New approach to patency and flow assessment after left internal thoracic artery hypoperfusion syndrome with additional saphenous vein graft to the left anterior descending artery with phase-contrast magnetic resonance angiography

OBJECTIVE

Perioperative and early postoperative flow reduction of a left internal thoracic artery conduit is a rare complication of myocardial revascularization and may lead to the potentially fatal left internal thoracic artery hypoperfusion syndrome. It has been advocated that an additional vein graft be placed to the distal left anterior descending artery to provide sufficient myocardial perfusion. Some evidence exists, however, that this high-flow vein might lead to competing or even backward flow through the internal thoracic artery.

METHODS

In the past 2 years, 21 patients received an additional vein graft to the distal left anterior descending artery for left internal thoracic artery hypoperfusion syndrome. Nineteen of these patients were available for magnetic resonance imaging. Early (< 6 months) and late (> 12 months) postoperative flow measurements, both in the left internal thoracic artery and in the saphenous vein grafts, were performed by means of conventional and a segmented k-space phase-contrast magnetic resonance angiography technique.

RESULTS

Early magnetic resonance examinations indicated that all conduits had adapted to the coronary flow type with predominant diastolic perfusion. Patency rate both at the early and at the late study was 100%. No concurrent flow, flow reversal, or steal phenomena were observed. Mean flow rates were 49.2 ml/min for the left internal thoracic artery and 72.6 ml/min for the saphenous vein graft.

CONCLUSION

On the basis of the flow data obtained with magnetic resonance angiography, the use of an additional saphenous vein graft as the treatment of choice in left internal thoracic artery hypoperfusion syndrome does not lead to occlusion of the artery. Conduit flow adaptation to the diastolic predominance occurs in the first 6 months after operation.

[Immediate and mid-term clinical and angiographic results after implantation of AVE intracoronary micro-stents in 140 consecutive cases. An experience in Lausanne]

Two hundred AVE (Arterial Vascular Engineering) microstents measuring 4 to 30 mm were implanted in 140 patients aged 62 +/- 10 years with Class II to IV angina of the Canadian Cardiovascular Society Classification. The indications were: de novo lesions (30%), suboptimal angioplasty results (54%), acute occlusion (8%) or restenosis (8%). The stents of 3.0 to 4.0 mm diameter were implanted in the left main coronary artery (1%) the left anterior descending artery (20%), the left circumflex artery (19%), the right coronary artery (44%) or a venous bypass graft (7%) after intravenous injection of 15,000 IU of heparin. Daily treatment with aspirin 100 mg and ticlopidine 500 mg was instituted from the day of the procedure. The success rate was 98.5% with only 3 technical failures. The minimal luminal diameter and percentage stenosis ranged from 0.80 +/- 0.2 mm and 74 +/- 13% before to 2.66 +/- 0.38 mm and 15 +/- 7% after the procedure in vessels with an average reference diameter of 3.05 +/- 0.35 mm. There were 3% of stent-related immediate clinical complications. In February 1996, 97 patients had survived 6 months. With a 97% follow-up rate, the clinical event rate was 18%. The angiographic follow-up rate was 70% and the restenosis rate was 27%. The authors conclude that the AVE microstents are easy to implant and provide excellent immediate angiographic results with a low complication rate.

Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective?

OBJECTIVE

In a prospective, randomized study, postoperatively prolonged antibiotic prophylaxis is evaluated in a high-risk group of patients undergoing cardiac operations. These patients had postoperative low cardiac output necessitating inotropic support and intraaortic balloon pumping.

METHODS

Between January 1991 and 1994, 53 patients were enrolled in the study (42 men, mean age 65 years). All patients received the usual perioperative (24 hours) cefazolin prophylaxis. In the study group (n = 28) a prolonged regimen of prophylaxis with ticarcillin/clavulanate was performed for 2 days and vancomycin was added in a low dose until removal of the intraaortic balloon pump. The control group (n = 25) did not receive a prolonged regimen of prophylaxis. Follow-up ended at hospital discharge.

