunt that may clinically manifest as cholestasis,dyspnea,or hepatic encephalopathy,among other conditions.Early diagnosis and classification are very important to further guide treatment.Typically,patients with congenital portosystemic shunts have no characteristics of portal hypertension.Herein,we report an 18-year-old female with prominent portal hypertension that manifested mainly as rupture and bleeding of esophageal varices.Imaging showed a thin main portal vein,no portal vein branches in the liver,and bleeding of the esophageal and gastric varices caused by the collateral circulation upwards from the proximal main portal vein.Patients with Abernethy malformation type I are usually treated with liver transplantation,and patients with type II are treated with shunt occlusion,surgery,or transcatheter coiling.Our patient was treated with endoscopic surgery combined with drug therapy and had no portal hypertension and good hepatic function for 24 mo of follow-up.CASE SUMMARY This case report describes our experience in the diagnosis and treatment of an 18-year-old female with Abernethy malformation type IIC and portal hypertension.This condition was initially diagnosed as cirrhosis combined with portal hypertension.The patient was ultimately diagnosed using liver histology and subsequent imaging,and the treatment was highly effective.To publish this case report,written informed consent was obtained from the patient,including the attached imaging data.CONCLUSION Abernethy malformation type IIC may develop portal hypertension,and traditional nonselective beta-blockers combined with endoscopic treatment can achieve high efficacy.

Loss-of-function CFTR p.G970D missense mutation might cause congenital bilateral absence of the vas deferens and be associated with impaired spermatogenesis

Congenital bilateral absence of the vas deferens(CBAVD)is observed in 1%–2%of males presenting with infertility and is clearly associated with cystic fibrosis transmembrane conductance regulator(CFTR)mutations.CFTR is one of the most well-known genes related to male fertility.The frequency of CFTR mutations or impaired CFTR expression is increased in men with nonobstructive azoospermia(NOA).CFTR mutations are highly polymorphic and have established ethnic specificity.Compared with F508Del in Caucasians,the p.G970D mutation is reported to be the most frequent CFTR mutation in Chinese patients with cystic fibrosis.However,whether p.G970D participates in male infertility remains unknown.Herein,a loss-of-function CFTR p.G970D missense mutation was identified in a patient with CBAVD and NOA.Subsequent retrospective analysis of 122 Chinese patients with CBAVD showed that the mutation is a common pathogenic mutation(4.1%,5/122),excluding polymorphic sites.Furthermore,we generated model cell lines derived from mouse testes harboring the homozygous Cftr p.G965D mutation equivalent to the CFTR variant in patients.The Cftr p.G965D mutation may be lethal in spermatogonial stem cells and spermatogonia and affect the proliferation of spermatocytes and Sertoli cells.In spermatocyte GC-2(spd)ts(GC2)Cftr p.G965D cells,RNA splicing variants were detected and CFTR expression decreased,which may contribute to the phenotypes associated with impaired spermatogenesis.Thus,this study indicated that the CFTR p.G970D missense mutation might be a pathogenic mutation for CBAVD in Chinese males and associated with impaired spermatogenesis by affecting the proliferation of germ cells.

Clinical features and microsurgical reconstruction of congenital unilateral absence of the vas deferens with obstructive azoospermia:a tertiary care center experience

Patients with congenital unilateral absence of the vas deferens(CUAVD)manifest diverse symptoms from normospermia to azoospermia.Treatment for CUAVD patients with obstructive azoospermia(OA)is complicated,and there is a lack of relevant reports.In this study,we describe the clinical features and evaluate the treatments and outcomes of CUAVD patients with OA.From December 2015 to December 2020,33 patients were diagnosed as CUAVD with OA in Shanghai General Hospital(Shanghai,China).Patient information,ultrasound findings,semen analysis,hormone profiles,and treatment information were collected,and the clinical outcomes were evaluated.Of 33 patients,29 patients were retrospectively analyzed.Vasoepididymostomy(VE)or cross VE was performed in 12 patients,the patency rate was 41.7%(5/12),and natural pregnancy was achieved in one of the patients.The other 17 patients underwent testicular sperm extraction as the distal vas deferens(contralateral side)was obstructed.These findings showed that VE or cross VE remains an alternative treatment for CUAVD patients with OA,even with a relatively low rate of patency and natural pregnancy.

