Ventricular Rupture due to Myocardial Infarction without Obstructive Coronary Artery Disease

An 87-year-old woman presenting with myocardial infarction and ST-segment elevation in the electrocardiogram suffered from pericardial effusion due to left ventricular rupture. After ruling out obstructive coronary artery disease and aortic dissection, she underwent cardiac surgery showing typical infarct-macerated myocardial tissue in situ. This case shows that even etiologically unclear and small-sized myocardial infarctions can cause life-threatening mechanical complications.

In-Hospital Outcome of Patients with Diabetes Mellitus after CTO Recanalization with Third-Generation Drug-Eluting Stents

Background: Percutaneous coronary intervention (PCI) of total chronic coronary occlusions (CTOs) still remains a major challenge in interventional cardiology. There is little knowledge in the literature about differences in CTO-PCI between diabetic and nondiabetic patients in the era of third-generation drug-eluting stents (DESs). In this study, we analyzed the impact of diabetes mellitus (DM) on procedural characteristics, complications, and acute outcomes in a cohort of 440 patients. Methods: Between 2012 and 2016, we recruited 440 consecutive patients, 116 of them with DM. All the patients underwent PCI for at least 1 CTO. Antegrade and retrograde CTO recanalization techniques were applied. Only third-generation DESs were used. We used t-tests and the Pearson chi-quadrat test to test the significant differences in the variables between the 2 groups. Results: The patients with DM were older than the nondiabetics (64.5 y vs. 61.1 y; P=0.003), and they suffered more frequently from a chronic kidney disease (7.1% vs. 2.4%; P=0.001). The nondiabetics less frequently had arterial hypertension (75.3% vs. 89.7%; P=0.001); however, they more often had a family liability for CAD (32.1% vs. 22.4%; P=0.050) and had a higher left ventricular ejection fraction (59.2% vs. 56.7%; P=0.011). The success rate was 85.2% in the patients without DM and 81.2% in the patients with DM (P=0.403). The existence of DM had no impact on the procedural success and complication rates. Conclusion: Our study on 440 patients shows that diabetics and nondiabetics have similar success and complication rates after the recanalization of CTOs using third-generation DESs. It is a feasible and safe procedure and can be recommended as an alternative treatment.

The atherogenic index of plasma and its impact on recanalization of chronic total occlusion

BACKGROUND

The plasma-derived atherogenic index (AIP) is associated with an increasing risk for cardiovascular diseases. Whether an increased AIP may predict the complexity of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), according to available research, has never been investigated before.

METHODS

Three hundred seventeen patients were included prospectively and treated with PCI for at least one CTO between 2012 and 2017. High-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) plasma levels were measured 24 h before PCI. All patients were stratified into tertiles of AIP (defined as 0.11, 0.11-0.21, > 0.21) based on their TG/HDL-C (AIP) levels.

RESULTS

Mean AIP of all patients undergoing CTO-PCI was 0.53 ± 0.29. The majority of patients were male (82.6%), and mean age was 61 ± 10.4 years. Increased AIP > 0.21 was associated with longer occlusion length (statistical trend p = 0.082) and stent routes (p = 0.022) and with a higher number of implanted stents (n > 4) (statistical trend p = 0.072). Success rates were similar in all AIP categories (p = 0.461). In-hospital PCI-related complications were rare and not statistically different (p = 0.852).

CONCLUSIONS

This study demonstrates for the first time that an increased AIP may predict the complexity of CTO-PCI and additionally may help to improve planning and quality of CTO-PCI.

Acute outcome of chronic total occlusion (CTO) recanalizsation in the elderly

OBJECTIVES

Percutaneous coronary intervention (PCI) of total chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. There is only insignificant knowledge reported in the literature about age differences in CTO recanalization. We analyzed in this study the issue of the impact of age on procedural characteristics, complications and short-term outcome.

METHODS

Between 2012-2016 we included 440 patients. They underwent PCI for at least one CTO. Antegrade and retrograde CTO techniques were applied. The retrograde approach was used only after failed antegrade intervention. Continuous data are presented as the mean ± standard deviation; categorical data are presented as numbers and percentages unless otherwise specified. We used Twosamplet- t-test with equal variance to test the significant differences of the variables between the two cohorts.