RESULTS

Early mortality was 7 of 28 patients (25%) in the prophylaxis group and 8 of 25 patients (32%) in the control group (p = 0.397). Defined infections (pneumonia, n = 22; sepsis, n = 8; deep sternal wound infection, n = 2) occurred in 50% of the study group and 68% of the control group (p = 0.265). In all patients with septicemia, only coagulase-negative staphylococci could be isolated from the bloodstream (5 patients in the prophylaxis group vs 3 in the control group). Infectious parameters were controlled daily and did not differ significantly between groups. A total of 1158 bacteriologic tests were performed (blood cultures, n = 389; intravascular catheters, n = 208; bronchial aspirates, n = 411; intraaortic balloon pumps, n = 42; wound secretions, n = 108) showing bacterial growth in 322 (28%) without a significant difference between the groups. In the prophylaxis group, 13 intravascular catheters and intraaortic balloon pumps showed bacterial growth versus 11 in the control group. No side effects were seen.

CONCLUSIONS

In a high-risk group of patients undergoing cardiac operations, infectious outcome could not be effectively influenced by an additional and prolonged postoperative prophylaxis regimen with low-dose vancomycin and ticarcillin/clavulanate. Low-dose vancomycin did not reduce the rate of infections or colonizations of intravascular catheters with gram-positive organisms.

Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms

OBJECTIVE

Assess outcome of patients with descending thoracic aortic aneurysms complicated by aortobronchial and aortoesophageal fistulae in comparison to patients undergoing repair of aortic aneurysms without fistulae.

METHODS

In a consecutive series of 145 patients (age 60 +/- 12 years) with repair of descending thoracic and thoracoabdominal aortic aneurysms, 11 patients (8%; age 63 +/- 9; NS) primarily presented for hematemesis and/or hemoptysis. In 8/11 patients (73%) an aortobronchial fistula was identified, and 3/11 patients (27%) suffered from an aortoesophageal fistula. Five of 11 patients (45%) had undergone previous aortic surgery in the same region.

RESULTS

Extent of aortic segments (range 1-8) replaced was 3.1 +/- 1.4 for all versus 2.6 +/- 0.9 for fistulae (NS). Aortic cross clamp time was 38 +/- 22 min for all versus 45 +/- 15 min for fistulae (NS). Mortality at 30 days was 18/145 (12%) for all versus 16/134 (12%) without fistulae versus 2/11 (18%) with fistulae (NS). Paraparesis and or paraplegia was observed in 11/145 (8%) for all versus 10/134 (7%) without fistulae versus 1/11 (9%) for cases with fistulae (NS). Nine additional patients died after hospital discharge, seven without fistulae and two with fistulae (days 80, and 120) bringing the 1-year mortality up to 23/134 (17%) without fistulae versus 4/11 (36%) with fistulae (NS). Further analysis shows that the 1-year mortality accounts for 1/8 patients (13%) with aorto-bronchial fistulae versus to 3/3 patients (100%) with aorto-esophageal fistulae (esophageal versus bronchial fistula: P = 0.018; esophageal versus no fistula: P = 0.006).

CONCLUSIONS

Outcome of patients suffering from descending thoracic aortic aneurysms complicated by aorto-bronchial fistulae can be similar to that without fistulae, whereas for cases complicated by aorto-esophageal fistulae the prognosis seems to remain poor even after successful hospital discharge.

Effect of high intensity exercise training on central hemodynamic responses to exercise in men with reduced left ventricular function

OBJECTIVES

The aim of this study was to evaluate the effects of high intensity exercise training on left ventricular function and hemodynamic responses to exercise in patients with reduced ventricular function.

BACKGROUND

Results of studies on central hemodynamic adaptations to exercise training in patients with chronic heart failure have been contradictory, and some research has suggested that training causes further myocardial damage in these patients after a myocardial infarction.

