Статті в журналах з теми "Tache focale"

«J’vais bien, j’suis pas malade !», disent-ils fièrement, droit dans les yeux, comme s’il fallait déplacer la mire, ou changer de focale… Santé : «État de bien-être physique, psychique et social», dit l’OMS. Sans doute, la parole se gagne-t-elle, c’est l’un des objets de la consultation proposée aux jeunes des Bosquets de Montfermeil, ou du Bois-du-Temple, de la Forestière, du Chêne Pointu, autres appellations bucoliques de quartiers de Clichy-sous-Bois. Voilà donc ce qui peut être observé, et donc dit, au Point Santé de la mission locale, après cinq années d’exercice.

A 58-year-old male patient presented with advanced hepatocellular carcinoma underwent transarterial chemoembolization (TACE) for hepatic focal lesions followed by TACE for a solitary hilar nodal metastasis combined with regorafenib therapy. One month later, the patient developed progressive jaundice. Work-up showed obstructive jaundice with intrahepatic biliary radicles dilatation. The diagnosis and treatment was achieved by combining endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography and showed uncommon cause of obstructive jaundice due to common bile duct compression by a choledocho-nodal fistula following TACE of a metastatic hilar lymph node.

A short ischemic event (ischemic preconditioning (IPC)) can result in subsequent resistance to severe ischemic injury (ischemic tolerance (IT)). The expression and neuroprotective role of tumor necrosis factor (TNF- α) have been described in models of IPC and we have showed the participation of its processing enzyme, the TNF- α convertase enzyme (TACE) in this process. We have now decided to explore the expression and localization of TNF receptors (TNFR) as well as other signalling mechanisms involved in IT. A period of 10 mins of temporary middle cerebral artery occlusion (tMCAO) was used for focal IPC. To evaluate the ability of IPC to produce IT, permanent MCAO was performed 48 hours after IPC. Ischemic preconditioning produced a reduction in infarct volume, as we showed previously. Ischemic preconditioning caused upregulation of neuronal TNFR1 that was reduced by the selective TACE inhibitor BB1101. Intracerebral administration of TNFR1 antisense oligodeoxynucleotide, which caused a reduction in TNFR1 expression, inhibited the IPC-induced protective effect, showing that TNFR1 upregulation is implicated in IT. Moreover, treatment with BB1101, TNFR1 antisense and lactacystin—a specific proteasome inhibitor—blocked IPC-induced NF- κB. Immunohistochemical studies showed the expression of TACE and TNFR1 in neurons. In summary, these data show that IPC produces neuronal upregulation of TACE and TNFR1, and that the pathway TACE/TNF- α/TNFR1/NF- κB is involved in IT.

106 Background: The objective of this work was to develop recommendations for the organization and delivery of focal tumor ablation services. New, minimally-invasive ablation technologies such as radiofrequency ablation (RFA), microwave ablation (MWA), and transcatheter arterial chemoembolization (TACE) offer treatment options for patients with a variety of cancers. These emerging therapies can improve patient care (minimize side-effects, offer more rapid recovery with comparable or enhanced outcomes) compared to traditional approaches. However, they are often resource intensive, necessitating a planned system-level approach to ensure appropriate access to high quality services while optimizing care and resource utilization. Methods: This work was led by an Advisory Committee with regional, clinical, administrative and patient representatives and was based on best available evidence, current practice in Ontario, Canada, and guidance from other jurisdictions and experts in the field. A variety of data sources (clinical, system, provider), consultation with external stakeholders and consensus building supported the final recommendations. Results: Thirteen recommendations were developed. Clinical criteria are detailed for RFA for liver, kidney and lung tumors and TACE for hepatocellular carcinoma. MWA is not recommended for lung, liver or kidney tumors. System recommendations include infrastructure (capital equipment, multidisciplinary management and case conference review), the importance of volume-related expertise, and oversight for funding and collaborative planning. Results were broadly disseminated through 12 stakeholder groups connecting with over 40,000 individuals. Conclusions: A systematic approach to understanding opportunities and challenges for focal tumor ablation therapies resulted in multi-level recommendations spanning clinical criteria through to quality oversight. These recommendations will support improvements in care delivery in daily practice and at the system level.

Contrast enhancement at the margins/rim of embolization areas in hepatocellular-carcinoma (HCC) lesions treated with transarterial chemoembolization (TACE) might be an early prognostic indicator for HCC recurrence. The aim of this study was to evaluate the predictive value of rim perfusion for TACE recurrence as determined by perfusion CT (PCT). A total of 52 patients (65.6 ± 9.3 years) underwent PCT directly before, immediately after (within 48 h) and at follow-up (95.3 ± 12.5 days) after TACE. Arterial-liver perfusion (ALP), portal-venous perfusion (PVP) and hepatic-perfusion index (HPI) were evaluated in normal liver parenchyma, and on the embolization rim as well as the tumor bed. A total of 42 lesions were successfully treated, and PCT measurements showed no residually vascularized tumor areas. Embolization was not entirely successful in 10 patients with remaining arterialized focal nodular areas (ALP 34.7 ± 10.1 vs. 4.4 ± 5.3 mL/100 mL/min, p < 0.0001). Perfusion values at the TACE rim were lower in responders compared to normal adjacent liver parenchyma and edges of incompletely embolized tumors (ALP liver 16.3 ± 10.1 mL/100 mL/min, rim responder 8.8 ± 8.7 mL/100 mL/min, rim non-responder 23.4 ± 8.6 mL/100 mL/min, p = 0.005). At follow-up, local tumor relapse was observed in 17/42, and 15/42 showed no recurrence (ALP 39.1 ± 10.1 mL/100 mL/min vs. 10.0 ± 7.4 mL/100 mL/min, p = 0.0008); four patients had de novo disseminated disease and six patients were lost in follow-up. Rim perfusion was lower compared to adjacent recurring HCC and not different between groups. HCC lesions showed no rim perfusion after TACE, neither immediately after nor at follow-up at three months, both for mid-term responders and mid-term relapsing HCCs, indicating that rim enhancement is not a sign of reactive hyperemia and not predictive of early HCC recurrence.

