Systemic right ventricle complications in levo-transposition of the great arteries: A case report and review of literature

BACKGROUND Congenitally corrected levo-transposition of the great arteries(L-TGA)is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy.In L-TGA,the double discordance,atrioventricular and ventriculoarterial,create an acyanotic milieu which allows patients to survive their early decades,however,progressive systemic right ventricle(sRV)dys-function creates complications later in life.sRV dysfunction and remodeling predisposes patients to intracardiac thrombus(ICT)formation.CASE SUMMARY A 40-year-old male with L-TGA presented with symptoms of acute decom-pensated heart failure.In childhood,he had surgical repair of a ventricular septal defect.In adulthood,he developed sRV dysfunction,systemic tricuspid valve(sTV)regurgitation,and left-bundle branch block for which he underwent cardiac resynchronization therapy.Transthoracic echocardiogram showed a sRV ejection fraction of 40%,severe sTV regurgitation,and a newly identified sRV ICT.ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardio-graphy.Our patient was optimized with guideline-directed medical therapy and diuresis.Anticoagulation was achieved with a vitamin K antagonist(VKA)and he was later referred for evaluation by advanced heart failure and heart transplant services.CONCLUSION Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease.This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.

Unroofed coronary sinus,left-sided superior vena cava and mitral insufficiency:A case report and review of the literature

BACKGROUND Unroofed coronary sinus(UCS)is a rare subtype of atrial septal defect.It is frequently associated with a persistent left superior vena cava and is often part of a more intricate cardiac malformation.CASE SUMMARY This report describes a rare case of an adolescent patient with UCS featuring atrial situs solitus,absence of the right superior vena cava and a persistent left superior vena cava draining into the left atrium consistent with total unroofing of the coronary sinus.This was associated with concurrent severe mitral insufficiency secondary to redundant and prolapsing leaflets,and a substantial left-to-right shunt across the coronary sinus orifice.A comprehensive examination of the existing literature is included,shedding light on the diagnostic challenges of UCS and describing the available surgical options within the context of mitral valve surgery.CONCLUSION UCS is a complex condition requiring careful consideration of associated anomalies and a tailored surgical approach.

News Report and Human Rights Protection——Interview with Xinhua News Agency Deputy-Editor-in-Chief Ju Mengjun

Q： What progress has China＇s journalism circle made over the past 30 years of reform and opening up？ How do you assess the situation in China＇s journalism？

Bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome: A case report

BACKGROUND We report a rare case of numbness in the right hand,finally diagnosed as bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome and explain the cause of these diseases.CASE SUMMARY The patient was a 65-year-old woman.She complained of dizziness,numbness and weakness of the right hand for 6 mo.She was diagnosed with bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome by ultrasound,enhanced computed tomography,computed tomography angiography and other examinations.Considering the surgical risks,the patient refused the aberrant right subclavian artery stent implantation and was discharged.We hypothesize that these two kinds of deformity and right subclavian steal syndrome may not occur by accident and result from multiple malformations.CONCLUSION Bilateral common carotid artery common trunk with aberrant right subclavian artery combined with right subclavian steal syndrome is rare.This case reminds interventional radiologists of the possibility of these abnormalities before surgery.

Successful totally laparoscopic right trihepatectomy following conversion therapy for hepatocellular carcinoma:A case report

BACKGROUND About 20%-30%of newly diagnosed hepatocellular carcinoma(HCC)patients are surgically feasible due to a variety of reasons.Active conversion therapy may provide opportunities of surgery for these patients.Nevertheless,the choice of surgical procedure is controversial after successful conversion therapy.We report a patient with HCC who underwent successful laparoscopic right trisectionectomy after conversion therapy with portal vein embolization and transarterial chemoembolization.CASE SUMMARY A 67-year-old male patient presented to our hospital with epigastric distention/discomfort and nausea/vomiting for more than 1 mo.Contrast-enhanced computed tomography scan of the abdomen demonstrated multiple tumors(the largest was≥10 cm in diameter)located in the right liver and left medial lobe,and the left lateral lobe was normal.The future remnant liver(FRL)of the left lateral lobe accounted for only 18%of total liver volume after virtual resection on the three-dimensional liver model.Conversion therapy was adopted after orally administered entecavir for antiviral treatment.First,the right portal vein was embolized.Then tumor embolization was performed via the variant hepatic arteries.After 3 wk,the FRL of the left lateral lobe accounted for nearly 30%of the total liver volume.Totally laparoscopic right trisectionectomy was performed under combined epidural and general anesthesia.The in situ resection was performed via an anterior approach.The operating time was 240 min.No clamping was required during the surgery,and the intraoperative blood loss was 300 mL.There were no postoperative complications such as bile leakage,and the incision healed well.The patient was discharged on the 8th postoperative day.During the 3-mo follow-up,there was no recurrence and obvious hyperplasia of residual liver was observed.Alpha-fetoprotein decreased significantly and tended to be normal.CONCLUSION Due to the different biological characteristics of the liver cancer and the pathophysiological features of the liver from other organs,the conversion treatment should take into account both the feasibility of tumor downstaging and the volume and function of the remnant liver.Our case provides a reference for clinicians in terms of both conversion therapy and laparoscopic right trisectionectomy.

