Gunma Prefectural Cardiovascular Center

Biliary inflammatory pseudotumor (IPT) of the liver is a rare benign tumor of which radiographic images, such as biliary stricture and dilatation, resemble those of cholangiocarcinoma (CC). Although repeated biliary cytology via endoscopic nasobiliary drainage (ENBD) is performed for differential diagnosis, a correct diagnosis remains difficult. The present study describes the case of a 76-year-old female patient with chronic liver disease. During surveillance, intrahepatic CC was suspected by imaging analyses; however, the carcinoembryonic antigen and CA19-9 levels were within normal ranges. Percutaneous core needle biopsy was not performed due to technical reasons; however, a left lobectomy was performed based on the diagnosis of malignancy by ENBD bile cytology. A pathological examination of the resected liver demonstrated biliary IPT. Reflecting on the cytological diagnosis of this case, a multi-reviewer re-evaluation of the biliary cytology of this IPT case and 2 cases of well-differentiated CC was then performed, which demonstrated difficulty in distinguishing between them. On the whole, ENBD cytology can play a limited role in differentiation between benign and malignant bile strictures. Surgical indication should be carefully determined and percutaneous core needle biopsy may be warranted in patients with normal tumor marker levels.

Central nervous system (CNS) prophylaxis is recommended for patients with diffuse large B-cell lymphoma (DLBCL) who are at high risk of CNS relapse. This study aimed to determine the impact of CNS prophylaxis on CNS relapse rates and overall survival (OS) in this patient population, as well as the optimal method for CNS prophylaxis. This was a retrospective analysis of 178 patients with DLBCL at high risk of CNS relapse who were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) or its derivatives with (N = 60) or without (N = 118) CNS prophylaxis. The 2-year CNS relapse rate was 17.6% in the all-prophylaxis group (HD-MTX 17.4%, IT 48.1%, and HD-MTX + IT 6.2%) and 13.0% in the non-prophylaxis group, with no significant difference between groups. However, HD-MTX + IT decreased the risk of CNS relapse. After a median follow-up of 72.8months, HD-MTX + IT addition significantly improved the 5-year OS (HD-MTX 73.5%, IT 44.4%, HD-MTX + IT 93.2%; non-prophylaxis group 58.0%; p = 0.013). This advantage was maintained in the multivariate analysis (hazard ratio: 0.160; 95% confidence interval: 0.039-0.663; p = 0.012). CNS prophylaxis with HD-MTX + IT improved the prognosis of patients with DLBCL at high risk of CNS relapse.

Pulsed field ablation (PFA) has emerged as a novel tool for catheter ablation of atrial fibrillation (AF) in recent years. This tool induces apoptosis through electroporation of cardiomyocytes by generating an electrical field. Due to different threshold for the electroporation among various cell/tissue types, PFA can selectively target cardiac myocytes, resulting in minimal damage to surrounding non-cardiac structures and thus offering a superior safety profile. However, electrical field strength diminishes as distance increases.

The simple patch closure technique is an alternative method for repairing ventricular septal rupture following myocardial infarction. This single-center study aimed to investigate the outcomes of ventricular septal rupture repair. This retrospective study included 23 patients who underwent initial surgery using the simple patch-closure technique between January 2009 and August 2024. Three primary endpoints were established: the rupture recurrence rate, in-hospital mortality rate, and mid-term survival rate. Survival curves were constructed using the Kaplan-Meier method. The mean patient age was 71.0years, and 13 patients were male. Intraoperative transesophageal echocardiography detected no residual shunts; however, five (21.7%) patients experienced rupture recurrence at a median of 21 (range, 12-150) days postoperatively, all requiring reoperation. The hospital mortality rate was 8.7%, with one death each in the early and late surgery groups. The 60month survival rate was 75.7% over a median follow-up period of 36months (range: 4-149months). The simple patch closure technique is safe and effective for ventricular septal rupture repair, even in early surgery; however, recurrence remains a challenge. Preventive measures, such as bovine pericardial patches and the double-patch technique for extensive infarctions, warrant further validation through larger studies with longer follow-up periods.

AimsParadoxical embolism from a patent foramen ovale (PFO) can cause cryptogenic stroke. Agitated saline contrast transthoracic echocardiography (ASC-TTE), with the Valsalva manoeuvre (VM), is crucial for diagnosing PFO. However, the VM is associated with false-negative outcomes. The party balloon inflation manoeuvre (PBIM) provides improved visualisation of provocation; however, its real-world efficacy remains uncertain. This study aimed to demonstrate the superiority of the PBIM over standard provocative methods (conventional or abdominal compression VM) during ASC-TTE.Methods and resultsThis multicentre retrospective observational registry study involved 117 consecutive patients (62.3% male; mean age, 56.2 ± 13.8 years) with PFO detected by transoesophageal echocardiography. During ASC-TTE, patients underwent PBIM and standard provocative methods. The primary endpoint was a five-point microbubble grading [representing a right-to-left (RL) shunt] change. Diagnostic performance of a significant RL shunt defined as Grade ≥2 in the five-point microbubble grading was assessed using McNemar’s test. Compared with standard provocative methods using Wilcoxon paired analysis, the PBIM resulted in microbubble upgrading in 51 patients, no change in 54, and downgrading in 12. The PBIM had a significantly higher microbubble grade than standard provocative methods [median, 3.0; interquartile range (IQR), 3.0–4.0 vs. 3.0; IQR, 1.7–4.0; P < 0.001]. For significant RL shunts, where transcatheter PFO closure would be clinically advised, PBIM improved diagnostic performance from 75.2% to 91.5% (P < 0.001).ConclusionPBIM indicated transcatheter PFO closure in patients with cryptogenic stroke and suspected PFOs, particularly those with false-negative diagnoses for shunts. PBIM demonstrates greater efficacy than standard provocative methods during ASC-TTE, providing clinical practicality.Clinical Trial RegistrationuMIN Clinical Trials Registry UMIN000051954 (https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000058907).