Hepatocellular carcinoma (HCC) is a common malignancy worldwide. HCC-related mortality is high because most cases are diagnosed at an advanced stage. HCCs are relatively resistant to radiation and the liver is unable to tolerate the radiation doses required to achieve tumoricidal effects by standard external-beam radiation. Focal radiation techniques employing a 3D approach have been shown to safely permit higher levels of radiation to targeted regions within the liver. Delivery of therapy through hepatic artery branches preferentially affects HCC tumors and spares the surrounding liver parenchyma. Selective targeting of radionuclides to tumors has been shown to achieve high radiation dose ratios. Transarterial radionuclide therapies have been developed with the objective of achieving selective intra-arterial delivery of radiotherapy, including radioactive iodine-131 (131I), rhenium-188 (188Re), yttrium-90 (90Y) (resin or glass microspheres), and others. These treatments have been used to treat HCC via a selective transarterial approach as an alternative to TACE. Portal vein thrombosis (PVT) is a relative contraindication to transarterial chemoembolization (TACE); in contrast, high specific activity radiomicrospheres do not occlude a significant portion of the hepatic arterial vascular bed and can therefore be used in patients with PVT. The devices, toxicities, and results with use of the available radioembolic devices are reviewed in this article.

The role of stereotactic body radiotherapy (SBRT), which can deliver high radiation doses to focal tumors, has greatly increased in not only early-stage hepatocellular carcinoma (HCC), but also in portal vein or inferior vena cava thrombi, thus expanding this therapy to pre-transplantation and the treatment of oligometastases from HCC in combination with immune checkpoint inhibitors (ICI). In early-stage HCC, many promising prospective results of SBRT have been reported, although SBRT is not usually indicated as a first treatment potion in localized HCC according to several guidelines. In the treatment of portal vein or inferior vena cava tumor thrombi, several reports using various dose-fraction schedules have shown relatively good response rates with low toxicities and improved survival due to the rapid advancements in systemic therapy. Although SBRT is regarded as a substitute therapy when conventional bridging therapies to transplantation, such as transarterial chemoembolization (TACE) and radiofrequency ablation (RFA), are not applicable or fail in controlling tumors, SBRT may offer advantages in patients with borderline liver function who may not tolerate TACE or RFA, according to several reports. For oligometastases, the combination of SBRT with ICI could potentially induce an abscopal effect in patients with HCC, which is expected to provide the rationale for SBRT in the treatment of oligometastatic disease in the near future.

In 2007 the Italian National Institute of Health issued Guidelines for the use of diagnostic imaging techniques in the detection and the characterization of focal liver lesions. Since the publication of these guidelines in 2008, several studies relating to this topic have been published. Thus, we felt the need to assess whether interval research and new advancements in diagnostic imaging have yielded new evidence that should modify the recommendations that were previously issued. The literature search confirmed the appropriateness of the current guidelines. Although most modalities did not show substantial changes, interval introduction of DW-MRI is a valuable technique with a high diagnostic accuracy in the detection and characterization of FLLs, and its sensitivity is higher when combined with MRI. Abbreviations: AASLD: American Association for the Study of Liver Disease; CE-IOUS: contrast-enhanced intraoperative US; CEUS: contrast-enhanced ultrasound; CRLM: colorectal liver metastasis; DW-MRI: diffusion weighted MRI; EOB-MRI: gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid MRI; FLLs: focal liver lesions; HCC: hepatocellular carcinoma; LR+: positive likelihood ratio; LR-: negative likelihood ratio; NPV: negative predictive value; PET: positron emission tomography; PPV: positive predictive value; RF: radiofrequency; TACE: transarterial chemoembolization

Microglia respond to focal cerebral ischemia by increasing their production of the neuromodulatory cytokine tumor necrosis factor, which exists both as membrane-anchored tumor necrosis factor and as cleaved soluble tumor necrosis factor forms. We previously demonstrated that tumor necrosis factor knockout mice display increased lesion volume after focal cerebral ischemia, suggesting that tumor necrosis factor is neuroprotective in experimental stroke. Here, we extend our studies to show that mice with intact membrane-anchored tumor necrosis factor, but no soluble tumor necrosis factor, display reduced infarct volumes at one and five days after stroke. This was associated with improved functional outcome after experimental stroke. No changes were found in the mRNA levels of tumor necrosis factor and tumor necrosis factor-related genes (TNFR1, TNFR2, TACE), pro-inflammatory cytokines (IL-1β, IL-6) or chemokines (CXCL1, CXCL10, CCL2); however, protein expression of TNF, IL-1β, IL-6 and CXCL1 was reduced in membrane-anchored tumor necrosis factorΔ/Δ compared to membrane-anchored tumor necrosis factorwt/wt mice one day after experimental stroke. This was paralleled by reduced MHCII expression and a reduction in macrophage infiltration in the ipsilateral cortex of membrane-anchored tumor necrosis factorΔ/Δ mice. Collectively, these findings indicate that membrane-anchored tumor necrosis factor mediates the protective effects of tumor necrosis factor signaling in experimental stroke, and therapeutic strategies specifically targeting soluble tumor necrosis factor could be beneficial in clinical stroke therapy.

