Left aorto-ventricular tunnel: A differential diagnosis to aortic regurgitation

Left aorto-ventricular tunnel is a rare congenital heart disorder. A then 19-year-old young lady was referred to our clinic for chronic rheumatic heart disease with aortic regurgitation. However, because of an almost continuous murmur, and an unusual transthoracic echo, she underwent various investigations, finally revealing a rare type 2 left aorto-ventricular tunnel. She had been variously diagnosed as chronic rheumatic heart disease with aortic regurgitation, bicuspid aortic valve with aortic regurgitation, and then possibly coronary arterial (cameral) fistula (based on 2D transthoracic echo) and finally left aorto-ventricular tunnel. This is the first case described in South East Asia who is asymptomatic, apart from a murmur, and her long journey to this final diagnosis illustrates the need to "chase shadows" on echoes, to come to a proper conclusion for the patient.

Lactate determination in pleural and abdominal effusions: a quick diagnostic marker of exudate-a pilot study

Pleural or abdominal effusions are frequent findings in ICU and Internal Medicine patients. Diagnostic gold standard to distinguish between transudate and exudate is represented by "Light's Criteria," but, unfortunately, the chemical-physical examination for their calculation is not a rapid test. Pursuing an acid-base assessment of the fluid by a blood-gas analyzer, an increase of lactate beyond the normal serum range is reported in the exudative effusions. The advantages of this test are that it is a very fast bed-side test, executable directly by the physician. The aim of this study is to evaluate whether the increase in lactate in pleural and abdominal effusions might be used as a criterion for the differential diagnosis of the nature of the fluid. Sixty-nine patients with pleural or abdominal effusions and clinical indication for thoracentesis or paracentesis were enrolled. Acid-base assessment with lactate, total protein, and LDH dosage on the serum, and acid-base assessment with lactate, total protein, and LDH dosage, cytology, and bacterial culture on the fluid were performed to each patient. Fluid-blood lactate difference (ΔLacFB) and fluid-blood lactate ratio (LacFB ratio) were calculated. A statistical analysis was carried out for fluid lactate (LacF), ΔLacFB, and LacFB ratio, performing ROC curves to find the cut-off values with best sensitivity (Sn) and specificity (Sp) predicting an exudate diagnosis: LacF: cut-off value: 2.4 mmol/L; AU-ROC 0.854 95% CI 0.756-0.952; Sn 0.77; Sp 0.84. ΔLacFB: cut-off value: 0.95 mmol/L; Au-ROC 0.876 95% CI 0.785-0.966; Sn 0.80; Sp 0.92. LacFB ratio: cut-off value: 2 mmol/L; Au-ROC 0.730 95% CI 0.609-0.851; Sn 0.74; Sp 0.65. Lactate dosage by blood-gas analyzer on pleural and abdominal effusions seems to be a promising tool to predict a diagnosis of exudate.

Clinical features and natural history of cryptogenic cirrhosis compared to hepatitis C virus-related cirrhosis

AIM

To characterize natural history of cryptogenic cirrhosis (CC) and compare its clinical features and outcomes to those of hepatitis C virus (HCV)-related cirrhosis.

METHODS

A prospective cohort of 102 consecutive patients at their first diagnosis of CC were enrolled in this study. The clinical data and outcomes were compared to an age- and Child-Pugh class-matched cohort of 110 patients with HCV-related cirrhosis. Diagnosis of cirrhosis was based on compatible clinical and laboratory parameters, ultrasound/endoscopic parameters and, whenever possible, on histological grounds and transient elastography. All cases of cirrhosis without a definite etiology were enrolled in the CC group. The parameters assessed were: (1) severity of liver disease at the time of first diagnosis; (2) liver decompensation during follow-up; (3) hepatocellular carcinoma (HCC); (4) orthotopic liver transplantation; and (5) death. The independent associated factors were evaluated by multiple logistic regression analysis, and survival and its determinants by the Kaplan-Meier model, log-rank test and Cox regression.

RESULTS

At the first observation, median age was 66 and 65 years and male gender was 36% and 58% for CC and HCV cirrhosis, respectively. CC showed Child-Pugh class A/B/C of 47%/31%/22%, respectively. Compared to HCV cirrhosis, CC exhibited a significantly higher prevalence of metabolic syndrome (12% vs 54%, respectively), overweight/obesity, high BMI, impaired glucose tolerance, high blood pressure, dyslipidemia, hyperuricemia, cardiovascular diseases, extrahepatic cancer, and gallstones. Over a median period of 42 mo of follow-up, liver decompensation, HCC development and death for CC and HCV-related cirrhosis were 60.8%, and 54.4%, 16.7% and 17.2%, 39.2% and 30%, respectively. The median survival was 60 mo for CC. Independent predictors of death were age and Child-Pugh class at diagnosis. CC showed an approximately twofold higher incidence of HCC in Child-Pugh class A.

CONCLUSION

Undiagnosed nonalcoholic fatty liver disease has an etiologic role in CC that is associated with a poor prognosis, early HCC development, high risk of cardiovascular disease and extrahepatic cancer.

Perinatal management of cardiac tumors: a case series

Primary cardiac tumours in the foetuses and neonates are uncommon. Foetuses with cardiac tumour have risk for heart failure and hydrops fetalis. Therefore, an early decision for delivery should be made in the evidence of foetal compromise. Early neonatal care varies on tumour size, type, location and obstructive features. Antenatal detection of foetal cardiac tumours ensures better prenatal and postnatal management. We describe our 5- year experience in managing 5 cases of primary cardiac tumours from 1st January 2006 to 31st December 2010.