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer:A case report

BACKGROUND Pure natural orifice transluminal endoscopic surgery(NOTES)for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges,including loss of triangulation,in-line orientation,and instrument collision.Transvaginal(v)NOTES,however,can overcome these technical challenges.We report a case of pure vNOTES right hemicolectomy for colon cancer,attached with surgical video.CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons.The operative time was 200 min and the estimated blood loss was 30 mL.No intraoperative or postoperative complications occurred within 30 d after the surgery.The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3.The patient was discharged at postoperative day 6.The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.CONCLUSION vNOTES right hemicolectomy,performed by well-experienced surgeons,overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

Delayed right coronary ostial obstruction after J-valve deployment in transcatheter aortic valve implantation: A case report

BACKGROUND Aortic stenosis is the most common valve disease in adults.Transcatheter aortic valve implantation(TAVI)is being increasingly applied for intermediate-to lowrisk patients.Here,we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.CASE SUMMARY A 73-year-old woman with a EuroSCORE II of 1.21%underwent transapical TAVI because of severe aortic stenosis.The surgical procedure was uneventful.However,during routine monitoring after valve placement,the patient had a sudden onset of slow heart rate,the systolic blood pressure dropped sharply from 115 to 60 mmHg,and the central venous pressure abruptly increased from 10 to 33 cmH2O.The patient had a poor response to vasoactive agents.Transesophageal echocardiography revealed poor myocardial contractility,and electrocardiography showed a significant depression of ST-segment.Another angiography was performed immediately,which suggested complete obstruction of the right coronary artery.An emergency protocol was initiated.Cardiopulmonary bypass was established immediately.An aortic biological valve replacement under cardiopulmonary bypass was performed.CONCLUSION Perioperative monitoring,early recognition,and diagnosis of obstruction of coronary arteries in TAVI are important.Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation.Emergency protocols should be established during TAVI.

Cortical infarction of the right parietal lobe and neurogenic heart disease A report of three cases

Three male patients were diagnosed with new cortical infarctions of the right parietal lobe on the basis of head magnetic resonance imaging; high-intensity signals indicating lesions in the right parietal lobe were noted on diffusion-weighted images at admission. Two of them presented with left hand weakness, and one exhibited left upper limb weakness. Treatment for improving blood supply to the brain was administered. One patient died suddenly because of ventricular fibrillation 3 days after admission. The other two patients had increased troponin levels and abnormal electrocardiograms, and were diagnosed with acute myocardial infarction half a month after admission. When lesions exist in field 7 of the parietal cortex （resulting in paralysis of the contralateral hand）, the sympathetic center of the posterior lateral nucleus of the hypothalamus demonstrates compensatory excitement, which easily causes tachyarrhythmia and sudden death. Our experimental findings indicate that close electrocardiograph monitoring and cerebral infarction treatment should be standard procedures to predict and help prevent heart disease in patients with cerebral infarction in the right parietal lobe and left upper limb weakness as the main complaint.

Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion:A case report

BACKGROUND Typically,right coronary artery(RCA)occlusion causes ST-segment elevation in inferior leads.However,it is rarely observed that RCA occlusion causes STsegment elevation only in precordial leads.In general,an electrocardiogram is considered to be the most important method for determining the infarct-related artery,and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy.In this case,an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion.CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial STsegment elevation with dynamic changes.Myocardial injury markers became positive.Coronary angiography indicated acute total occlusion of the proximal nondominant RCA,mild atherosclerosis of left anterior descending artery and 75%stenosis in the left circumflex coronary artery.Percutaneous coronary intervention was conducted for the RCA.Repeated manual thrombus aspiration was performed,and fresh thrombus was aspirated.A 2 mm×15 mm balloon was used to dilate the RCA with an acceptable angiographic result.The patient’s chest pain was relieved immediately.A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation.The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed.Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum(ejection fraction of 54%),and the right ventricle was slightly dilated.The patient was asymptomatic during the 9-mo follow-up period.CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.