Abstract Tissue inhibitors of metalloproteinases (TIMPs) inhibit matrix metalloproteinases and some members of a disintegrin and metalloproteinase domain (ADAM) family. In addition, recent studies unveiled novel functions of TIMPs in the regulation of apoptosis. TIMP-1 inhibits intrinsic apoptosis by inducing TIMP-1 specific cell survival pathways involving focal adhesion kinase (FAK). TIMP-3, however, was shown to enhance extrinsic cell death by inhibiting the shedding of the cell surface death receptors mediated by tumor necrosis factor-α converting enzymes (TACE/ADAM-17). Here, we examined whether TIMP-1, an inhibitor of some of the ADAM family members, enhances the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)–induced extrinsic apoptotic pathway. Surprisingly, we found that TIMP-1 effectively protects human breast epithelial cells from TRAIL-induced apoptosis, demonstrating opposite roles of TIMP-1 and TIMP-3 for the regulation of extrinsic apoptosis. TIMP-1 inhibition of TRAIL-induced apoptosis does not depend on its ability to inhibit matrix metalloproteinases or ADAM activities and is unrelated to its ability to stabilize active or decoy death receptors. Importantly, inhibition of PI 3-kinase signaling by wortmannin and down-regulation of FAK expression using siRNA significantly diminish TIMP-1 protection of human breast epithelial cells against TRAIL-induced extrinsic apoptosis. In addition, the in vitro three-dimensional culture studies showed that TIMP-1 inhibits lumen formation and apoptosis during morphogenesis of MCF10A acini. Taken together, these studies suggest that TIMP-1 may exert oncogenic activity in breast cancer through inhibition of both intrinsic and extrinsic apoptosis involving the FAK survival signal transduction pathway.

AbstractThe rising prevalence of the metabolic syndrome has led to an increase of non-alcoholic fatty liver disease (NAFLD), and its progressive-inflammatory form called non-alcoholic steatohepatitis (NASH). In recent years, NAFLD and NASH have become major risk factors for developing liver cirrhosis and hepatocellular carcinoma (HCC). In this case, we report a 46-year-old patient with type 2 diabetes mellitus and metabolic comorbidities including obesity and arterial hypertension, who was referred because of rising liver enzymes. After clinical and diagnostic evaluation, the patient was diagnosed with NASH-associated liver cirrhosis, Child-Pugh stage B. A normal blood sugar level was difficult to achieve, and the patient presented with consistently elevated HbA1c-levels irresponsive to insulin therapy. Due to the underlying liver cirrhosis, the patient was enrolled in the HCC-surveillance program. Sonography during follow up showed a focal lesion. On magnetic resonance imaging (MRI), the diagnosis of HCC (BCLC stage A) was confirmed based on typical contrast enhancement and portal-venous wash-out. The patient was evaluated for liver transplantation with a labMELD of 17, and an intermittent therapy with TACE was initiated. Only 2 months after liver transplantation, the patient developed severe and lethal complications. Overall, this case highlights the different medical issues of patients with metabolic syndrome developing a chronic liver disease. In this patient, a rapid progression from NASH-associated liver cirrhosis to HCC was seen, and therefore highlights the importance of close surveillance to identify and treat potential risk factors early in the course of the disease.

Liver cancer is characterized by high mortality and low survival rates in most countries of the world. According to the WHO data, more than 1.3 million people with liver cancer die annually in the world and according to the data of the 9th volume of "Cancer on five continents" - the highest standardized incidence rates are in Korea - 44.9 per 100 thousand population as well as in Thailand, Japan, China. Low rates were in Algeria, India, Belgium and the Netherlands. In Russia 61.5% of patients die of liver cancer progression in the first year after diagnosis [1,2].<br /> Information on the global burden of cancer in 2018 showed that the specific weight of liver cancer in the structure of malignant neoplasms (MN) is 8.2%, and in 2020 - 8.3% [3].&nbsp;&nbsp;<br /> The worldwide peculiarity of liver cancer is its late diagnosis. Several evidence-based treatment options for liver cancer are currently available: liver transplantation for hepatocellular liver cancer (HCC) (according to the Milan criteria), radiofrequency ablation as a radical treatment option (RFA), chemoembolization for intrahepatic cholangiocarcinoma (TACE), and the administration of Sorafenib as systemic therapy [4].<br /> Current approaches for the treatment of early-stage primary liver cancer are represented by hepatic RFA, and the efficacy of this approach depends on the subjective attentiveness and visual acuity of the clinician. The latest technique used in liver RFA is the hyperspectral imaging which utilize objective assessment [2].<br /> Ultrasound is usually used to detect liver lesions, but the detection rate is low for many reasons, such as clinician skills and technical capabilities. Modern approaches of diagnostic capabilities, such as contrast-enhanced ultrasound integrated imaging (CEUS) and comprehensive ultrasound imaging - contrast-enhanced CT (CECT) or contrast-enhanced MRI (CEMRI) for visualization of focal liver lesions (FLL) - increase the confidence of the interventional physician so it should be recommended for use as a routine procedure [5-6].<br /> The ratio of morbidity and mortality in many countries reaches 91.6%, which represents the third most important cause of cancer deaths [7-9].

