Multiple peripheral pulmonary artery stenoses in adults: a rare cause of severe pulmonary hypertension necessitating lung transplantation

Stenoses of multiple peripheral pulmonary artery branches represent a rare cause of pulmonary hypertension in children, but the prognosis is very poor for such patients. Herein we describe 2 patients with multiple peripheral pulmonary artery stenoses (MPPAS) presenting with severe pulmonary arterial hypertension in adulthood, which has only once been described previously. Both patients lived without significant health problems for decades; however, after onset of symptoms, their medical condition declined rapidly, necessitating lung transplantation several months after the diagnosis despite vasodilator therapy. Because MPPAS mimics chronic thromboembolic pulmonary hypertension, this entity may being underdiagnosed, decreasing the possibility of adequate therapy.

[A 16-year-old patient with dysphagia]

A 16-year-old man with an 8-year history of progressive dysphagia was referred to hospital. There was no specific finding in his family history. Physical examination was unremarkable. Complete blood count, serum electrolytes, and liver and kidney function tests were normal. Barium swallow revealed an extrinsic impression of the upper esophagus posteriorly. Magnetic resonance angiography demonstrated an aberrant origin of the right subclavian artery, leaving the aorta below the left subclavian artery. The artery had a retroesophageal course, causing the esophageal narrowing. Due to the persistence and worsening of the patient's symptoms, resection and reconstructive bypass surgery were recommended. Surgical correction was performed through a combined right supraclavicular incision and left posterolateral thoracotomy. After application of a vascular clamp, the aberrant right subclavian artery was ligated almost at its origin, and an end-to-side anastomosis was made with the right common carotid artery. At the end of the operative procedure, good pulses were palpated in the right radial artery. Postoperatively, the patient tolerated a regular diet without symptoms of dysphagia and was discharged on postoperative day 7.

[Atrioventricular heart block in Lyme disease]

Lyme disease is the most common tick-borne disease in Europe and in the United States. In comparison to dermatological, neurological and rheumatological manifestations, heart disease is quite rare. Atrioventricular heart block is nevertheless the most frequent cardiological manifestation. We hereby report the case of a patient with high degree heart block due to Lyme disease. We focus on the electrocardiographical evolution during antibiotic therapy, as well as on microbiological and diagnostic aspects. Lyme disease is a rare cause of conduction disturbances but it is treatable and potentially reversible.

[Oral anticoagulants in cardiac patients undergoing elective surgical procedures: what attitude to adopt?]

Clinicians are often required to decide how to manage patients receiving long-term anticoagulant therapy, and who need a surgical procedure. The decisions are based on the perceived risk of continuing or stopping the treatment. Generally, warfarin must be stopped before all interventions at high risk of bleeding, but can be maintained unchanged before oral and skin surgery. For patients with a high risk of thromboembolism, heparin should be administered preoperatively, when the INR is <2. The estimation of this risk depends largely on the undelying heart disease. In the postoperative phase, the restarting of anticoagulant therapy must be weighed against both thromboembolic and hemorragic risks.

Deadly Carousel or Difficult Interpretation of New Diagnostic Tools for Whipple?s Disease: Case Report and Review of the Literature

Whipple's disease is a rare systemic disorder classically presenting with weight loss, arthralgias, and diarrhea, which was first described in 1907. The causative bacterium Tropheryma whipplei, is a fastidious organism not growing on conventional media. Before the introduction of polymerase chain reaction (PCR)-based methods, the diagnostic gold standard was histological detection of diastase-resistant periodic acid Schiff (PAS)-positive macrophages or electron microscopy. As in the present case, contradictory results between the former and new diagnostic methods may obscure the correct diagnosis. We critically summarize the performance of the different diagnostic methods and discuss their impact on the clinical management of patients with suspected Whipple's disease.