Intra-atrial course of right coronary artery:A case report

BACKGROUND Intra-atrial right coronary artery(RCA)is a rare and generally asymptomatic anomaly of development of the coronary arteries.This malformation could potentially expose the patient to a catastrophic outcome in the case of injury during interventional or surgical procedures.Currently,only a few case reports and no systematic reviews are available in the literature.CASE SUMMARY We report the case of a 54-year-old man with atypical chest pain who underwent multi-detector computed tomography angiography(MDCTA).The exam revealed no significant coronary artery stenoses;however,an intra-atrial course of mid RCA was evident.Medical therapy was administered,and the patient was discharged to home without undergoing a conventional angiography.Previously reported autoptic and clinical cases were retrieved from the PubMed literature database to compare the clinicopathological features of this case.CONCLUSION MDCTA depicted the abnormal course of the coronary artery in this patient as an intra-atrial course of the mid RCA.Finding this abnormality was crucial to avoid an inadvertent injury during interventional or surgical procedures.

Hepatocellular carcinoma with tumor thrombus extends to the right atrium and portal vein:A case report

BACKGROUND Hepatocellular carcinoma(HCC)is the most important primary malignant liver disease.A large proportion of patients with advanced HCC have macrovascular invasion.HCC tends to infiltrate vascular structures,particularly the portal vein and its branches,and more rarely,the hepatic veins.The intravascular tumor thrombus can affect the inferior vena cava(IVC)or even the right atrium(RA),the latter having a poor prognosis.CASE SUMMARY HCC is one of the most aggressive malignant tumors.Tumor thrombus(TT)formation in advanced HCC stages is common and usually involves the hepatic or portal veins.Herein,we report a 69-year-old woman who presented with dyspnea to the emergency department.A ventilation/perfusion lung scan was performed,ruling out pulmonary embolism.Hepatopulmonary syndrome and portopulmonary hypertension were discarded with contrasted echocardiography,but a mass in the RA was detected and confirmed by cardiac magnetic resonance imaging.Abdominal computed tomography showed a liver mass with a dynamic enhancement pattern compatible with HCC and an intraluminal IVC mass extending from the hepatic vein into the RA.HCC with TT expansion to IVC and RA is rare and indicates poor prognosis.CONCLUSION HCC with TT expansion to IVC and RA is rare and indicates poor prognosis.There is no consensus about anticoagulation or other interventions in these patients.

Intestinal microbiome changes in an infant with right atrial isomerism and recurrent necrotizing enterocolitis:A case report and review of literature

BACKGROUND Necrotizing enterocolitis(NEC)is a multifactorial disease that predominantly affects premature neonates.Intestinal dysbiosis plays a critical role in NEC pathogenesis in premature neonates.The main risk factor for NEC in term infants is mesenteric hypoperfusion associated with ductaldependent congenital heart disease(CHD)that eventually leads to intestinal ischemia.The incidence of NEC in neonates with critical CHD is 6.8%-13%.However,the role of the intestinal microbiome in NEC pathogenesis in infants with ductal-dependent CHD remains unclear.CASE SUMMARY A male term neonate with right atrial isomerism underwent modified Blalock-Taussig shunt placement on the 14^(th)day of life and had persistent mesenteric hypoperfusion after surgery.The patient had episodes of NEC stageⅡA on the 1^(st)and 28^(th)days after cardiac surgery.Fecal microbial composition was analyzed before and after cardiac surgery by sequencing region V4 of the 16S rRNA gene.Before surgery,species belonging to genera Veillonella and Clostridia and class Gammaproteobacteria were detected,Bifidobacteriaceae showed a low abundance.The first NEC episode was associated with postoperative hemodynamic instability,intestinal ischemiareperfusion injury during cardiopulmonary bypass,and a high abundance of Clostridium paraputrificum(Clostridium sensu stricto I)(56.1%).Antibacterial therapy after the first NEC episode resulted in increased abundance of Gammaproteobacteria,decreased abundance of Firmicutes,and low alpha diversity.These changes in the microbial composition promoted the growth of Clostridium sensu strictoⅠ(72.0%)before the second NEC episode.CONCLUSION A high abundance of Clostridium sensu strictoⅠand mesenteric hypoperfusion may have contributed to NEC in the present case.

