[Mitral valve prolapse in the 8th and 9th decades of life. Anatomo-pathologic study of 3 cases]

Different anatomo-clinic aspects from three mitral valve prolapse cases are compared to those commonly presented in the literature and are also utilized as a basis for a new classification of this disease. The patients are more than 77 years old, what is in contrast with the current concept of MVP as a disease of young-middle aged women. The first case shows marked ostial dilation and many ruptured chordae: as a consequence, this patient showed severe cardiac dysfunction. The anterior, rather than the posterior leaflet, presented intense myxoid degeneration. In the second case, no ruptured chordae were detected and, consequently, the degree of heart failure was lesser than the first one, in spite of the same degree of ostial dilation. Both leaflets showed the same degree of myxoid degeneration. The third patient, who does not have heart failure, showed myxomatous degeneration of both cusps, but no ostial dilation or chordal rupture were present. These aspects reinforce the impression that isolated mixomatous degeneration of the cusps is not so deleterious when compared to those cases where the mitral valvar ring is dilated or its chordae are also involved by that degenerative process. Therefore ostial dimension (normal or enlarged) and the state of the chordae (with or without rupture) appears to be important points to be considered in MVP.

[The mitral valve apparatus: an anatomo-echocardiographic approach]

The shape of the mitral valve ring, the position of its chordae and of its leaflets were studied in 34 normal hearts fixed through intra-ventricular injection of tamponate formalin. As the authors have assumed that the post-rigor left ventricle has an architecture very similar to that seen at to the end of ventricular systole, comparisons were made between the anatomical and the echocardiographic features usually seen at the end of the phase of the cardiac cycle. The mitral ring has the shape of a hyperbolic paraboloid, and this peculiar geometry explains why the "apical-four chambers" view, which explores the most superficial ring segments, is the more appropriate view for detecting mitral valve prolapses. In that incidence the valvar diameter is longer (2.43 +/- 0.45 cm) that in the "parasternal view" (1.99 +/- 0.45 cm) and the angle made by the leaflets is comparatively less acute ("four chambers" = 127.41 +/- 16.45 degrees; "parasternal" = 102.05 +/- 0.17 degrees). In the "four chamber" view the point of coaptation (which represents the vertex of the referred angle) is 0.45 +/- 0.17 cm far from the echographic line usually taken as the valvar plane (EVPL-echocardiographic valvar plane line) whereas in the other view, it is more distant from this line (0.59 +/- 0.16 cm). These two last factors make both leaflets closer to the left atrium and explains why mitral valve prolapse, when present, is more easily seen in that incidence.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of metronidazole, chloramphenicol, clindamycin and penicillin G on growth and neuraminidase activity of Bacteroides fragilis

The effects of subinhibitory concentrations of metronidazole, chloramphenicol, clindamycin and penicillin G on cell growth and neuraminidase activity of Bacteroides fragilis were tested in six strains from clinical specimens and two type collection strains. All showed significant inhibition of cell growth at one half the MIC after 24 h incubation. Metronidazole at one quarter the MIC was significantly inhibitory after 24 and 48 h incubation. The neuraminidase activity remained unaltered, in comparison with controls, when metronidazole and clindamycin were tested. Chloramphenicol reduced the enzyme activity at both one half and one quarter the MIC. On the other hand, penicillin G enhanced the neuraminidase activity, although the difference was not statistically significant. These in-vitro effects may simulate the behaviour of the bacteria in abscesses in vivo.

[Pulmonary arteriovenous fistula. A case report and review of the literature]

The aim of this paper is to review clinical and laboratory features of this unusual pathology and its complications, indicating transcatheter embolization as a first choice for its management. Our case report is of a seven year-old child, with complex pulmonary arteriovenous fistula of the anterior segment of right superior lobe, which was diagnosed mainly by cintilography and pulmonary angiogram. Clinically she had cyanosis, fatigue with exertion, clubbing of the fingers and polycythemia with low partial pressure of oxygen (PAO2: 68.1 mmHg; Sat O2: 92.4%; Hct: 47.5%; Hb: 16 gr%). She did not have Rendu-Osler-Weber disease. The anatomic structure and localization of the complex fistula was showed by cineangiographic study. We preferred to manage this fistula with transcatheter embolization with a 02 gauge stainless steel coil occluding device (Gianturco-Wallace), as it was single and the patient was too young for sustain surgical trauma and the outcome would be positively satisfactory. After the embolization cyanosis was relieved and we could see normal pulmonary circulation following the point of the pre-existing fistula. We concluded that a judicious assessment by cineangiography could help select the transcatheter embolization procedure as an attractive therapeutic approach instead of surgery.

[Use of the gracilis muscle in reconstructing the perineum]

Ten patients had their vulvar and perineal areas reconstructed using musculocutaneous flaps of the gracilis muscle. Seven patients had extensive resections done for skin carcinomas, two due to traumas and one due to a sequel of Fournier's Syndrome. Reconstruction in tumor cases were performed primarily and the other secondarily. The skin island measured 12 x 8 centimeters and the muscle was taken entirely. The results were satisfactory in all cases. The muscle survived completely, but there was partial skin island loss in 8 instances. In 3 of those cases, there was need for a revision of the flap and skin grafting. The authors concluded that there is always a risk to take the skin island together with the gracilis muscle and the use of the isolated muscle with skin grafting should be considered im most cases.

Anatomy of the buccal fat pad and its clinical significance

Interest in the anatomy of the buccal fat pad was aroused by two clinical cases where the fat pad was involved by pathology. In one, there was an extensive lipoma of the buccal fat pad which had been unsuccessfully operated on on two previous occasions. The reason for the lack of success was incomplete removal of the fat pad. In the second case, there was an arteriovenous malformation involving the fat pad which necessitated complete removal. Fresh cadaver dissections were carried out to accurately determine the anatomy. Particular attention was paid to the temporal extension, since this area is frequently disregarded.

[Breast reconstruction after mastectomy. Critical analysis of 240 cases]

A retrospective study on 240 cases of breast reconstruction was undertaken in order to make a critical analysis of the results of different techniques as silicone prosthesis, tissue expanders, and the myocutaneous flaps of latissimus dorsi and rectus abdominis. The authors discuss the indications, advantages, inconveniences and complications of each technique and point out the particular indications for each one, depending on the type of mastectomy performed and the quality of the remaining tissues. Good results can be obtained using prosthesis, or flaps, but the indications must be very criterious, as the number of complications may be high, and many operations might be needed to achieve a satisfactory result.

The distal pedicle fascia flap of the leg

An anatomical study was undertaken in order to obtain data on the vascularity of the posterior fascia of the leg. Injection studies revealed there to be three "distal" pedicles; one between the peroneal and soleus muscles, emerging 10-15 cm above the lateral malleolus and two other, smaller ones, 5 cm above the medial and lateral malleolus. Clinical experience included seven cases: five with trauma and two with varicose ulcers. We had good results in five, a partial loss in one and a total loss in one. The distal pedicle fascia flap should be considered an alternative method for repairing defects in the lower third of the leg.