Abstract Introduction Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted as the established treatment options for patients diagnosed with early-stage hepatocellular carcinoma (HCC) who are deemed unfit for surgical procedures. However, the effective implementation of these techniques is hindered by various challenges, primarily associated with the precise targeting of tumors within the liver. The utilization of thermal ablative methods is not recommended for hepatocellular carcinoma (HCC) that is located near intestinal loops, bile ducts, or in eccentric positions. The unmet need for non-thermal methods in the treatment of hepatocellular carcinoma (HCC) was addressed following the introduction of irreversible electroporation (IRE) as an innovative approach. Aim of the work To assess the efficacy, safety, and outcomes of IRE in the treatment of difficult-located HCC compared to transarterial chemoembolization (TACE). Methods This is a prospective study that included 24 patients with HCC who presented to the National Hepatology and Tropical Medicine Research Institute (NHTMRI) during the period from January 2017 to January 2020. Ten patients underwent IRE, while 14 patients underwent TACE. Results Sixteen patients (66.7%) were males; eight patients were females (33.3%). Their median age was 60.5 years (48–70 years). Seventeen patients (70.8%) were Child–Pugh class A, while seven patients (29.2%) were Child–Pugh class B. All the study population had a single focal lesion; the mean size of the focal lesions was 2.94 ± 0.59 cm. The most frequent difficult locations of HCC were segment V focal lesions adjacent to both the common bile duct and portal vein in eight patients (33.3%) followed by lesions adjacent to the inferior vena cava in five patients (20%) followed by the subcapsular lesions in three patients (12.5%) and lesions adjacent to the right kidney in two patients (8.3%). Complete response (CR) was higher in the IRE group (80%) compared to the TACE group (50%). Clinical decompensation occurred in six patients in the IRE group (60%) and eight patients in the TACE group (57.1%) (P value 1). Recurrence occurred in five patients (50%) treated with IRE and in seven patients (50%) treated with TACE (P value 1). Within the IRE group, two patients (20%) remained alive; on the other hand, within the TACE group six patients (42.9%) remained alive by the end of the study (P value 0.388). Conclusion Our data suggest that IRE is an effective procedure in the treatment of difficult-located HCC in terms of complete response, fewer sessions, and fewer side effects as compared to TACE.

Abstract Background Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy of adults. One of the established treatment procedures performed worldwide for HCC is transcatheter arterial chemoembolization (TACE). By using conventional angiography in TACE, we can detect and identify the vascular anatomy of the liver through obtaining 2D images. Recently C-arm cone beam computed tomography (CBCT) is introduced for obtaining cross-sectional and three-dimensional (3D) images for better visualization of small tumors and their feeding arteries. Results The number of detected focal lesions by angiography was 51 compared to 87 focal lesion detected by CBCT; of those, 45 and 77 were active lesions by both procedures respectively. For lesions, less than 1 cm CBCT detected 23 lesions while angiography detected only one lesion. Angiography detected 87 feeding arterial branch while cone beam CT-HA detected 130 branches to the same number of target lesion. Feeder tractability and confidence were better by CBCT. Conclusion CBCT is superior to angiography in tumor detectability, detection of lesions less than 1 cm, feeder detection, and feeder traction; however, conventional angiography and DSA are irreplaceable. Thus, combination of CBCT with angiography during TACE produces better results and less complication.

Introduction: Long non-coding RNA (lncRNA) refers to a category of non-coding RNA molecules exceeding 200 nucleotides in length, which exerts a regulatory role in the context of ovarian development. There is a paucity of research examining the involvement of lncRNA in the regulation of ovary development in Taihe Black-Bone Chickens. In order to further investigate the egg laying regulation mechanisms of Taihe Black-Bone Chickens at different periods, transcriptome analysis was conducted on the ovarian tissues at different laying periods.Methods: This study randomly selected ovarian tissues from 12 chickens for RNA-seq. Four chickens were selected for each period, including the early laying period (102 days, Pre), the peak laying period (203 days, Peak), and the late laying period (394 days, Late). Based on our previous study of mRNA expression profiles in the same ovarian tissue, we identified three differentially expressed lncRNAs (DE lncRNAs) at different periods and searched for their cis- and trans-target genes to draw an lncRNA-mRNA network.Results and discussion: In three groups of ovarian tissues, we identified 136 DE lncRNAs, with 8 showing specific expression during the early laying period, 10 showing specific expression during the peak laying period, and 4 showing specific expression during the late laying period. The lncRNA-mRNA network revealed 16 pairs of lncRNA-target genes associated with 7 DE lncRNAs, and these 14 target genes were involved in the regulation of reproductive traits. Furthermore, these reproductive-related target genes were primarily associated with signaling pathways related to follicle and ovary development in Taihe Black-Bone Chickens, including cytokine-cytokine receptor interaction, TGF-beta signaling pathway, tyrosine metabolism, ECM-receptor interaction, focal adhesion, neuroactive ligand-receptor interaction, and cell adhesion molecules (CAMs). This study offers valuable insights for a comprehensive understanding of the influence of lncRNAs on poultry reproductive traits.