RESULTS

Procedural success proved independently of age. There was no significant interaction between age and procedural success (p=0.5). Complication rates were low in both groups (2.7% vs. 4%; p=0,4) with no difference in statistical significance.

CONCLUSIONS

Our study suggests that in an aging society patients with severe coronary artery disease and chronical total occlusions an interventional therapy should be used more intensively. It can be performed safe and feasible.

Multiple procedures and cumulative individual radiation exposure in interventional cardiology: A long-term retrospective study

INTRODUCTION

Various studies address discrepancies between guideline recommendations for coronary angiographies and clinical practice. While the issue of the appropriateness of recurrent angiographies was studied focusing on the role of the cardiologist, little is known about individual patients' histories and the associated radiation exposures.

METHODS

We analyzed all patients with coronary artery disease (CAD) in an academic teaching practice who underwent at least one angiography with or without intervention between 2004 and 2009. All performed angiographies in these patients were analyzed and rated by three physicians for appropriateness levels according to cardiology guidelines. Typical exposure data from the medical literature were used to estimate individual radiation exposure.

RESULTS

In the cohort of 147 patients, a total of 441 procedures were analyzed: between 1981 and 2009, three procedures were performed per patient (range 1-19) on average. Appropriateness ratings were 'high/intermediate' in 71%, 'low/no' in 27.6% and data were insufficient for ratings in 1.4%. Procedures with 'low/no' ratings were associated with potentially avoidable exposures of up to 186 mSv for single patients.

CONCLUSIONS

Using retrospective data, we exemplify the potential benefit of guideline adherence to decrease patients' radiation exposures.

KEY POINTS

• A cohort study of 147 patients showed 27.6% low appropriateness procedures. • Potentially avoidable radiation exposure cumulated up to about 186 mSv for single patients. • Predisposing factors were prior bypass surgery and first treatment in a tertiary centre. • 7.5% of the patients received 58% of the potentially avoidable radiation exposure. • The benefits of guideline adherence in decreasing patient radiation exposure are exemplified.

Inadvertent intravitreal gentamicin injection

PURPOSE

To describe the management and consequences of an accidental injection of gentamicin in the vitreous.

METHODS

A retinal detachment developed in a 70-year-old male. During a vitrectomy operation, gentamicin (20mg) was accidentally injected in to the eye. The surgeon immediately began vigorous lavage of the vitreal cavity with balanced salt solution.

RESULTS

No toxic signs appeared after the operation, despite the devastating consequences described in previous reports.

CONCLUSIONS

The immediate vigorous lavage may have reduced the concentration of the toxic material and its consequences.

Pulsatile ocular blood flow in diabetic retinopathy

PURPOSE

To assess circulatory properties of eyes with progressive stages of diabetic retinopathy.

METHODS

The intraocular pressure, pulse amplitude (PA) and pulsatile ocular blood flow (POBF) were measured with a pneumatonometer (OBF Labs UK Ltd). The eyes were grouped: (a) normal control, n = 26, (b) diabetes with no observable diabetic retinopathy (NDR), n = 18, (c) mild to moderate non-proliferative diabetic retinopathy (NPDR), n = 20, and (d) very severe pre-proliferative and proliferative diabetic retinopathy (PPDR/PDR), n = 12.

RESULTS

The PA and POBF values were lower than normal values in the earliest stage (NDR). The POBF increased but was still below normal levels at the NPDR stage, and then increased to an above normal level in the PPDR/PDR stage of diabetic retinopathy. The PA was at normal levels in these later two stages.

CONCLUSION

An initial decrease in pulsatile ocular blood flow is present with the onset of diabetes where no diabetic retinopathy has yet occurred. Subsequently, the pulsatile ocular blood flow increases with the severity of the retinopathy.

Total internal reflection of laser light in eyes filled with silicone oil

BACKGROUND AND OBJECTIVES

This is the first report of clinical settings in which total internal reflection of laser light in eyes filled with silicone oil was observed. The authors analyze this phenomenon and outline the potential hazards it may present to patient, surgeon, and operating room personnel.

MATERIALS AND METHODS

The authors observed significant reflection of laser light off the silicone-water interface both intraoperatively and in the clinic. The critical angle according to Snell's law (i.e., the angle at which total internal reflection occurs at the interface between silicone oil and vitreous) was calculated. The critical angle was found to be 71.9691 degrees(72 degrees).