Arrhythmogenic right ventricular cardiomyopathy characterized by recurrent syncope during exercise:A case report

BACKGROUND Arrhythmogenic right ventricular(RV)cardiomyopathy is a rare and currently underrecognized cardiomyopathy characterized by the replacement of RV myocardium by fibrofatty tissue.It may be asymptomatic or symptomatic(palpitations or syncope)and may induce sudden cardiac death,especially during exercise.To prevent adverse events such as sudden cardiac death and heart failure,early diagnosis and treatment of arrhythmogenic RV cardiomyopathy(ARVC)are crucial.We report a patient with ARVC characterized by recurrent syncope during exercise who was successfully treated with combined endocardial and epicardial catheter ablation.CASE SUMMARY A 43-year-old man was referred for an episode of syncope during exercise.Previously,the patient experienced two episodes of syncope without a firm etiological diagnosis.An electrocardiogram obtained at admission indicated ventricular tachycardia originating from the inferior wall of the right ventricle.The ventricular tachycardia was terminated with intravenous propafenone.A repeat electrocardiogram showed a regular sinus rhythm with negative T waves and a delayed S-wave upstroke from leads V1 to V4.Cardiac magnetic resonance imaging showed RV free wall thinning,regional RV akinesia,RV dilatation and fibrofatty infiltration(RV ejection fraction of 38%).An electrophysiological study showed multiple inducible ventricular tachycardia as of a focal mechanism from the right ventricle.Endocardial and epicardial voltage mapping demonstrated scar tissue in the anterior wall,free wall and posterior wall of the right ventricle.Late potentials were also recorded.The patient was diagnosed with ARVC and treated with combined endocardial and epicardial catheter ablation with a very satisfactory follow-up result.CONCLUSION Clinicians should be aware of ARVC,and further workup,including imaging with multiple modalities,should be pursued.The combination of epicardial and endocardial catheter ablation can lead to a good outcome.

Congenital absence of the right coronary artery:A case report

BACKGROUND As a rare anomaly,congenital absence of the right coronary artery(RCA)occurs during the development of coronary artery.Patients with congenital absence of the RCA often show no clinical symptoms,and this disease is considered benign.The left coronary artery gives blood supply to the whole myocardium.The prevalence of congenital absence of the RCA is approximately 0.024%-0.066%.There are few cases reported as for this disease.In this work,a patient,with congenital absence of the RCA diagnosed by coronary angiography(CAG),was described.CASE SUMMARY A 41-year-old man arrived at our hospital for treatment,due to the repeated palpitations for a duration of one year.Considering the possibility of coronary heart disease,the patient underwent CAG that indicated the congenital absence of the RCA.Unfortunately,the patient refused to accept computed tomography coronary angiography(CTCA),to further confirm the congenital absence of the RCA.CONCLUSION Single coronary artery is a rare type of coronary artery abnormality,which usually has no obvious clinical manifestations and is considered as a benign disease.CAG is the main means by which congenital absence of the RCA can be diagnosed,and the disease can also be further confirmed by CTCA.

Anesthetic management of a child with double outlet right ventricle and severe polycythemia: A case report

BACKGROUND Double outlet right ventricle(DORV)is a rare and complex congenital heart defect,and the surgical repairs vary with type and pathophysiology consequences.Due to prolonged progressive hypoxemia,severe polycythemia is common in patients with DORV,which ultimately leads to coagulation dysfunction and increases the risk of thrombosis and infarction.Consequently,the anesthetic management is challenging and how to manage severe polycythemia and avoid hypoxia-related complications in such patients is of great significance.CASE SUMMARY Herein,we report the anesthetic management of a 10-year-old female patient with a DORV.She lived in the low-oxygen Qinghai-Tibet Plateau,and presented with severe polycythemia(hemoglobin,24.8 g/dL;hematocrit,75%).She underwent a modified Fontan surgery,which was satisfactory and without any perioperative complications.Our anesthetic management highlights the importance of perioperative hemodilution in decreasing the risk of thromboembolism and the importance of correcting coagulopathy in preventing hemorrhage.CONCLUSION Anesthetic management is challenging in rare cyanotic congenital heart disease patients with severe polycythemia.It is important to adopt perioperative hemodilution and correction of coagulopathy in preventing thrombosis and hemorrhage.