Abstract Background Hepatic arterial anatomy is important in performing many surgical and endovascular procedures. Familiarity with variations in the hepatic arterial anatomy is essential to achieving adequate embolization. In some patients, in addition to anatomic variations of the hepatic arteries, different extrahepatic collateral arteries may provide partial or total vascular supply to hepatocellular carcinoma (HCC), which makes transcatheter arterial chemoembolization (TACE) technically challenging. We aim to evaluate the different feeding vessels of HCC using multi-detector computed tomography angiography (MDCTA) as a pre-procedural step before planning suitable management. Results One hundred patients with 150 focal HCC lesions were involved in our study. The anatomy of the blood supply and the morphological characteristics of HCC, including the size, location, and history of previous hepatitis, were quantitatively assessed and statistically analysed. The number of patients who had classic hepatic arterial supply for the HCC lesions in our study was 54 (54%). The number of patients with additional extrahepatic supply is 26, while the number of patients with anatomical vascular variants is 20. Among these 26 patients with extrahepatic (parasitic) blood supply, six patients were supplied by the right inferior phrenic artery, four patients were supplied by the right internal mammary artery, and two patients were supplied by each other type of extrahepatic feeder, which are the left inferior phrenic artery, left internal mammary artery, left gastric artery, cystic artery, right lumbar artery, direct branch from the aorta, omental arteries, right renal artery, and LHA from the LGA. Twelve of the 20 patients with anatomical vascular variants had replaced RHA from the SMA; four patients had replaced LHA from the LGA; two patients had replaced RHA from the GDA; and two patients had replaced CHA from the SMA. Only 50 cases of CT findings were correlated with the data from the interventional procedures of these patients. Conclusions Because of the differences in HCC blood supply between typical, parasitic, and anatomical vascular variants, MDCTA has significant clinical significance prior to TACE and any interventional procedure.

Abstract The aim of this work was to assess HCC cases after trans-arterial chemoembolization by subtraction dynamic contrast enhanced MRI to detect its accuracy, sensitivity and specifity in detecting residual tumor and assess the need for further treatment. Patients and methods: This was a retrospective comparative study will be conducted on 35 patients hepatocellular carcinoma (HCC); to assess HCC cases after trans-arterial chemoembolization (TACE) by subtraction dynamic contrast enhanced MRI to detect its accuracy, sensitivity and specificity in detecting residual tumor and assess the need for further treatment. We found that; the mean age of all patients was (62.31 ± 7.14) years. Regarding gender of the patients, the majority (88.6%) of patients were males; while only (11.4%) were females. Regarding residence, the majority (77.1%) of patients live in rural areas, while only (22.9%) live in urban areas. Comparative study between D-MRI and DS-MRI assessments revealed; highly significant increase in disease detection rate, sensitivity, and NPV in favor of DS-MRI in HCC patients; with highly significant difference (p &lt; 0.01 respectively). Comparative study between D-MRI and DS-MRI assessments revealed; non-significant difference in specificity and PPV in HCC patients; with non-significant difference (p &gt; 0.05). We found a moderate agreement between D-MRI and DS-MRI assessments of reactivity among HCC patients (kappa =0.44). Conclusion: Dynamic MRI is valuable in detecting recurrent lesions however, this value is augmented by the addition of subtraction technique especially in lesions having high signal before administration of contrast medium. So we recommend adding the subtraction technique in the protocol of MRI in the follow up after transarterial chemoembolization as it increases the diagnostic confidence. This may help to facilitate the appropriate clinical management of patients including the need for re-treatment sessions.

Complex fractionated atrial electrograms (CFEs) have been described as a target during atrial fibrillation (AF) ablation, however, the mechanism leading to CFEs is poorly understood. We used noncontact mapping in a canine model of AF to determine the activation patterns in areas characterized by CFEs. Sustained AF was induced in 5 canines with 12 weeks of atrial tachy-pacing. A noncontact Multielctrode Array (MEA) was deployed in the left atrium (LA) and a contact bipolar CFE map was constructed. Areas of CFE were outlined on the map, and the MEA was then used to reconstruct wavefront propagation through CFE areas during 3 separate recording segments for each CFE site. There were 18 CFE regions identified (3.8/dog) and 54 noncontact CFE activation sequences studied. Activation patterns during the three recoding segments over time were consistent in 11/18 CFE regions (61%). The CFE regions were stereotypically located at the PV/LA junctions and the LA roof. Thirty-five CFE regions were characterized by wavefront collision, usually between circulating LA wavefronts and entry/exit from the PVs. Thirteen CFE regions were noted to be the central functional barrier of a rotor (Figure ) or partial rotor. Five regions were characterized by repeated conduction through a central isthmus with wavebreak. In this pacing-induced AF model, common causes of CFEs include collision between circulating LA wavefronts conduction through channels of functional block, the central vortex of a circulating rotor. The vast majority of these CFE regions were caused by heterogeneous anatomy and areas of functional block rather than true “drivers” of AF.

Abstract Introduction Recurrent atrial tachycardias (AT) after ablation of persistent atrial fibrillation (AF) including substrate modification on top of pulmonary vein isolation (PVI) only, are complex and challenging procedures. Key to an effective reablation is the understanding of the individual pathomechanism and therewith identification of proper ablation targets. The aim of this study was to evaluate the potential of 3-D high density mapping to better define the underlying tachy-mechanism and develop individual successful ablation strategies. Methods 31 consecutive patients (pts) with stable ATs were prospectively included. High density activation mapping was performed with a 3-D mapping system using a mapping catheter with 5 arms equipped with 4 electrodes (2–6-2 spacing) each. The activation mapping was performed using software supported automated mapping (Tissue proximity indication on, strict to moderate settings for position and local activation time settings) aiming for a minimum of 2000 mapping points with minimum density of 1mm. The maps were analyzed and an ablation strategy developed based on the suspected AT mechanism. Acute success was defined as termination of the arrhythmia during ablation following the initial strategy: in focal AT, termination with ≤3 ablations in the predefined area. In macroreentry tachycardia, termination during completion of predefined linear target. Results 31 pts (16 f/15 m), age 68±9 y with ECG diagnosed AT after ablation of persistent AF were included. At baseline patients had undergone a mean of 2.2 (range 1 to 6) ablation procedures for persistent AF with the first procedure performed 2,2 y (range 3 mon– 8 y) earlier. In 81% of the pts additional ablations (≥3 lines and/or rotor ablation) were added to PVI and/or Re-PVI in earlier procedures. 41 ATs in 31 pts with a mean cycle length of 328 ms (range 200 to 580 ms) were analyzed: 58% macroreentries (24/41), 22% microreentries (9), 10% focal (4). 4 AT maps were inconclusive (3 after multiple previous ablations and in one patient due to multiple alternating ATs, 1 was defined focal in retrospective analysis). All 13 ATs with focal / microreentrant pattern were successfully ablated with ≤3 ablations and 18/24 of the macroreentries with the line attempted first after identification of an isthmus or zone of slow conduction. This adds up to an 84% (31/37) acute success rate of ablation of the identified ablation target and a first attempt success of 76% of all ATs mapped. The total procedure time was 134±43 min (60 to 220 min), fluoroscopy 17±9 min. With a mean FU of 8±6 mon (range 4–25 mon) success was 61%, defined freedom of recurrence without antiarrhythmic drugs. Conclusion High density mapping of recurrent ATs after ablation of persistent AF is an effective tool to reveal the pathomechanism of the tachycardia and develop an effective individual ablation strategy in complex substrates with a high acute and mid-term success rate.