Aortic valve replacement with the Cryolife-O'Brien stentless aortic bioprosthesis: five-year experience

AIM

Improved hemodynamics with stentless bioprosthesis compared to stented valves have been well documented. It has been suggested that a simplified implant model, the Cryolife-O'Brien, offers less satisfactory outcomes compared with standard stentless models. This study was conducted to prospectively evaluate the midterm results after aortic valve replacement with the Cryolife-O'Brien stentless bioprosthesis.

METHODS

In 1996, the prospective clinical trial using different stentless valves was initiated in our center. From September 1996 through August 2001, 132 consecutive patients with a mean age of 72.5 years underwent aortic valve replacement with the Cryolife-O'Brien porcine stentless bioprosthesis by the same surgeon. The predominant aortic valve lesion was stenosis in 110 cases and insufficiency in 22 cases. Patients have been followed-up from 2 to 60 months, mean 28 months. Echocardiography was performed by the same echocardiographer preoperatively, intraoperatively, postoperatively at discharge, 2 to 6 months later and annually thereafter.

RESULTS

Sixty-five percent of patients received a valve 25 mm in diameter or larger, 42% had concomitant coronary bypass grafting. The 30-day operative mortality rate was 6.8 %. Nine late deaths, none related to the valve, have occurred. Severe aortic insufficiency caused by oversizing led to early reoperation in 3 patients. The peak and mean systolic gradients decreased significantly during the first 12 months after implantation (p<0.001) and the effective valve areas increased significantly during this time interval (p<0.001). Eleven patients have aortic insufficiency, trivial in 7 and mild in 4. The actuarial survival at 5 years was 86+/-3%. The rate for freedom from endocarditis was 100% and for freedom from thromboembolic events 92%.

CONCLUSIONS

The Cryolife-OBrien stentless bioprosthesis has superior hemodynamics and a low rate of valve-related complications thus representing a very good alternative to conventional stented bioprosthesis. The midterm results are encouraging but further follow-up is needed to determine the valve's durability.

Muscle and Myocutaneous Flaps in Reconstructive Surgery of Thoracic Defects

Reconstructive surgery of thoracic defects presents a challenge for the surgeon. With defects of different aetiology and the need for precise localisation of the area to be treated, a broad range of experience is required. We present our interdisciplinary experience in dealing with full thickness thoracic wall defects and intrathoracic cavities. The latissimus dorsi muscle as well as the pectoralis major muscle and their covering skin are the most commonly used flaps in covering an intrathoracic or extrathoracic defect. They have the advantage of being easily and safely dissected. Other flaps such as the greater omentum, serratus anterior, the transverse rectus abodominal muscle (TRAM), and the filet of the arm are less frequently used. Indications and applications of these flaps are reviewed. Our interdisciplinary surgical treatment of thoracic wall defects allows optimal operative excision and reconstruction as well as giving best functional and aesthetic results for the patients.

Non-steroidal anti-inflammatory drugs decrease the quality of pleurodesis after mechanical pleural abrasion

OBJECTIVE

Non-steroidal anti-inflammatory drugs (NSAIDs) are often applied for pain management after thoracic surgery. Since these drugs diminish collagen deposition through inhibition of the prostaglandin synthesis, we investigated their effects on adhesion formation after endoscopic mechanical pleural abrasion, which is often applied in the therapy of pneumothorax.

METHODS

Mechanical pleural abrasion was performed unilaterally by the use of video-assisted thoracoscopic surgery technique in an established pig model. Ten animals (41.3+/-3.4 kg) were divided into a treatment group and a control group. In the treatment group, animals received 100 mg diclofenac (2 mg/kg body weight) orally daily for 3 weeks after surgery. At 3 weeks, all animals were sacrificed and efficacy of pleurodesis was macroscopically assessed by three independent reviewers blinded to the treatment of animals using a five-point severity pleurodesis score (from 0, no adhesions to 4, complete symphisis) and obliteration grade rating the distribution of adhesions (from 0, no adhesions to 4, adhesions in the whole chest). Microscopic evaluation was performed by two pathologists blinded to the study groups as well. A four-point score assessed the amount of collagen deposition (from 1, a few collagen fibers to 4, scar).