Diagnosis of lacrimal canalicular diseases using ultrasound biomicroscopy: a preliminary study

· AIM: To evaluate the application of ultrasound biomicroscopy(UBM) in the examination of lacrimal canalicular diseases, and to investigate UBM image characteristics of lacrimal canaliculi in disease states.·METHODS: Sixty cases(63 eyes, 69 canaliculi) of lacrimal canalicular diseases were enrolled that included32 patients(32 eyes, 32 canaliculi) with chronic lacrimal canaliculitis, 18 patients(18 eyes, 18 canaliculi) with previous lacrimal canalicular laceration, 9 patients(12eyes, 18 canaliculi) with congenital absence of lacrimal puncta and canaliculi, and 1 case(1 eye, 1 canaliculus)of canalicular mass. The patients were examined using UBM, and disease-specific features of the UBM images were noted.· RESULTS: UBM imaging of lacrimal canaliculi in chronic canaliculitis patients showed obvious ectasia of the lacrimal canalicular lumen. Dot-like moderate echoic signals were detected on some ectatic lumina of the lacrimal canaliculus. Some lumen-like structures of the lower lacrimal canaliculus were observed in 2(2 eyes, 2canaliculi) of the 9 patients(12 eyes, 18 canaliculi) with congenital absence of the lacrimal canaliculus. Of the 18patients(18 eyes, 18 canaliculi) with previous lacrimal canalicular laceration, the lacerated end on the nasal side of the lacrimal canaliculus was detected only in 14patients(14 eyes, 14 canaliculi).·CONCLUSION: UBM can be used to evaluate lacrimal canalicular diseases and can provide an imaging basis for the diagnosis of lacrimal canalicular diseases.

Evaluation of the azoospermic male

When presented with an azoospermic patient, a thorough history and careful, considered physical examination often leads to a definite or presumptive diagnosis. An algorithmic, logical thought process is important to have in mind when embarking on the evaluation. Adjunctive laboratory tests, such as hormonal assays or genetic studies, are often complementary and/or additive and allow a very precise determination to be made as to the etiologies, either genetic or acquired. It is only with this information that a therapeutic plan can be made for the patient. As will be discussed, a targeted approach to testing is far more satisfying and cost-effective than a blind, shotgun approach.

Sperm retrieval and intracytoplasmic sperm injection outcomes in men with cystic fibrosis disease versus congenital bilateral absence of the vas deferens

Recent data suggest that cystic fibrosis transmembrane conductance regulator(CFTR)gene alterations negatively impact male fertility beyond obstruction.We sought to compare gene alterations,sperm retrieval rates,and intracytoplasmic sperm injection(ICSI)outcomes among men with cystic fibrosis(CF)disease and congenital bilateral absence of the vas deferens(CBAVD)only.We retrospectively evaluated all men who underwent surgical sperm retrieval at two academic,high-volume andrology centers from 2010 to 2018.Only men with documented CFTR alterations and obstructive azoospermia from either CBAVD or CF were included.Differences between groups for CFTR abnormality,sperm retrieval,and ICSI outcomes were statistically analyzed.Overall,39 patients were included with 10 in the CF and 29 in the CBAVD groups.Surgical sperm retrieval rates were significantly lower in the CF group for sperm concentration(14.8×10^(6)ml^(-1)vs 61.4×10^(6)ml^(−1),P=0.02)and total motile sperm count(2.9 million vs 11.4 million,P=0.01).This difference was only predicted by homozygous delta F508 CFTR mutations(P<0.05).The CF group also demonstrated a significantly higher rate of rescue testicular sperm extraction(70.0%vs 27.6%,P<0.03)and lower fertilization rate with ICSI(32.5%vs 68.9%,P<0.01).In conclusion,those with CF demonstrated lower sperm quality,greater difficulty with sperm retrieval,and worse ICSI outcomes compared with CBAVD-only patients.Homozygous delta F508 CFTR mutations appear to significantly impair spermatogenesis and sperm function.