Une erreur que la médecine a longtemps partagée est d’attribuer à une envie ou à un effet de l’imagination de la mère pendant la gestation, les difformités, excroissances ou taches qu’un enfant porte en naissant. L’imagination serait capable d’imprimer à la matière des modifications extérieures et aurait des incidences sur les perceptions et le développement sensoriel du fœtus. Revenant brièvement sur la généalogie et la postérité du topos, cet article se focalise sur les succès et réfutations du paradigme malebranchiste au xviiie siècle, au travers d’un corpus de textes de vulgarisation médicale où les débats opposent les partisans de l’imagination (imaginationistes) pour lesquels l’émotion altère les organes du fœtus et les détracteurs de cette thèse (anti-imaginationistes) qui n’y voient que préjugé. Les systèmes mécanistes avaient en commun de faire l’économie de l’âme pour expliquer la vie. Bien que chaque époque possède son système herméneutique de représentations et que la médecine — étroitement dépendante des conceptions philosophiques et morales de son temps — soit aussi une production culturelle, il n’est pas inintéressant néanmoins de s’interroger sur la fortune d’un motif et l’actualité scientifique de la question. Que perçoit le bébé in utero ? Ressent-il la douleur de sa mère ? Jusqu’où l’imaginaire et le vécu maternel peuvent-ils « marquer » le corps de l’enfant ? Éclairées par les technologies de l’imagerie fonctionnelle, des recherches récentes sur la vie embryonnaire reviennent sur le lien symbiotique des interactions mère-fœtus. Des convergences apparaissent entre ce xviiie siècle et notre xxie siècle. En aucun cas, on a voulu opposer les scientifiques d’aujourd’hui en prise solide avec le réel et leurs prédécesseurs en proie à l’imagination. La science, quelle que soit l’époque, se nourrit toujours d’imaginaire.

Introduction: In 1961 J. A. Hayes from Boston City Hospital reported in the British Heart Journal a case of myocarditis in a young man who died. Autopsy revealed inflammatory cells confined to the right heart. With the advent of cardiac MRI in the 1990s and its capability of detecting myocardial edema due to inflammation, it became apparent the some cases of arrhythmogenic right ventricular dysplasia (ARVD) were actually myocarditis. Since then, there has been no systematic study of right heart myocarditis. Hypothesis: Myocarditis confined to the right heart is detectable with cardiac MRI. Methods: An institutional cardiac imaging database was queried for all cases of CMR diagnosed myocarditis using published criteria, requiring 2 of the following 3 criteria: Myocardial enhancement on T2 weighted imaging (T2E), “early” myocardial gadolinium uptake (EGE) and standard late gadolinium enhancement (LGE). Patients with CMR evidence of myocarditis confined to the right heart constituted the study population. These patients were also required to have no evidence of left heart myocarditis, ie no T2E, EGE or DHE of LV myocardium. Results: 172 of 3,250 patients (5.3%) had evidence of myocarditis by CMR criteria. Of these 172 patients with myocarditis, 16(9.3%) were confined to the right heart. A typical case of right heart myocarditis is shown below, a T2 weighted 4 chamber CMR image showing myocardial enhancement(edema). All 16 patients complained of fatigue and palpitations. 4 of 16 had mild right heart failure on exam and RV hypokinesis on CMR or 2-D echo. 14 of 16 had documented atrial or ventricular tachy-arrhythmias. 14 of 16 had contiguous focal pericarditis (also confined to the right heart). Conclusions: Myocarditis confined to the right heart is evident in approximately 9% of patients with a CMR diagnosis of myocarditis. Palpitations and fatigue are the most common symptoms. Nearly all have a documentable arrhythmia and evidence of contiguous pericarditis on CMR.