RESULTS

Gross observation showed more dense adhesions in control animals with a median pleurodesis score of 3.67+/-1.0 in comparison to 2+/-2.2 in the treatment group (P = 0.01 *, Mann-Whitney non-parametric test). Distribution of adhesions was comparable in both groups with a median obliteration score of 3.67+/-1.3. Histopathologic examination showed a higher amount of collagen deposition in the control group, suggesting more dense adhesions, whereas in the treatment group there was loose granulation tissue (score of 4.0+/-0.8 vs. 2.3+/-1.0 in the treatment group, P = 0.06). The degree of inflammatory reaction was comparable in the two groups.

CONCLUSIONS

Our results demonstrate that perioperative use of NSAIDs highly affects the quality of pleural adhesions obtained after mechanical abrasion in this pig model, which further suggests that these drugs should be avoided for pain management when a pleurodesis is performed.

Aberrant tendinous chords with tethering of the tricuspid leaflets: a congenital anomaly causing severe tricuspid regurgitation

OBJECTIVE

To define the entity of tricuspid regurgitation caused by tethering of the tricuspid valve leaflets by aberrant tendinous chords.

DESIGN

Retrospective study.

SETTING

Tertiary care centre (university teaching hospital).

PATIENTS

10 patients with unexplained severe tricuspid regurgitation.

METHODS

The last 13 500 echocardiographic studies from our facility were reviewed to identify patients with severe unexplained tricuspid regurgitation. Tethering was defined by the presence of aberrant tendinous chords to the tricuspid valve leaflets limiting the mobility of the tricuspid leaflet and resulting in incomplete coaptation and apical displacement of the regurgitant jet origin. Aberrant tendinous chords were defined as those inserting at the clear zone of the tricuspid leaflet and not originating from the papillary muscle. Patients fulfilling the diagnostic criteria for Ebstein's anomaly were excluded.

RESULTS

10 patients with aberrant tendinous chords tethering one or more tricuspid valve leaflets were identified. There were short non-aberrant tendinous chords in seven patients, five of whom also had right ventricular or tricuspid annulus dilatation.

CONCLUSIONS

Tethering of the tricuspid valve leaflets by aberrant tendinous chords can be the sole mechanism of congenital tricuspid regurgitation. It is often associated with short non-aberrant tendinous chords, which may develop secondary to right ventricular or tricuspid annulus dilatation. Awareness of tethering as a cause of tricuspid regurgitation may be important in planning reconstructive surgery.

Stenting of the ductus arteriosus and banding of the pulmonary arteries: basis for various surgical strategies in newborns with multiple left heart obstructive lesions

OBJECTIVE

To present an institutional experience with stent placement in the arterial duct combined with bilateral banding of the pulmonary artery branches as a basis for various surgical strategies in newborns with hypoplastic left heart obstructive lesions.

DESIGN

Observational study.

SETTING

Paediatric heart centre in a university hospital.

PATIENTS

20 newborns with various forms of left heart obstructive lesions and duct dependent systemic blood flow.

INTERVENTIONS

Patients underwent percutaneous ductal stenting and surgical bilateral pulmonary artery banding. Atrial septotomy by balloon dilatation was performed as required, in one premature baby by the transhepatic approach.

MAIN OUTCOME MEASURES

Survival; numbers of and reasons for palliative and corrective cardiac surgery.

RESULTS

One patient died immediately after percutaneous ductal stenting. One patient died in connection with the surgical approach of bilateral pulmonary banding. Stent and ductal patency were achieved for up to 331 days. Two patients underwent heart transplantation and two patients died on the waiting list. Ten patients had a palliative one stage procedure with reconstruction of the aortic arch and bidirectional cavopulmonary connection at the age of 3.5-6 months. There was one death. One patient is still awaiting this approach. Two patients received biventricular repair. In one, biventricular repair will soon be provided.