METHODS

Twenty-five men with left ventricular dysfunction after a myocardial infarction or coronary artery bypass graft surgery were randomized to an exercise training group (mean age +/- SD 56 +/- 5 years, mean ejection fraction [EF] 32 +/- 7%, n = 12) or a control group (mean age 55 +/- 7 years, mean EF 33 +/- 6%, n = 13). Patients in the exercise group performed 2 h of walking daily and four weekly sessions of high intensity monitored stationary cycling (40 min at 70% to 80% peak capacity) at a residential rehabilitation center for a period of 2 months. Ventilatory gas exchange and upright hemodynamic measurements (rest and peak exercise cardiac output; pulmonary artery, wedge and mean arterial pressures; and systemic vascular resistance) were performed before and after the study period.

RESULTS

Maximal oxygen uptake (VO2max) increased by 23% after 1 month of training, and by an additional 6% after month 2. The increase in VO2max in the trained group paralleled an increase in maximal cardiac output (12.0 +/- 1.8 liters/min before training vs. 13.7 +/- 2.5 liters/min after training, p < 0.05), but maximal cardiac output did not change in the control group. Neither stroke volume nor hemodynamic pressures at rest or during exercise differed within or between groups. Rest left ventricular mass, volumes and EF determined by magnetic resonance imaging were unchanged in both groups.

CONCLUSIONS

High intensity exercise training in patients with reduced left ventricular function results in substantial increases in VO2max by way of an increase in maximal cardiac output combined with a widening of maximal arteriovenous oxygen difference, but not changes in contractility. Training did not worsen hemodynamic status or cause further myocardial damage.

[Reconstructive plastic surgery of thoracic wall defects]

Full-thickness defects of the thoracic wall following tumor resection, irradiation damage or secondary wound healing in thoracic surgery require early interdisciplinary cooperation to achieve patient-specific treatment modalities. Plastic surgical differential therapy allowing for sufficient soft tissue coverage, stabilisation of the thoracic wall and space filling in intrathoracic cavities, is presented and critically discussed.

[Long-term prognosis for patients undergoing thrombolysis during the acute phase of myocardial infarction]

OBJECTIVE

The objective of this study was to analyse the long-term mortality and morbidity of a group of patients undergoing thrombolysis during the acute phase of myocardial infarction and to determine the factors influencing the prognosis. One hundred and seventy five patients (149 mean and 26 women, mean age: 54 years) were included in a randomized study, comparing the efficacy of 2 thrombolytic substances administered during the acute phase of myocardial infarction. A standard questionnaire was sent to the various attending physicians to follow-up of these 175 patients.

RESULTS

The hospital mortality was 5% (9 patients) and 14 patients (9%) died after a mean follow-up of 4.3 +/- 2.1 years. The 5-year actuarial survival was 81%. Fourteen patients (8%) were lost to follow-up and 49 patients (32%) underwent surgical or percutaneous revascularization during follow-up. Revascularized patients had a significantly better survival than non-revascularized patients. The mean left ventricular ejection fraction of patients who died was lower (48% versus 71%) than that of survivors. Patients with an ejection fraction < 40% also had a significantly lower survival (p = 0.01). Patency of the vessel after thrombolysis was associated with a slightly better survival; this difference was not significant. The ejection fraction at 6 month was also significantly higher (60 +/- 10% versus 49 +/- 11%) for patients with a patent artery. Three risk factors for death or reinfarction were identified: age > 65 years at the time of infarction, disease in more than one coronary vessel and absence of angina pectoris before infarction. The probability of a coronary accident varied from 2 to 88% according to the number of risk factors present. At the time of follow-up, 60% of patients presented hypercholesterolaemia versus only 7% before infarction 73% of patients received anticoagulant or antiaggregant treatment and 81% of patients were asymptomatic.

CONCLUSION

The mortality and the acute and long-term morbidity of myocardial infarction remain high, as only 34% of our patients did not develop any events during follow-up, despite serious medical management and follow-up. The ejection fraction has an important prognostic value. Patient management should take the abovementioned risk factors into account.

Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction: application of magnetic resonance imaging

BACKGROUND

There are conflicting reports on the effects of training on the remodeling process in post-myocardial infarction patients with ventricular damage.

METHODS AND RESULTS

Twenty-five patients with reduced ventricular function (mean ejection fraction, 32.3+/-6%) after an anteroseptal or inferolateral myocardial infarction were randomized to an exercise group (n=12) or a control group (n=13). Patients in the exercise group resided in a rehabilitation center for 2 months and underwent a training program consisting of two 1-hour sessions of walking daily, along with four monitored 45-minute sessions of stationary cycling weekly. Before and after the study period, maximal exercise testing and cardiac MRI were performed. Oxygen uptake increased 26% at maximal exercise (19.7+/-3 to 23.9+/-5, P<.05) and 39% at the lactate threshold (P<.01) in the exercise group, whereas control values did not change. No differences were observed within or between groups in MRI measures of end-diastolic (187+/-47 pre versus 196+/-35 mL post in the exercise group and 179+/-52 pre versus 180+/-51 mL post in the control group), end-systolic volume (118+/-41 pre versus 121+/-33 mL post in the exercise group and 119+/-54 pre versus 116+/-56 mL post in the control group), or ejection fraction (38.0+/-9 pre versus 38.2+/-10% post in the exercise group and 37.0+/-10 pre versus 38.3+/-13% post in the control group). Myocardial wall thickness measurements at end diastole and end systole and their difference in 80 myocardial segments determined by MRI yielded no significant interactions between groups. When myocardial wall thickness measurements were classified by infarct or noninfarct areas, no differences were observed between groups over the study period.

CONCLUSIONS

A high-intensity, 2-month residential cardiac rehabilitation program resulted in substantial increases in exercise capacity among patients with reduced left ventricular function. In contrast to some recent reports, the training program had no deleterious effects on left ventricular volume, function, or wall thickness regardless of infarct area.

Salivary gland-like tumors of the sellar region

Herein we present a group of rare tumors of the sella region that have not been previously recognized. Although clinically and radiographically the tumors resemble nonfunctioning pituitary adenomas, their histologic, immunohistochemical, and ultrastructural features differ and indicate a salivary gland origin. The lesions cover a morphologic spectrum that includes cellular pleomorphic adenoma, monomorphic adenoma, oncocytoma, and low-grade adenocarcinoma of the salivary gland. All tumors except the oncocytoma were immunoreactive for cytokeratin and were negative for pituitary hormones and synaptophysin. Ultrastructural characteristics in the cases examined include hypodense stromal material, basal lamina, and tonofilament bundles. The single oncocytoma was packed with mitochondria and lacked membrane-bound secretory granules. DNA ploidy based on image analysis and MIB-1 labeling indices showed diversity within this group of tumors, with labeling indices ranging from 0.06% to 15%. The presumed origin of these rare neoplasms is from salivary gland rests related to the normal pituitary gland. Despite their varied morphology, such tumors are easily confused with pituitary adenoma. Although rare, tumors of salivary gland origin should be considered in the differential diagnosis of unusual adenohypophyseal tumors.

