Extrauterine pelvic arteriovenous malformation mimicking the clinical presentation of structural heart disease

A case is reported of an extrauterine pelvic arteriovenous malformation involving branches of the internal iliac arteries. Cardiomegaly and a rough cardiac murmur were the clinical presentations mimicking a structural heart disease. A continuous bruit could only be detected by the diaphragm of the stethoscope applied firmly to the left lower abdomen. Multiple blood samplings from inferior vena cava, and iliac and femoral veins for determination of oxygen saturation may be necessary for suspected cases. However, selective arteriography remains the best method for diagnosing the presence, extent, and multiplicity of the lesions before surgery or percutaneous arterial embolization.

[A case of Carney complex]

HISTORY AND CLINICAL FINDINGS

For some months a 57-year-old woman had noted increasing shortness of breath, associated in the last few weeks with undirected vertigo and several brief periods of lost consciousness. She was finally admitted because of additional central facial paresis. On auscultation a high-frequency systolic murmur was heard over the apex and a discrete diastolic murmur over Erb's point. There were numerous facial freckles and three cutaneous myxomas.

INVESTIGATIONS

Echocardiography revealed irregular tumours throughout the left atrium and a large broad-based one prolapsing through the mitrale valve in diastole. Computed tomography demonstrated a 6 x 6 cm tumour in the left lower abdomen, probably arising from the left ovary, and a second 3 x 3 cm presacral tumour.

TREATMENT AND COURSE

At cardiac surgery four tumours were found in the left atrium and resected: histologically they were benign myxomas. Removal required extensive resection in the area of the interatrial septum and the atrial wall, resulting in 2 degrees AV block for which a VDD pacemaker was implanted.

CONCLUSION

Atrial myxomas may be the cardinal sign of the Carney Complex, an autosomal dominant syndrome with cutaneous myxomas, myxoid abdominal tumours, hormone-producing tumours in the testicles, adrenal cortex or hypophysis, schwannoma as well as lentigines. For this reason, further tumours should be looked for if freckles and/or cutaneous tumours are found in association with an atrial myxoma. The patient and family should be informed about the genetic aspects.

Does an early neonatal diagnosis of a later spontaneously closed ventricular septal defect impair quality of life?

The hypothesis that early diagnosis of a ventricular septal defect (VSD) with spontaneous closure later on may impair the parental-infant bonding process, with consequences for the child's quality of life in the longer term, was tested in 51 children born in 1986-1991 (gestational age > or = 37-42 weeks) with VSDs diagnosed in the early neonatal period and closing spontaneously during the first 24 months of life. The results were compared to 83 healthy controls matched for gestational age, time and place of birth. A method (questionnaire) taking into consideration the quality of life spheres of external living conditions and the interpersonal and personal conditions of the child was used. Except for a lower satisfaction with family network in the VSD group (p < 0.05), no differences were found between the VSD group and the controls for any of the parameters tested or for overall quality of life (p>0.05).

[Closure of the persistent ductus with detachable coils]

34 patients aged 3 months to 20 years underwent transcatheter-occlusion of their patent ductus arteriosus with detachable coils (Cook). Eight patients had a residual ductus after previous implantation of a Rashkind-occluder; 7 patients had various other cardiac malformations in addition. Only 6 patients had a large ductus with a diameter between 3 and 4 mm; all had systolic-diastolic murmurs. All other patients had ductus-diameters below 3 mm; three of them had systolic-diastolic murmurs, 17 had systolic murmurs, and 8 patients had no murmur at all. The ductus was closed in 24 patients using arterial access only, in 6 patients via a venous, and in 4 patients both via venous and arterial catheterization. One coil was used in 23 patients, 2 coils in 9, and 3 coils in 2 patients. There were no complications of the intervention. Within 24 hours 31 patients (93%) had complete closure of the ductus and 32 patients (94%) after 6 months. Coil-embolisation of the persistent ductus is a quick, safe and cheap method to close a ductus and has clear advantages compared to an operation.

A case of a coronary artery arising from the pulmonary artery

We present a case of an anomalous origin of the left coronary artery arising from the pulmonary artery in a 60 year old woman with ventricular arrhythmias and ischemic electrocardiographic changes but who had tolerated eleven normal pregnancies and deliveries without complications. No cardiac surgical repair has been performed and she is asymptomatic and has been well controlled with diisopyramide during a ten year follow up.

Beat-to-beat variability of left ventricular indexes measured by acoustic quantification: influence of heart rate and respiration--correlation with M-mode echocardiography

Influence of heart rate and respiration on beat-to-beat variability of left ventricular indexes measured by acoustic quantification was examined. These indexes were correlated with their counterparts measured by M-mode echocardiography. Parameters of left ventricular performance were recorded for 1 full minute in 43 children with a mean age of 5.9 +/- 3.9 years. Beat-to-beat variability was documented. The effect of respiration on such variability was examined in another 10 subjects. A wide range of heart rates and respiration did not show significant influence on the degree of variance among these parameters. The indexes measured correlated well with their counterparts measured by M-mode echocardiography. Acoustic quantification separated those with normal from those with abnormal left ventricular function with the same statistical significance as did M-mode echocardiography. A moderate degree of beat-to-beat variability occurs in acoustic quantification-derived left ventricular indexes. Heart rate variability and respiration do not influence the beat-to-beat variance of parameters of left ventricular performance measured with the acoustic quantification. Excellent correlation was documented between this technique and M-mode echocardiography.

Incidence of intracranial bruits in neonates

Although standard texts state that intracranial bruits are common in childhood, experience suggests they are uncommon in neonates. This study investigated the incidence of intracranial bruits in 1,000 consecutive neonates. Only one bruit was heard, which was due to a transmitted cardiac murmur. Uncommon physical findings require caution in deciding whether to immediately consider it a benign finding, or to pursue additional evaluation with noninvasive imaging. We suggest that listening for intracranial bruits in neonates may be an important addition to the standard neonatal screening examination. Further study to determine if pathologic bruits can be detected in the presymptomatic state is needed.

[Clinical manifestation of aortopulmonary window as mitral regurgitation caused by secondary dilatation of the valvar anulus]

Two patients with huge aortopulmonary window, both ten months-old, that showed curiously up at a clinical viewpoint, including echocardiography, as a mitral valve regurgitation with a dilated mitral ring secondary to the accentuated blood volume through it, were reported. Early signs of heart failure, accentuated systolic murmur at mitral area and overload of left heart cavities, characterized clinical impression of a congenital mitral insufficiency, in both cases. The correct diagnosis was established at operation and at necropsy study, bringing it to us the need to a more accurate analysis of the different diagnostic elements, especially in anomalies which clinical manifestations show great similarities.

Familial occurrence of discrete subaortic membrane

The first case of multiple family members with discrete subaortic membrane and no other congenital defects is presented. One family member presents with findings suggesting a forme fruste of this disease. Increased surveillance of family members of individuals with discrete subaortic membrane is warranted, as the clinical findings of mild subaortic obstruction may be indistinguishable from those of an innocent flow murmur.

Congenital aortic regurgitation caused by a rudimentary noncoronary cusp: report of a case

A 14-year-old asymptomatic boy was admitted to our department for investigation of a diastolic murmur which had been discovered by his family doctor during a routine examination. Echocardiography showed aortic regurgitation with dilatation of the left ventricle. Inspection of the aortic valve at the time of operation revealed normal left and right cusps with a rudimentary noncoronary cusp. An aortic commissuro-plication was performed and a new bicuspid aortic valve successfully reconstructed. His postoperative course was uneventful and he has been well and leading an active life since his discharge from hospital.