CONCLUSIONS

Stenting the arterial duct combined with bilateral pulmonary artery banding in newborns with hypoplastic left heart or multiple left heart obstructive lesions allows a broad variation of surgical strategies depending on morphological findings, postnatal clinical conditions, and potential ventricular growth.

InP(001)-(2 x 1) surface: a hydrogen stabilized structure

The InP(001)(2 x 1) surface has been reported to consist of a semiconducting monolayer of buckled phosphorus dimers. This apparent violation of the electron counting principle was explained by effects of strong electron correlation. Combining first-principles calculations with reflectance anisotropy spectroscopy and LEED experiments, we find that the (2 x 1) reconstruction is not at all a clean surface: it is induced by hydrogen adsorbed in an alternating sequence on the buckled P dimers. Thus, the microscopic structure of the InP growth plane relevant to standard gas phase epitaxy conditions is resolved and shown to obey the electron counting rule.

[Management of unilateral traumatic bulb luxation with disruption of the optic nerve]

Luxation of the eyeball, which means that the eye protrudes between the eyelids,may occur spontaneously or as a rare sequel to major trauma to the orbital wall. It can be accompanied by a disruption of the optic nerve, which is called optic nerve avulsion. In most cases primary enucleation is performed as therapeutic treatment. In our case of a 1 1/2-year-old child bulb luxation with disruption of the optic nerve followed a relatively slight trauma,presumably a fall onto a toy. An irreversible amaurosis was diagnosed. To guarantee symmetrical growth of the orbita and face, the eyeball was replaced into the orbit under microscopic and endoscopic vision via a transnasal and transethmoidal approach.Postoperative examinations showed an exotropy with unrestricted motility of the globe and amaurosis. Five years after the trauma we found symmetrical facial development with uniform orbital cavities. The clinical features and management of globe luxation are discussed, importance of a rapid reposition of the eyeball in contrast to primary enucleation for functional, cosmetic and psychological reasons is emphasized.

[Comparison between line immunoassay (LIA) and enzyme-linked immunosorbent assay (ELISA) for the determination of antibodies to extractable nuclear antigenes (ENA) with reference to other laboratory results and clinical features]

INTRODUCTION

The line immunoassay (LIA) for the determination of antibodies to individual extractable antinuclear antigens (ENA) is a development of the enzyme-linked immunosorbent assay (ELISA) in which the antigens to be tested are adsorbed onto a nylon test strip. In addition, the antigen subspecificities B/B' and D in the case of Sm, the 70 kD, A and C components in the case of U1-snRNP and the Ro52 and Ro60 components in the case of SSA/Ro are present separately on the strips. The aim of the study was to determine whether the line immunoassay is suitable for routine laboratory use by means of a comparison with the ELISA.

METHODS

Sera from 92 patients stored in our serum bank with known ENA profile as determined by ELISA and with at least one antibody to ENA were tested again with LIA. The clinical features and other available laboratory data taken from the patient records were used to classify the disease according to the relevant diagnostic criteria. In discrepant cases, antibodies to ENA were also determined by Western blot. These data were used to determine which of the two methods gave the more plausible results and to calculate the sensitivity and specificity for each autoantibody.

RESULTS

There was good correlation between the two methods, especially for anti-CENP-B (centromere protein B) and anti-Jo1 (histidyl-tRNA transferase) antibodies. For anti-Sm, there was a trend toward higher specificity with the LIA in patients with systemic lupus erythematosus (SLE) if antibodies to Sm D were detected. The LIA was significantly more specific for the detection of antibodies to ribonucleoprotein (RNP) in mixed connective tissue disease and, if antibodies to the 70 kD component were present, also in SLE, although the sensitivity was significantly lower in this case. For anti-SSA/Ro, the specificity of the LIA was significantly higher than ELISA if anti-Ro60 was detected. In the case of anti-SS-B/La, anti-Scl70 (topoisomerase I), anti-CENP-B (centromere protein B) und anti-Jo-1 (histidyl-tRNA transferase), the sensitivity and specificity of the two methods were not significantly different. The LIA was significantly more specific but less sensitive for the detection of anti histone antibodies.