Right-heart contrast echocardiography reveals missed patent ductus arteriosus in a postpartum woman with pulmonary embolism: A case report

BACKGROUND As an established,simple,inexpensive,and surprisingly effective diagnostic tool,right-heart contrast echocardiography(RHCE)might help in solving a vexing diagnostic problem.If performed appropriately and interpreted logically,RHCE allows for differentiation of various usual and unusual right-to-left shunts based on the site of injection and the sequence of microbubble appearance in the heart.CASE SUMMARY A 31-year-old woman was readmitted to hospital with a 2-mo history of worsening palpitation and chest distress.Two years prior,she had been diagnosed with postpartum pulmonary embolism by conventional echocardiography and computed tomography angiography.While the latter showed no sign of pulmonary artery embolism,the former showed pulmonary artery hypertension,moderate insufficiency,and mild stenosis of the aortic valve.RHCE showed microbubbles appearing in the left ventricle,slightly delayed after rightheart filling with microbubbles;no microbubbles appeared in the left atrium and microbubbles’appearance in the descending aorta occurred nearly simultaneous to right pulmonary artery filling with microbubbles.Conventional echocardiography was re-performed,and an arterial horizontal bidirectional shunt was found according to Doppler enhancement effects caused by microbubbles.The original computed tomography angiography findings were reviewed and found to show a patent ductus arteriosus.CONCLUSION RHCE shows a special imaging sequence for unexplained pulmonary artery hypertension with aortic valve insufficiency and simultaneous patent ductus arteriosus.

Can we suppress excessive post-surgical scar formation:A case report

BACKGROUND Hypertrophic scars(HSs)formation is a complication that occurs after wounds heal with secondary intention and sometimes after clean surgical incisions.Many treatments are in vogue now with varying successes.Although the mechanism or mechanisms that cause a HS to form are not clearly understood,one thing that is clear is that once scar tissue matures,any intervention will not be successful.In this paper,we report on a case where a patient who was known to develop HS was treated with a new combination of ingredients(Phyto-chemicals+Silicone JUMI)to suppress HS formation.CASE SUMMARY A 68-year-old female of African descent presented a severe HS post total knee replacement(TKR),which the patient describes as itchy and painful.Due to complications caused by the scar,she was apprehensive about undergoing TKR on her other knee.However,after the TKR of the contralateral side post-removal of skin clips,JUMI anti-scar cream(JASC)was used to suppress excessive scar formation.CONCLUSION JASC appears potent and efficacious at suppressing excessive scar formation.We believe that this warrants further studies on larger patient groups and on different surgical sites.

Inflammatory pseudotumors in the liver associated with influenza:A case report

BACKGROUND Inflammatory pseudotumor(IPT)is a rare and benign lesion that mimics malignancy and can develop in any part of the body.The pathophysiology and etiology of these quasineoplastic lesions remain unclear.CASE SUMMARY We report a case of a 65-year-old male who presented with fevers,night sweats,and unintentional weight loss following an influenza infection and was found to have multiple hepatic IPT’s following an extensive work up.CONCLUSION Our case highlights the importance of considering hepatic IPT’s in the differential in a patient who presents with symptoms and imaging findings mimicking malignancy shortly following a viral infection.

Ball-shaped right atrial mass in renal cell carcinoma: A case report

BACKGROUND Renal cell carcinoma(RCC)is an aggressive tumor,with an incidental discovery in most patients.Classic presentation is rare,and it has a high frequency of local and distant metastasis at the time of detection.CASE SUMMARY We present a rare case of a 58-year-old man with a ball-shaped thrombus in the right atrium at the time of first incidental identification of RCC in the emergency department.Cardiac metastasis,especially thrombus in the right atrium,is rare.It could either be a bland thrombus or a tumor thrombus,and physicians should consider this potentially fatal complication of RCC early at the time of initial presentation.CONCLUSION Ball-shaped lesions in the right atrium are rare,and bland thrombus should be differentiated from tumor thrombus secondary to intracardiac metastasis.

Promoting Human Rights Or Creating Confrontation?——On U.S. State Department's Human Rights Report

The U.S. State Department published on June 24, 2003 a report entitled Supporting Human Rights and Democracy: The U.S. Record 2002-2003. The report for the first time highlights the U.S. efforts to "promote human rights and democracy" in 92 countries and entities—the 92 claimed to have "the most human rights abuses"—in addition to its annual country report that heaps on accusations against 196 countries and entities for what it calls their human rights conditions.