A. Natale

Which are the most reliable predictors of recurrence of atrial fibrillation after transcatheter ablation?: a meta-analysis.

CONTEXT Transcatheter ablation of atrial fibrillation (AF) has undergone important development, with acceptable midterm results in terms of the safety and recurrence. A meta-analysis was performed to identify the periprocedural complications, midterm success rates and predictors of recurrence after AF ablation. METHODS AND RESULTS 4357 patients with paroxysmal AF, 1083 with persistent AF and 1777 with long standing AF were included. The pooled analysis showed that there was an in-hospital complication rate of tamponade requiring drainage of 0.99% (0.44-1.54; CI 99%), stroke with neurological persistent impairment of 0.22% (0.04-0.47; CI 99%), and stroke without of 0.36% (0.03-0.70; CI 99%) After a follow up of 22 (13-28) months and 1.23 (1.19-1.5; CI 99%) procedures per patient, the AF recurrence rate was 31.20% (24.87-34.81; CI 99%). The persistent AF patients exhibited a greater risk of recurrence after the first ablation (OR 1.78 [1.14, 2.77] CI 99%), but a trend towards non significance was present in the patients with more than one procedure (OR 1.69 [0.95, 3.00] CI 99%). The most powerful predictors of an AF ablation failure in the overall population were a recurrence within 30-days (OR 4.30; 2.00-10.80), valvular AF (OR 5.20; 2.22-9.50) and a left atrium diameter of more than 50mm (OR 5.10 2.00-12.90; all CI 95%). CONCLUSIONS Persistent AF remains burdened from higher recurrence rates, however not so following redo-procedures. Three predictors, valvular AF, a left atrium diameter longer than 50mm and recurrence within 30 days, could be appraised to drive selection of patients and therapeutic strategy.

Human chorionic gonadotropin level as a predictor of trophoblastic infiltration into the tubal wall in ectopic pregnancy: a blinded study

OBJECTIVE To determine the relationship between gestational age, tubal ultrasonographic diameter, and serum hCG levels and different stages of trophoblastic infiltration of the tubal wall in ectopic pregnancy. DESIGN Blinded prospective study. SETTING University-based clinic in Italy. PATIENT(S) Thirty-seven consecutive patients with an ampullary ectopic pregnancy. INTERVENTION(S) Laparoscopic salpingectomy. MAIN OUTCOME MEASURE(S) Gestational age, diameter of the tubal mass as determined by transvaginal ultrasonography. and hCG level on the day of surgery. Ectopic pregnancy was classified according to the depth of trophoblastic infiltration: trophoblast limited to the tubal mucosa (stage I), extension to the tubal muscularis (stage II), or complete tubal wall infiltration up to the serosa discontinued by trophoblastic cells (stage III). RESULT(S) Fifteen patients (40.5%) had stage I tubal infiltration, 14 (37.8%) had stage II infiltration, and 8 (21.6%) had stage III infiltration. Gestational age and diameter of the tube did not differ among the three groups. The median hCG level was 1,710.5 mIU/mL (range, 113-5,635 mIU/mL) for patients with stage I infiltration. 4,690.0 mIU/mL (range, 150-21,531 mIU/mL) for patients with stage II infiltration, and 15,700.0 mIU/mL (range, 13,809-21,650 mIU/mL) for patients with stage III infiltration. All the patients with hCG levels > 6,000 mIU/mL had stage II or III invasion. CONCLUSION(S) These findings may explain why the conservative treatment of ectopic pregnancy is less successful in patients with high hCG levels than in patients with low levels. Use of radical procedures may be justified in the former group.

Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity

STUDY OBJECTIVE To evaluate the integrity of the endoscopic bag after transvaginal in-bag morcellation of uteri that need to be removed by vaginal morcellation during total laparoscopic hysterectomy (TLH). DESIGN Prospective pilot study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Twelve patients with uteri that needed to be removed and who required vaginal morcellation underwent TLH from September 2014 to February 2015, without suspected or confirmed malignancy. INTERVENTIONS After transvaginal in-bag morcellation of uteri at the end of TLH, careful visual inspection of the endoscopic pouch, using diluted methylene blue, was carried out, highlighting any minimal bag damage. MEASUREMENTS AND MAIN RESULTS No gross rupture was encountered after morcellation; however, 4 minimal ruptures were recognized (33%) after filling up the bag with diluted methylene blue. CONCLUSIONS Minimal lesions of the bag may occur after transvaginal morcellation of uteri that need to be removed by vaginal morcellation; this may potentially affect the spread of cancer cells into the abdominal cavity.

Human chorionic gonadotropin patterns after a single dose of methotrexate for ectopic pregnancy.