CONCLUSION

The suitability of the LIA for routine laboratory determinations was confirmed.

[Out of hours coronary angiography: changing indications]

The authors have recently demonstrated that 13% of indications for cardiac catheterisation performed "after hours" (week ends, holidays or from 6 pm to 7 am) are Class III of the AHA/ACC recommendations (i.e. indications not based on recognised medical evidence). In order to limit procedures performed for these unrecognised indications, a consensus of experts has defined a number of local recommendations. The aim of this paper was to study the impact of these recommendations on the indications of "out of hours" cardiac catheterisation. Two patient populations were identified and compared with respect to these recommendations. The first group comprised 157 consecutive patients treated between 1993 and 1994 (average age 58 +/- 13 years; 35% females) and the second one of 148 consecutive patients treated from 1998 to 1999 (average age 57 +/- 13 years; 25% females). The local recommendations were respected in 61% of cases and not applied in 39% of cases. This was a satisfactory result in view of the fact that the local recommendations are more restrictive than international guidelines as they cover emergency indications. In the second group of patients, there were no AHA/ACC Class III indications (30% Class I, 6% Class IIa and 3% Class IIb). There was a significant increase in the number of primary angioplasties for acute myocardial infarction (27 vs 2%; p < 0.001) and an expected reduction in salvage angioplasties (17 vs 7%; p < 0.01). There was no significant change in the indications in patients with unstable angina, the European and American guidelines having been published at the end of data collection. Therefore, the introduction of recommendations for out of hours cardiac catheterisation has limited the number performed for unrecognised indications in favour of evidence based procedures.

Beating heart coronary artery surgery: is sternotomy a suitable alternative to minimal invasive technique?

OBJECTIVES

To evidence the respective advantages and drawbacks of minimal invasive-thoracotomy (MIDCAB) and off-pump sternotomy (OPCAB) coronary bypass techniques.

METHODS

The perioperative and mid-term (3 months) results of the first 31 MIDCABs and 39 OPCABs performed by a single experienced coronary surgeon (F.S.) were compared. Differences were assessed by two-tailed chi-square or unpaired t-test, and significance assumed for P-values < or =0.05.

RESULTS

Groups were widely comparable. There were no in-hospital deaths nor permanent neurologic events. OPCAB patients received more anastomoses (mean 1.09/patient vs. 1.89/patient, P<0.001) during a shorter coronary occlusion period (26.1+/-8 vs. 16.6+/-4.5min, P<0.001), whilst immediate extubation prevailed in MIDCABs (22/31 vs. 17/39, P<0.05). Significant complications occurred in seven MIDCABs vs. none in OPCABs (P<0.01). Other in-hospital parameters were similar. Controls at 3 months evidenced more residual discomfort among MIDCAB patients (14/30 vs. 7/39, P<0.05).

CONCLUSIONS

Differences in early complication rates may be due to a learning effect. However, OPCAB allows us to implant more grafts and is more comfortable for both patient and surgeon. These advantages may well counterbalance the cosmetic benefits of MIDCAB procedures.

Successful endovascular repair of a leaking abdominal aortic aneurysm under local anesthesia

Local anesthesia is a safe and less invasive anesthetic management for the endovascular approach to elective aortic aneurysm. We have successfully extended the indication of local anesthesia to a high-risk patient with leaking aneurysm and stable hemodynamics.