Diagnosis and management of blunt great vessel trauma

Traditionally, thoracic aortic rupture, suspected after blunt thoracic trauma, is characterized by a chest radiograph showing a widened mediastinum. The diagnostic machinery consecutively activated still depends heavily on the pressure as additional traumatic lesions. A patient with additional cranio-cerebral trauma would typically undergo contrast-enhanced computed tomography or magnetic resonance imaging of head, chest, and other regions. In a number of patients these analyses would confirm the presence of blood in the mediastinum without formal proof of an aortic disruption. This is because mediastinal hematomas may be caused not only by an aortic rupture, but also by numerous other blood sources including fractures of the spine and other macro- and microvascular lesions providing similar images. Therefore, aortic angiography became our preferred diagnostic tool to identify or rule out acute traumatic lesions of not only the aorta but with great vessels. However recently, a number of traumatic aortic transsections have been identified by transoesophageal echocardiography (TEE). TEE has the additional advantage of being a bed-side procedure providing additional information about cardiac function. The latter analysis allows for identification and quantification of cardiac contusions, post-traumatic myocardial infarctions, and valvar lesions which are of prime importance to develop an adequate surgical strategy and to assess the risk of the numerous emergency procedures required in patients with polytrauma. The standard approach for repair of isthmic aortic rupture is through a lateral thoracotomy. Distal and proximal control of the aorta can be achieved in a substantial number of cases before complete aortic rupture occurs and a higher proportion of direct suture repair can be achieved under such circumstances. Most proximal descending aortic procedures are performed without cardiopulmonary bypass (clamp and go) but paraplegia may occur before, during, or after the procedure. Ascending aortic lesions and disruption of the aortic arch, the supra-aortic vessels, the main pulmonary arteries, the great veins as well as cardiac lesions are best approached through a sternotomy, which may have to be extended. Cardiopulmonary bypass allowing for deep hypothermia and circulatory arrest is often required and carries its own complications. It is not clear whether the increasing proportion of ascending aortic and cardiac lesions which are observed nowadays are due to a change in trauma mechanics (i.e., speed limits, seat belts, air-bags), an improvement of the diagnostic tools or both.

The infected aorta

BACKGROUND

Despite the improvements achieved in antibiotic therapy, severe aortic infection resulting in mycotic aneurysms is still a highly lethal disease and surgical management remains a challenging task.

PATIENTS AND METHODS

A total of 43 patients with severe aortic infections were analyzed and separated in four groups: (1) Infections of the aortic root Ventriculo-aortic disconnection due to deep aortic infection (6 patients). Two patients were operated using homo-composit grafts. Of the 6 patients total, one died early and two died late during a mean follow-up of 6 years. The two patients with homografts are still alive. (2) Infections of the ascending aorta and the aortic arch. In situ repair for mycotic aneurysmal lesions of the ascending aorta was performed in 6 patients using synthetic graft material in 4/6, biological material in 1/6 and direct suture in 1/6. Two patients had to be reoperated; one of them died early. There was no recurrent infection during a mean follow-up of 6 years. (3) Infections of the descending thoracic and thoraco-abdominal aorta in-situ repair for mycotic aneurysmal lesions of the descending and thoraco-abdominal aorta was performed in 12 patients using homografts in five. Two patients died early and two other patients died late during a mean follow-up of 6 years. (4) Infections of the infrarenal abdominal aorta. In this series of 19 patients with mycotic infrarenal aortic aneurysms, in situ reconstruction was performed in 12 (5/12 with homografts) and extra-anatomic reconstruction (axillo-femoral bypass) was performed in 7. Hospital mortality was 5/19 patients and another 5/19 patients died during a mean follow-up of 6 years. One of the early deaths was due to aortic stump rupture. Two patients with axillo-femoral reconstructions were later converted to descending-thoracic-aortic-bifemoral bypasses. Five thromboses of axillo-femoral bypasses were observed in three of the seven patients with extra-anatomic repairs.

RESULTS

Infections of the aortic root, the ascending aorta and the aortic arch are approached with total cardio-pulmonary bypass, using cardioplegic myocardial protection and deep hypothermia with circulatory arrest if necessary. Proximal unloading and distal support using partial cardiopulmonary bypass is preferred for repair of infected descending and thoracoabdominal aortic lesions, whereas no such adjuncts are required for repair of infected infrarenal aortic lesions.

CONCLUSIONS

The anatomical location of the aortic infection and the availability of homologous graft material are the main factors determining the surgical strategy.