OBJECTIVE The great variability in human chorionic gonadotropin (HCG) levels after a single dose of methotrexate (MTX) for ectopic pregnancy makes it difficult to predict treatment failure. We describe different patterns of HCG levels. STUDY DESIGN Fifty patients were injected i.m. with 50mg/m(2) of MTX for an ectopic pregnancy. Venous blood samples for HCG detection were obtained on the day of treatment (day 0), day 3 and day 7 and weekly until values were undetectable. Patients were classified as: group 1, persistent pathology (n=11); group 2, complete resolution with a decrease of HCG levels at day 3 (n=30); group 3, complete resolution after a rise of HCG values at day 3 (n=9). Statistical analysis was performed using the Mann-Whitney non-parametric test with 95% confidence intervals. RESULTS Values of day 0 were similar for all the groups. HCG levels of group 3 decreased rapidly after day 3 and at day 7 they were significantly different from levels of group 1. Differences in HCG levels between groups 2 and 3 became indistinguishable from day 21. CONCLUSION The observation of patients undergoing resolution after an initial increase of HCG levels justify an expectant management for 1 week in clinically stable patients. The strategy to separate HCG curves in patients undergoing resolution may shed light on the different clinical responses to therapy for ectopic pregnancies. However, the phenomenon of the immediate rise of HCG should be better investigated.

Primary endometriosis of umbilical scar: case report and review of literature

We report a case of umbilical endometriosis and review the literature about the finding. The patient was a 39-year-old woman who presented with 6 months of umbilical bleeding and pain during the first day of her period. A soft tissue ultrasound scan showed 2 superficial solid masses within the periumbilical subcutaneous adipose tissue, suggestive for ectopic endometriosis localization. We decided to remove the umbilical nodules, excising 1 cm of the surrounding tissue. Reports in the literature indicate cases of umbilical endometriosis in about 0.5%-1% of women with endometriosis.

USEFULNESS OF ULTRASOUND-GUIDED FEMORAL VEIN ACCESS IN ATRIAL FIBRILLATION ABLATION

Vascular complications remain the most common complication in percutaneous electrophysiological procedures and are associated with increased morbidity and health-care costs. We sought to evaluate the effect of real-time ultrasound (US) guidance for femoral vein access in atrial fibrillation ablation

Implantable Cardioverter Defibrillator in Sport Participation

Although athletic participation lowers cardiovascular risk and improves quality of life, it may represent a hazard in high-risk group athletes such as those with cardiac abnormalities receiving an implantable cardioverter defibrillator (ICD). ICD sports participants are exposed to the potential risk of inappropriate shocks due to sinus tachycardia and other supraventricular arrhythmias during exertion as well as device injury. The safety of athletic participation of ICD-patients is not completely defined and ICD efficacy in interrupting malignant arrhythmias during intense exercise is partly unknown. This explains difficulties in current recommendations made by physicians, given the associated potentially ischemic, autonomic and metabolic conditions. The scope of this review is to underline specific considerations including potential risks and recommendations for athletic participation in this patient-group.

Salpingoscopy after a single dose of methotrexate for treatment of tubal pregnancy

A 35-year-old woman was referred to Macedonio Melloni Hospital, Milan, Italy, to undergo laparoscopy as a diagnostic test for infertility. Fourteen months earlier, the patient had been successfully treated for a right-sided tubal pregnancy with a single dose of systemic methotrexate (50 mg/m). On the day of methotrexate administration, serum levels of human chorionic gonadotropin had peaked at 2949 mIU/mL and ultrasound had confirmed a right-sided ampullary pregnancy. Laparoscopy showed bilateral tubal patency. Salpingoscopy was performed using a standard 2.9-mm diagnostic hysteroscope, with a 3.7-mm single-flow diagnostic sheath, introduced through an accessory port. It demonstrated normal tubalmucosa (grade 1 [1]) throughout the entire ampullary portion of the tube (Fig. 1). Given the pathogenesis and evolution of a tubal pregnancy, tubal damage may be present; it may precede the event, being the risk factor for the ectopic pregnancy itself, or it may be a consequence of tubal wall invasion by the trophoblast [2,3]. Conservative treatment that preserves the tube might also preserve tubal damage. The reparative potential of the tube after conservative treatment for ectopic pregnancy is still unknown. Kooi et al. [4] reported normal histology in tubes after methotrexate therapy. The present case seems to confirm—in vivo—the observation of Kooi that tubal mucosa may be completely normal after methotrexate therapy for ectopic pregnancy. Conflict of interest

Term Pregnancy and Vaginal Delivery from Unicornuate Uterus After Laparoscopic Treatment of a Cavitate Rudimentary Horn by an Endoscopic Stapler

Gynecologic and obstetric pathologies may be associated with the presence of a cavitate rudimentary horn such as hematometra, chronic pelvic pain, severe dysmenorhea, increased risk of endometriosis, uterine rupture in pregnancy when implantation occurs inside the pathologic horn and intrauterine growth retardation (IUGR) or preterm labor when the implantation is in the unicornuate uterus. Laparoscopy has been demonstrated to have an important role for the diagnosis and the treatment of this specific Mullerian anomaly. The removal of the cavitate rudimentary horn is always indicated. Normal pregnancies and vaginal deliveries have been described after laparotomic removal of the rudimentary horn: six cases of term pregnancy and five cases of vaginal delivery have been reported after laparoscopic laser treatment of the malformation. We describe a case of uneventful term pregnancy and uncomplicated vaginal delivery after laparoscopic treatment by an endoscopic stapler of an unicornuate uterus with controlater...