PATIENT AND METHODS

A 86 year old patient with renal insufficiency due to longstanding hypertension, coronary artery and chronic obstructive lung disease was transferred to our hospital with a leaking abdominal aortic aneurysm. Stable hemodynamics allowed to perform a fast CT scan, that confirmed the feasibility of endovascular repair. A bifurcated endograft (24 mm x 12 mm x 153 mm) was implanted under local anesthesia.

RESULTS

The procedure was completed within 85 minutes without problems. The complete sealing of the aneurysm was confirmed by CT scan on the third postoperative day. Twenty months later, the patient is doing well and radiological control confirmed complete exclusion of the aneurysm.

DISCUSSION

The endoluminal treatment is a minimally invasive technique. It's feasibility can be rapidly assessed by CT scan. The transfemoral implantation can be performed under local anesthesia provided that hemodynamics are stable. This anesthetic management seems to be particularly advantageous for leaking abdominal aortic aneurysm since it doesn't change the hemodynamic situation in contrast to general anesthesia. Hemodynamic instability, abdominal distension or tenderness may indicate intraperitoneal rupture and conversion to open graft repair should be performed without delay.

[Coronary artery bypass by mini-thoracotomy: noticeable benefits with clinical experience of the treatment team]

AIM OF THE STUDY

Minimally invasive coronary artery bypass surgery is fundamentally different as compared to open sternal approach under cardiopulmonary bypass. Modifications of the surgical, anesthesiologic and post-operative techniques are necessary before evaluation of its real benefit. We analyze the potential effect of a learning period on the short term results of this technique.

METHODS

From July 1997 to February 1999, 20 patients were operated using this method. We compare the results of the first 10 patients (group 1: 8M/2F, 59.6 +/- 13.8 years) to those of the last 10 patients (group 2: 8M/2F; age = 63.2 +/- 6.1 years).

DISCUSSION

Progress between the two groups is striking. Left anterior descending coronary clamping time could be reduced from 28.5 +/- 2.4 min. in group 1 to 22.2 +/- 1.8 min. in group 2 (p < 0.05), and operative time was reduced from 125 +/- 4 min. to 97 +/- 5 min. (p < 0.005). The post-operative atrial fibrillation rate diminished from 4/10 in group 1 to 1/10 in group 2.3/10 patients in group 1 suffered a post-operative pneumonia whereas none in group 2 had pulmonary complication. The stay in the intensive care unit could be reduced from 2.3 +/- 0.3 days to 1.4 +/- 0.2 days (p < 0.05) and the total post-operative stay diminished from 8.5 +/- 0.9 days to 4.7 +/- 0.5 days (p < 0.005).

CONCLUSION

There are evidence for a learning period in minimally invasive cardiac surgery. Short term benefits of this technique are then evident as demonstrated by a reduction in the ICU stay and the hospital stay.

Silver-coated prosthetic heart valve: a double-bladed weapon

A St. Jude Medical Silzone was implanted in a 72-year-old female, suffering from mitral valve disease. Four months later, the patient had acute cardiac failure due to partial detachment of the prosthetic valve. The mitral annulus was ulcerated and there were multiple erosions in the myocardial tissue in contact with the prosthetic valve. Histological examination revealed chronic inflammation with hemosiderine deposits and giant cells. No allergy to silver ions was found. The silver-coated sewing cuff had caused a chronic inflammatory reaction due to a toxic reaction to silver. The Silzone valve was withdrawn from the market on January 2000.

[Resection method and functional restoration in soft tissue sarcomas of the extremities]

In soft tissue sarcoma of the extremities wide tumor excision (R0) has become the most important factor for local control. The tactical and technical surgical parameters are defined, which allow for diminished complication rates during tumor biopsy and definite resection. Reconstructive plastic procedures play a key role in coverage of major defects and prevention of problems due to wound infection and irradiation. If localized within the periphery of limbs, the vast majority of cases will require sophisticated techniques to achieve limb salvage.