[Early results in the surgical treatment of type B aortic dissection]

In contrast to type A aortic dissection, the indication for acute surgical repair as treatment of choice in type B aortic dissection is not the actual dissection, but the complications resulting from the dissection (rupture, potential rupture and ischemic syndromes of the aortic branches). Between 1978 and 1994, 92 patients underwent surgical repair of type B aortic dissection at our institution. Following diagnostic confirmation by echocardiography and/or CT scan, all patients received conservative antihypertensive therapy. 52% of the patients underwent emergency surgical repair. Symptoms prompting surgical repair were: visceral ischemia (23%), pleural effusion (19%), paraparesis (17%), refractory hypertension (12%), further aortic enlargement (12%), and rupture (10%). In chronic type B aortic dissection, the main symptom in 84% of the cases was further enlargement of the aorta. The early mortality decreased in the course of initial treatment from 33% to 16%, and to 8% after exclusion of patients operated on for ruptured aorta. Improved early mortality has led to an increase in acute surgical repair. In cases of chronic dissection, strict antihypertensive therapy is indicated and regular checks on the width of the aorta, as well expeditious diagnostic confirmation of its enlargement, are important.

Functional and biochemical analysis of angiotensin II-forming pathways in the human heart

Blockade of the renin-angiotensin system by inhibition of angiotensin-converting enzyme (ACE) is beneficial for the treatment of hypertension and congestive heart failure. However, it is unclear how complete the blockade by ACE inhibitors is and if there is continuing angiotensin II (Ang II) formation during chronic treatment with ACE inhibitors. Indeed chymase, a serine protease, which is able to form angiotensin II from angiotensin I (Ang I) and cannot be blocked by ACE inhibitors, has been shown to be present in human heart. The goal of the present study was to evaluate the extent of renin-angiotensin system blockade and the Ang II-forming pathways in cardiac tissue of patients chronically treated with ACE inhibitors or in patients without ACE inhibition therapy. Our studies indicate an incomplete ACE inhibition in human heart tissue after chronic ACE inhibitor therapy. Moreover, ACE contributes only a small portion to the total Ang I conversion, as shown in biochemical studies in ventricular and coronary homogenates or functionally as Ang I contractions in isolated rings of coronary arteries. A serine protease was responsible for the majority of Ang II production in both the membrane preparation and Ang I-induced contractions of isolated coronary arteries. In humans, the serine protease pathway is likely to play an important role in cardiac Ang II formation. Thus, drugs such as renin inhibitors and Ang II receptor blockers might be able to induce a more complete blockade of the renin-angiotensin system, providing a more efficacious therapy.

Small-cell lung cancer is characterized by a high incidence of deletions on chromosomes 3p, 4q, 5q, 10q, 13q and 17p

The genetic mechanisms that define the malignant behaviour of small-cell lung cancer (SCLC) are poorly understood. We performed comparative genomic hybridization (CGH) on 22 autoptic SCLCs to screen the tumour genome for genomic imbalances. DNA loss of chromosome 3p was a basic alteration that occurred in all tumours. Additionally, deletions were observed on chromosome 10q in 94% of tumours and on chromosomes 4q, 5q, 13q and 17p in 86% of tumours. DNA loss was confirmed by loss of heterozygosity (LOH) analysis for chromosomes 3p, 5q and 10q. Simultaneous mutations of these six most abundant genetic changes were found in 12 cases. One single tumour carried at least five deletions. DNA under-representations were observed less frequently on chromosome 15q (55%) and chromosome 16q (45%). The prevalent imbalances were clearly indicated by the superposition of the 22 tumours to a CGH superkaryogram. In our view, the high incidence of chromosomal loss is an indication that SCLC is defined by a pattern of deletions and that the inactivation of multiple growth-inhibitory pathways contributes in particular to the aggressive phenotype of that type of tumour.

