Background Left ventricular noncompaction (LVNC) is a rare disorder characterized by increased left ventricular trabeculation, deep intertrabecular recesses, and a thin compacted myocardial layer with associated clinical sequelae. Cardiac imaging with echocardiogram and cardiac magnetic resonance (CMRI) can detect variable myocardial morphology including excessive trabeculations. Multiple CMRI and echocardiographic criteria have been offered that attempt to identify LVNC morphology. The aim of this study was to assess the utility of echocardiogram in identifying LVNC in a cohort of patients with LVNC detected on CMRI. Hypothesis Echocardiography fails to identify LVNC morphology in a large proportion of patients with LVNC/hypertrabeculation detected on CMRI. Methods There were 1060 CMRI studies collected from 2009 to 2015 at 2 institutions. The patients included in this study (n = 37) met the criteria for LVNC on CMRI and had complete CMRI and echocardiogram images Clinical and imaging data were retrospectively reviewed. Results Of the 37 patients with LVNC on CMRI, only 10 patients (27%) had LVNC identified on echocardiogram (P < 0.0001, 95% confidence interval: 25.7%‐66.2%). Echocardiography and CMRI were also significantly different in terms of identification of distribution of LVNC. Although 21 of 37 patients (57%) had evidence of LVNC in either the anterior or lateral walls on CMRI, there were 0 patients with LVNC detected in the anterior or lateral walls on echocardiogram (P = 0.019). Conclusions Echocardiogram fails to detect LVNC morphology/hypertrabeculation in a significant number of a cohort of patients with LVNC on CMRI. LVNC may be missed if echocardiogram is the only imaging modality performed in a cardiac evaluation.
Thoracic empyema with or without an associated bronchopleural fistula (BPF) is one of the most common complications after a pneumonectomy. We discuss the case of a 72-year-old gentleman with stage III poorly differentiated squamous cell carcinoma of the lung, who underwent right thoracoscopic pneumonectomy and mediastinal lymphadenectomy. Postoperatively, he developed a BPF and empyema with quinolone-resistant Pseudomonas aeruginosa. Subsequently, he underwent a right thoracoscopic drainage and debridement of the chest cavity followed by repair of the BPF with omental pouch. He was then treated with intravenous tigecycline and meropenem for 20 days with gradual clinical improvement. We discuss the pathophysiology of empyema, microorganisms involved, and the role of appropriate antibiotic therapy. We also describe various preoperative and intraoperative strategies to prevent the development of empyema and how both medical and surgical interventions play an important role in the management of these patients.B ronchopleural fistulas (BPFs) and empyemas are serious complications in patients after pneumonectomy. There is a 5% to 10% incidence of empyema within the first 4 weeks of lung resection, with 80% of cases associated with BPF. 1 Risk factors include age older than 60 years, diabetes, poor nutritional status, underlying lung disease, preoperative radiation or chemotherapy, prolonged mechanical ventilation, right-sided procedures, long bronchial stump (>25 mm), carcinoma at the bronchial margin, and a disrupted bronchial blood supply. 2 Early antibiotic therapy in combination with irrigation and drainage of the pleural space is imperative to decrease morbidity and mortality. In addition, closure with either omental flap or extrathoracic skeletal muscle is necessary to prevent recurrence in those cases complicated by BPF. Despite these interventions, the mortality rate after pneumonectomy for BPF and empyema is 10% to 20%. 3 We describe a case of a 72-year-old gentleman with non-small cell lung cancer who underwent right pneumonectomy and mediastinal lymphadenectomy that was complicated by BPF and empyema by multidrug-resistant Pseudomonas aeruginosa. CASE REPORTA 72-year-old gentleman with longstanding chronic obstructive pulmonary disease and newly diagnosed stage III poorly differentiated squamous cell carcinoma of the lung underwent a complete right thoracoscopic pneumonectomy with mediastinal lymphadenectomy. His postoperative course was complicated by respiratory failure secondary to inability to clear secretions, and a tracheostomy tube was placed. He also developed aspiration pneumonia and was treated with intravenous (IV) piperacillin/ tazobactam and metronidazole. While it is now well known that there is no need for double anaerobic coverage, this was not appreciated at the time of this patient's illness. 4 He continued to improve clinically, his tracheostomy tube was removed, and he was discharged home with oral amoxicillin/clavulanic acid and metronidazole after 12 days in the hospital.One month later...
The purpose of this article was to review the pathophysiology, imaging features, and imaging pitfalls of noncongenital ventricular septal defects (VSDs). Noncongenital VSDs can result from ischemic heart disease, trauma, infection, and iatrogenic causes. Ischemic VSDs typically involve the posterior descending or left anterior descending vascular territories and are commonly seen in the apical septum or basal-mid inferoseptum. VSDs can also occur in patients with infectious endocarditis or as a complication following cardiac surgery. Most of these involve the membranous portion of the interventricular septum. Traumatic VSDs are rare and commonly involve the mid to apical anteroseptum. Computed tomography and magnetic resonance imaging can accurately characterize the morphologic features of the defects and associated imaging findings.
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