Introduction: We present a case report of posterior reversible leukoencephalopathy syndrome (PRES) following transarterial chemoembolization (TACE) of liver metastasis of an intestinal neuroendocrine tumour.Case presentation: A 62-year-old female was evaluated for progressive bilateral vision loss following transarterial chemoembolization (TACE) of hepatic metastasis of a midgut carcinoid tumour with cisplatin. Vital signs were remarkable for significant hypertension (170-210/85-110) since having undergone TACE (baseline BP 136/74), despite pre-procedure administration of octreotide. Blood pressure failed to correct with administration of amlodipine, hydralazine, captopril and labetalol infusion but responded promptly to octreotide infusion. Magnetic resonance imaging showed findings compatible with PRES. The patient’s vision gradually corrected to her baseline over 2 days. Conclusion: TACE for neuroendocrine tumours can be complicated by carcinoid crisis despite pre-administration of octreotide. Rarely, this may present as a hypertensive emergency of which PRES is a manifestation. Prompt recognition and treatment with high dose octreotide are important and can avoid permanent neurological injury in patients.RésuméIntroduction : Il s’agit d’une étude de cas de syndrome de leuco encéphalopathie réversible postérieure (SERP) consécutive à la chimioembolisation transartérielle (CETA) d’une métastase hépatique d’une tumeur neuro-endocrinine intestinale.Présentation du dossier: Une femme de 62 ans est évaluée pour une perte de vision bilatérale progressive à la suite de la chimioembolisation transartérielle (CETA) de métastases hépatiques d’une tumeur du tube digestif effectuée au moyen du cisplatine. Les signes vitaux sont remarquables malgré une hypertension importante (170-210/85-110) depuis la CETA (p.a. de base 136/74) et l’administration d’octréotide préalable à l’intervention. La pression artérielle ne s’est pas corrigée avec l’administration d’amlodipine, d’hydralazine, de captopril et de labétalol en perfusion, mais a répondu promptement à l’octréotide en perfusion. Une imagerie par résonnance magnétique a fourni des résultats compatibles avec un diagnostic de SERP. La vision de la patiente s’est graduellement corrigée pour revenir à son état habituel en deux jours.Conclusion : Dans le cas de tumeurs neuro-endocriniennes, la CETA peut être compliquée d’une crise carcinoïde malgré l’administration d’octréotide au préalable. Cette condition peut, quoique rarement, représenter une urgence hypertensive dont le SERP est une manifestation. L’identification rapide de la condition et un traitement à l’aide d’octréotide à dose élevée sont de la plus haute importance et peuvent éviter des dommages neurologiques permanents.Carcinoid syndrome is a syndrome classically consisting of diarrhea, paroxysms of cutaneous flushing with or without hypotension and bronchospasm arising most frequently in the setting of hepatic metastases originating from midgut carcinoid tumours. However, these neuroendocrine tumours can synthesize a wide variety of polypeptides, prostaglandins, and biogenic amines and hence present atypical clinical manifestations such as pellagra, abdominal pain, right-sided heart failure from valvular lesions and paroxysmal hypertension. Tumour manipulation may result in a massive influx of hormones into the systemic vasculature, potentially resulting in life threatening swings in blood pressure, cardiac arrhythmias and bronchoconstriction, even in patients without liver metastases or preoperative carcinoid syndrome.1 We present a case report of hypertensive emergency presenting as posterior reversible leukoencephalopathy syndrome (PRES) after transarterial chemoembolization (TACE) of a hepatic metastasis of carcinoid tumour.Case PresentationA 62-year-old caucasian female was evaluated on the surgical ward for progressive bilateral vision loss about 10 hours following transarterial chemoembolization (TACE) of a hepatic metastasis of a midgut carcinoid tumour (Figure 1, Figure 2) with Lipiodol and cisplatin. Premedication with octreotide 100 mcg subcutaneously and dexamethasone 8 mg IV pre-procedure was given, and post-procedure orders were given for dexamethasone 4 mg bid, ondansetron as needed and D5% NaCl 0.45% at a rate of 150 mL/h. The rest of her past medical history was unremarkable, specifically without history of hypertension, cerebrovascular disease, or clinical manifestations of carcinoid syndrome prior to admission. She had undergone two intra-abdominal surgeries without complication. Her usual medication was limited to inhaled glycopyrronium and indacaterol. Figure 1. Axial computed tomography scan of hepatic metastasis. A mass is visible in hepatic parenchyma corresponding to a metastasis of the midgut carcinoid tumour. Figure 2. Fluroscopic image of transarterial chemoembolization of hepatic metastasis. Upon evaluation, the patient was somnolent but otherwise well oriented. Eye exam confirmed bilateral 0/20 vision though pupils were 4 mm and reactive. On motor exam, the patient had diffuse hyperreflexia with upgoing plantar reflexes but without focal weakness. Chart review was remarkable for blood pressures ranging from 170-210/85-110 since TACE (pre-procedure blood pressure 136/74). A presumptive diagnosis of PRES due to cisplatin was made.Initial cerebral computed tomography scan was suspicious for a right occipital sub-cortical hypodensity of 3 cm, possibly of ischemic nature. IV fluids were discontinued (NaCl 0.9% at a rate of 250 mL/h) and anti-hypertensive agents were begun. After failure of improvement of blood pressure or symptoms despite amlodipine, hydralazine, labetalol, and captopril, a diagnosis of carcinoid crisis was suspected and octreotide 300mcg IV bolus followed by an infusion of 50 mcg/h was started. The suspected diagnosis of carcinoid crisis was later confirmed by 24h urinary 5-HIAA dosing at 141.4 umol/day (normal 0–42, previously within normal limits pre-operatively). Serum chromogranin A was also elevated at 138.2 ug/L (normal 0–82), compatible with a neuroendocrine tumour.Characteristic changes of PRES were seen on cerebral magnetic resonance imaging (MRI) (Figure 3) including predominantly sub-cortical hyperintensities in the bilateral parietal and occipital lobes on T2 and FLAIR sequences which were also hyperintense on diffusion-weighted imaging (DWI), likely from T2 shine through, and apparent