Cardiac metastasis of an epitheloid leiomyoblastoma of the lung

A 73-year-old patient underwent an extended pneumonectomy on the left side on account of a central malignant epitheloid leiomyoblastoma of the upper lobe. During this operation a tumor invasion of the pulmonary vein was discovered by chance. During the postoperative course the patient suffered from a tumor-caused morbus embolicus which led to his death. The autopsy showed cardiac metastasis. Four aspects are discussed: the morphology and biology of the malignant leiomyoblastoma, the incidence of cardiac metastases and their clinical diagnosis as well as the intraoperative embolism of tumor masses during lung resections.

Placement of multiple and different stent types for very long dissections during coronary angioplasty

We have been investigating the safety and efficacy of multiple and different stent types placed in the unfavorable situation of a very long dissection (> 20 mm) after coronary angioplasty. We report our preliminary experience in 20 patients who were treated by the following combinations: Palmaz-Schatz and Micro stent (14 patients). Wallstent and Micro stent (4 patients); Wiktor and Micro stent (1 patient); and Palmaz-Schatz, Micro and Wallstent (1 patient). Normal distal flow was restored in all except one (no reflow phenomenon) patient and complete covering of the dissection was obtained in all but two patients. Event-free survival at 30 days was 90% (18 of 20 patients). During follow-up (mean period: 8 +/- 3 months), two patients died. Of the 18 other patients, 16 remained asymptomatic and free of complications. Symptomatic restenosis was treated by standard angioplasty in the two remaining patients. In conclusion, placement of different stent types seems a feasible, safe, and efficient treatment for very long dissections caused by standard angioplasty.

[Plastic soft tissue coverage in defect fractures of the tibia]

Sequential radical debridement and early soft-tissue reconstruction have considerably decreased the amputation rate, length of hospital stay, chronic osteitis, the rehabilitation period and secondary reconstructive procedures in lower leg injuries. The introduction of distraction osteotomy and "biologic osteosynthesis procedures" have led to shorter and safer osteoplastic methods. The indication, tactics and technical pitfalls of current interdisciplinary treatment options requiring modifications in soft-tissue coverage are presented.

Comparison of elective Wiktor stent placement with conventional balloon angioplasty for new-onset lesions of the right coronary artery

This study compared the clinical and angiographic outcome, during a 6-month follow-up period, of 84 patients with new-onset lesions of the right coronary artery randomized to either Wiktor stent implantation (42 patients) or conventional balloon angioplasty (42 patients). At hospital discharge, three patients in each group (7%, p = not significant [NS]) reached a clinical end point. At 6 months, these proportions were 24% (10 patients with stents) and 29% (12 patients with angioplasty) (p = NS). There were no incidents of death or myocardial infarction. Despite a larger minimal luminal diameter after stenting (2.87 mm [95% confidence interval; 2.66 to 2.96 mm] vs 2.37 mm [2.23 to 2.61 mm for angioplasty] [p = 0.001]), no difference was observed at 6 months of follow-up (1.75 mm [1.43 to 2.18 mm] vs 1.74 mm [1.45 to 2.03 mm] [p = NS], respectively). Accordingly, angiographic restenosis rates were 47.5% (19 of 40 patients with stents) and 35% (14 of 40 patients with angioplasty) (p = NS). Elective stenting with the Wiktor stent and conventional balloon angioplasty are safe and immediately effective therapeutic options for symptomatic, obstructive right coronary artery disease. At 6 months of follow-up, clinical and angiographic outcome did not differ. The role of Wiktor stent placement in primary restenosis prevention remains to be determined for lesions of the right coronary artery.

Bronchiolitis obliterans in a patient with localized scleroderma treated with D-penicillamine

D-penicillamine-associated bronchiolitis obliterans (BO) is a rare but well-known pulmonary complication in patients with rheumatoid arthritis or progressive systemic sclerosis. It has been assumed that in most, if not all cases, BO is a complication of the underlying disease rather than a side-effect of treatment. We report the case of a 46 year old man with scleroderma localized to his lower legs (morphea), who received a daily dose of 750 mg D-penicillamine. During the treatment of 1 yr duration, he developed progressive shortness of breath due to a worsening obstructive ventilatory defect suggesting BO, which was confirmed by surgical lung biopsy (constrictive BO). Bronchial obstruction progressed over the next 5 yrs and did not respond to corticosteroids. The patient finally underwent a successful single left lung transplantation. The histological features of constrictive BO were confirmed in the explanted lung. This observation suggests that D-penicillamine may induce bronchiolitis obliterans in the absence of a systemic connective tissue disease.