RESULTS

An analysis of each of the clinical conditions where this phenomenon was observed is presented. Clinical and surgical implications are discussed.

CONCLUSIONS

The hazard of total internal reflection of laser light in eyes filled with silicone oil should be recognized by ophthalmologists to avoid possible complications. Techniques for overcoming and circumventing the difficulties resulting from this phenomenon are proposed.

Nucleus fragmentation in a scleral pocket for small incision extracapsular cataract extraction

We present a technique for planned manual extracapsular cataract extraction (ECCE) incorporating a modification of mini-nuc ECCE in which the scleral tunnel is made wide enough to allow a nucleus of any size to settle in the tunnel. A 5.0 mm, inverted-V chevron incision is used in which the exposed part of the nucleus lodged in the scleral pocket can be manually picked and fragmented until it is small enough to be removed through the incision. The chevron incision is flexible enough to allow a medium-sized nucleus to be extracted without fragmentation and implantation of a rigid 6.0 mm poly(methyl methacrylate) lens. Vector analysis of preoperative and 3 month postoperative keratometric results in 30 patients showed that the surgically induced vector was 0.54 diopter (D) +/- 0.58 (SD). Mean reduction in astigmatism was 0.08 +/- 0.39 D. The sutureless technique is fast and safe, allows a nucleus of any size to be extracted through a constant size 5.0 mm incision, and results in minimal postoperative astigmatism.

Retinal periphlebitis after hormonal treatment

Two cases, those of a man and a woman, developed retinal periphlebitis after hormonal treatment for infertility and contraceptives, respectively. Both had a unilateral severe decrease in visual acuity, and a central scotoma and defect in color vision were also present. The fundus had retinal edema, especially of the macula, a hyperemic disc with blurred margins, normal arteries, congested veins, and marked sheathing along the main veins, with retinal hemorrhages in the inferior half of the retina. Fluorescein angiography showed a delayed filling of the veins in the affected retina and late staining of these veins. Since there was severe visual impairment in each case, systemic adrenocorticosteroids were administered, and a rapid improvement in visual acuity occurred. In one patient, a trace Marcus-Gunn sign, a few small paracentral scotomas, and a defect in color vision were permanent sequelae.

[Surgery in the diagnosis and interdisciplinary treatment of malignant lymphomas]

Surgical problems of diagnosis, staging and interdisciplinary therapy of malignant lymphomas are reviewed with special reference to diagnostic laparotomy with splenectomy and abdominal biopsies.

A Case of Pseudosarcoma of the Esophagus

Pseudosarcoma of the esophagus previously has been described and documented in only 13 patients. Our case, after a successful total esophagectomy with esophagogastroplasty, is physically well without any symptoms of recurrence to date (18 months postoperative).

Radical and Palliative Surgery of the Carcinoma of the Esophagus

Carcinoma of the esophagus is a squamous cell carcinoma in 90 % of cases and an adenocarcinoma in 10 %. It accounts for 50 % of esophageal diseases and 3 to 5 % of all malignant tumors. In 40 % of cases it is located in the middle third, in 40–45 % in the lower third and cardia, and in the remaining cases in the upper thoracic segment and in the cervical esophagus. Although the biological malignancy is relatively low, the clinical malignancy is high, due to delayed diagnosis and to the peculiar anatomic and topographic situation. For this reason radical surgery, which is conditioned by tumor site, ways of spread and the obstacles of mediastinal structures, is only possible in a restricted number of cases. The site determines the surgical approach, extent of resection, type and preparation of the plastic material and mode of insertion into the thorax. The stomach is an organ suitable for plastic repair whereas the jejunum and colon have some contraindications. The results of surgery in cases amenable to radical surgery are not unsatisfactory. Operative mortality has reached reasonable values in the past few years: 12 % for middle and high localizations, and 8 % for low localization in the author's experience. 5-year survival in cases of low localizations in 6 % in the examined cases and 15 % in the operated cases; in cases of middle localizations 2 % in the examined cases and 10 % in the operated cases. For the upper, supraaortic localizations no cases of survival are recorded in any surgical series. The longest survival in the author's series is 16 years for low localizations and 13 years for middle localizations. With regard to palliative treatment, simple choices should be made since the results are similar to those of major surgery. Complications may occur immediately, early or late; particular consideration is given to anastomotic fistulas and to reflux esophagitis.