diffusion coefficient (ADC) maps without restricted diffusion, hence confirming the finding of vasogenic edema compatible with PRES. Figure 3. FLAIR sequence, axial slice, cerebral magnetic resonance imaging. Subcortical hyperintensies in the bilateral occipital lobes reflecting vasogenic edema of the visual white matter tracts are seen. The patient’s blood pressure and her visual symptoms progressively normalized over 48 hours. On last follow-up 1 month after procedure, vital signs were normal (blood pressure 115/54) and vision was normal.DiscussionCarcinoid tumours are classically described as slow growing, mainly affecting the gastrointestinal (GI) tract. They are known to internists mainly for their capability to produce the carcinoid syndrome. However, only about 25% of carcinoids actually produce the mediators which produce the carcinoid syndrome and less than 10% of patients actually develop the carcinoid syndrome.2 The syndrome usually presents when midgut carcinoids metastasize to the liver, hence bypassing hepatic metabolism. Typical symptoms include secretory diarrhea (80%) and flushing of the head, neck, and upper torso (90%) which may be associated with hypotension and tachycardia. Less frequent manifestations are right heart failure due to carcinoid valve disease (30%), bronchospasm (15%) and pellagra (5%). 3 The classic triad of flushing, diarrhea and wheezing is infrequently found. Foregut (e.g., bronchial) and extra-digestive midgut (e.g., ovarian) bypass the liver and may result carcinoid syndrome without hepatic metastasis, although symptoms are usually atypical in these cases.Perioperative carcinoid crisis occurs in 10–30% of patients undergoing operative resection. Absence of preoperative carcinoid syndrome decreases the risk of carcinoid crisis, however it may still occur.1 This has led to the recommendation by some that patients be premedicated with somatostatin analogues to block bioactive peptide release and action, with or without other hormone antagonists (e.g., anti-histamines).3 However, the benefit of octreotide prophylaxis has been questioned by other studies.1 Once a carcinoid crisis has occurred, bolus doses of 25–500 mcg and intravenous infusions at rates of 50–150 mcg/h have been effective in case reports and case series, with higher doses being potentially required in patients on maintenance octreotide therapy or with carcinoid heart disease.4Despite a lack of data comparing it to surgical management, transarterial chemoembolization (TACE).5 is a frequent management strategy for patients with liver metastases, especially when patients present with hormonal symptoms and multiple metastases preclude resection. Rates of complication from TACE are difficult to estimate ranging from 0 to 100%, likely due to variable definitions and reporting. Only one study reported on the incidence of post embolization carcinoid crisis,6 with 2 of 12 patients developing the complication. Both had a history of carcinoid syndrome and had been premedicated with octreotide 200 mcg SC before procedure and q8h afterward. One group7 did report a patient who developed transient cortical blindness following TACE which possibly could have been due to PRES.PRES is a syndrome of failure of cerebral blood pressure autoregulation with acute onset elevations of blood pressure from baseline and a combination of altered level of consciousness, visual symptoms, headache and seizures.8 Blood pressure is often only moderately elevated, though significantly above the patient’s baseline. Etiologies are varied but include cytotoxic chemotherapy, eclampsia and other causes of hypertensive emergency. It was originally felt that the patient’s PRES was due to the cisplatin received during TACE with contribution from dexamethasone and iatrogenic fluid overload (NaCl 0.9% at 150 mL/h had been running for several hours) as she had no history of carcinoid syndrome, had been premedicated and had no other findings associated with the disease. However, her lack of response to standard anti-hypertensives and prompt response to octreotide suggest carcinoid crisis as the cause.Neuroimaging with MRI confirms the diagnosis. Findings are compatible with symmetrical white matter edema in the posterior cerebral hemispheres, particularly the parieto-occipital regions. The cortex, basal ganglia, brainstem, and cerebellar may also be involved though less so than the subcortical white matter, while anterior cortical involvement is seen only with the most severe cases. Importantly, the distribution is not confined to a single vascular territory. Classically lesions appear as punctate or confluent areas of hyperintensity on T2 and FLAIR sequences.9 DWI usually shows hypo or iso-intense signal (though sometimes mildly hyperintense from T2 shine through) while ADC maps show increased signal, thus distinguishing PRES from ischemic stroke. With prompt recognition and management, full recovery over a period of days to weeks can be expected. ConclusionsCarcinoid crisis is a well-known and dreaded complication of surgical manipulation of carcinoid tumours. Transarterial chemoembolization of these tumours may also result in carcinoid crisis and our report suggests that pre-procedure carcinoid syndrome is not a prerequisite for this. Presentation may be atypical, as it was in our patient, and so clinical suspicion should be high. When suspected, prompt management with octreotide and other supportive therapies should be instituted.Key Points1. Patients undergoing transarterial chemoembolization for carcinoid tumour metastases are at risk for carcinoid crisis, even if they have been premedicated with octreotide and have no history of carcinoid syndrome.2. Carcinoid crisis may present as hypertensive crisis rather than hypotension, and may give rise to PRES.References1. Condron ME, Pommier SJ, Pommier RF. Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis. Surgery 2016;159:358–67.2. Van Der Lely AJ, Herder WWd. Carcinoid syndrome: diagnosis and medical management. Arquivos Brasileiros de Endocrinologia & Metabologia 2005;49:850–60.3. Mancuso K, Kaye AD, Boudreaux JP, et al. Carcinoid syndrome and perioperative anesthetic considerations. J Clin Anesth 2011;23:329–41.4. Seymour N, Sawh SC. Mega-dose intravenous octreotide for the treatment of carcinoid crisis: a systematic review. Can J Anesth/J can d'anesthés2013;60:492–9.5. 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