[Heart surgery in acute heart infarct. Indications and results]

The therapy of acute myocardial infarction has made major advances in the last 10 years. Cardiac surgeons have to adapt their strategies to the more aggressive management of acute myocardial infarction. Only in mechanical complications of acute myocardial infarction is cardiac surgery nowadays the therapy of choice. In cardiac rupture and ventricular septal defect, surgery is the only therapeutic option. In ischemic mitral regurgitation, cardiac surgery is required in the event of concomitant cardiogenic shock and pulmonary edema after intra-aortic balloon pump placement. Coronary artery bypass surgery my be indicated at low risk in patients with unstable angina pectoris when PTCA is not feasible or has failed, or in catheter emergencies.

Wound fluid-derived heparin-binding EGF-like growth factor (HB-EGF) is synergistic with insulin-like growth factor-I for Balb/MK keratinocyte proliferation

Epidermal cell proliferation is required for re-epithelialization during wound repair. Re-epithelialization of partial thickness excisional wounds in pigs is complete by 6 days after injury. The presence of insulin-like growth factor-I (IGF-I) and heparin-binding molecules that are mitogenic for keratinocytes was examined in wound fluid obtained daily from these wounds. Two significant heparin-binding growth factor activities for Balb/MK keratinocytes were detected, a major one that was eluted from a heparin affinity column with 1.1 M NaCl and a minor one with 0.5 M NaCl. These activities appeared 1 day after injury, were maximal by 2-3 days later, and disappeared by 6 days after injury. The molecule eluting with 1.1 M NaCl was heparin-binding EGF-like (HB-EGF). The levels of IGF-I in wound fluid were 45-90 ng/ml during the first 3 days following injury, decreased thereafter, and were not detectable 6 days after injury. IGF-I at 100 ng/ml, increased HB-EGF mitogenic activity for Balb/MK keratinocytes by 40-50 fold. We conclude that the synergism between IGF-I and HB-EGF and their relative concentration at the various days after injury may be important variables for regulating re-epithelialization during wound repair.

Prospective study of the value of transbronchial lung biopsy after lung transplantation

Transbronchial lung biopsy (TBB) has become the gold standard for the diagnosis of acute rejection and cytomegalovirus (CMV) pneumonia in lung transplant recipients. The aim of this study was to assess the value of regular surveillance TBB in stable asymptomatic patients and to establish the role of TBB as a follow-up procedure 1 month after a previous pathological biopsy result. We prospectively evaluated 76 TBBs performed in 17 lung transplant recipients. A definite pathological results was found in 14 of 15 TBBs performed for clinical indications: CMV pneumonia (5), acute rejection grade > or = A2 according to the criteria of the International Society for Heart and Lung Transplantation (ISHLT) (4), bronchiolitis obliterans (3), and desquamative interstitial pneumonitis (2). Fifteen of 45 surveillance TBBs performed in asymptomatic patients revealed significant abnormalities. Ten episodes of acute rejection ISHLT grade > or = A2 and three episodes of CMV pneumonia detected by TBB had direct therapeutic consequences. Nine of 16 follow-up TBBs performed 1 month after a pathological biopsy result again showed relevant pathological findings. With the exception of one severe haemorrhage, no life-threatening complications occurred. Our results suggest that transbronchial lung biopsies performed on a regular basis after lung transplantation are important for the detection of asymptomatic and/or persistent acute rejection or injection. In the long-term, this strategy might be the most effective tool in reducing the incidence of bronchiolitis obliterans, which is still the main obstacle for further improvement of long-term survival after lung transplantation.