Severe pulmonary arterial hypertension associated with congenital cardiac shunts: evolution under specific treatment

Objective: The aim of this study was to compare the effects of Sildenafil, Bosentan and combined therapy in patients with congenital cardiac shunts associated pulmonary artery hypertension (CCS-PAH). Design: Prospective observational study (February 2011 - January 2014) with a historical control group (January 2009 - January 2011). Setting: "CC Iliescu" Institute for Emergency Cardiovascular Diseases of Bucharest, a tertiary university-affiliated center. Patients: All cases with CCS-PAH. Interventions: Specific vasodilatory therapy: Sildenafil, Bosentan or combined therapy. Outcome Measures: The primary outcome was the overall survival at 24 months. Results: Out of 108 patients with pulmonary arterial hypertension, there were 79 patients with CCS-PAH, 55 presenting a severe form of the disease. The mean age of the patients was 34.42±21.15 years, with 37 (67,3%) female patients. 23 patients received specific vasodilatory treatment (thirteen Sildenafil, seven Bosentan, three combined treatment), with 32 patients in the control group, without specific vasodilatory therapy. The specific vasodilatory therapy was associated with improved WHO/ NYHA functional class (p=0.025), oxygen saturation at the end of the six-minute walk test (p=0.011), decreased pulmonary artery systolic (p=0.002) and diastolic (p=0.004) pressures, and an increased S' wave in Tissue Doppler Imaging (p=0.008). Conclusions: Despite the complexity of CCS-PAH, with a complex constellation of underlying congenital heart defects, there are short-term benefits of a specific vasodilatory therapy.

Transarterial embolization of renal vascular lesions after percutaneous nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) represents a safe and efficient procedure in the surgical management of renal lithiasis. Nevertheless, surgeons have to face specific complications during and after the procedure, hemorrhage being one of the most common. In most cases the injuries are self-limited and do not need a surgical intervention. Renal arteriography with selective angiographic embolization is needed in patients with massive hemorrhage or continuous hematuria. Our objective was to evaluate the effectiveness of percutaneous transarterial embolization for the treatment of renal arterial post-PCNL bleeding.

MATERIAL AND METHOD

This retrospective study was performed between March 2007 and October 2012 and included 22 patients who had undergone renal embolization due to significant post-PCNL renal artery bleeding. The site, number, and type of bleeding lesions, and the result of the embolization procedure were recorded. We report on the incidence, treatment, radiological and clinical results of these serious vascular injuries at our institution.

RESULTS

Our study has included a large group of patients, the 95.45% angiographic success rate confirming that percutaneous transcatheter embolization is a valuable treatment for most renal vascular injuries. Renal angiography revealed pseudoaneurysm in 15 patients, arteriovenous fistula in 5 and arterial laceration in 2 patients. Significant risk factors on univariate analysis for severe hematuria requiring superselective angiography were multiple staghorn calculi, upper calix puncture and history of pyelonephritis. The severity of the hematuria after PCNL is influenced by many factors, including mean stone size and mean operative time and is correlated with duration of hospitalization and mean hemoglobin drop.

CONCLUSIONS

Percutaneous transarterial embolization of the injured vessel is an effective, minimally invasive and relatively easy procedure in experienced centers, with high rate of success and immediate benefits, thus saving the patient from the morbidity that results from severe renal bleeding.

Ventral buccal mucosa graft urethroplasty for penile urethral strictures: a predictable failure?

BACKGROUND

In the case of buccal mucosa graft (BMG) urethroplasty for penile urethral strictures (PUS), it is supposed that the ventral onlay (VO) would not assure sufficient nutritional and mechanical support. Because VO requires only one ventral incision of the stenotic urethral segment and does not affect the urethral vasculature, we have design a prospective study related to this issue.

METHODS

We selected 27 consecutive patients with PUS, other than due to lichen sclerosus or to multiple hypospadias surgery. Surgical technique used: circular incision of the penile skin just below the glans, degloving without dartos, ventral median incision of the stenosed urethral segment, tailoring of the buccal mucosa graft over a 22 Ch catheter and fixation at the urethral mucosa edges, covering the graft with two lateral dartos flaps.

RESULTS

Follow-up consisted of clinical examination, uroflowmetry, and urethral ultrasonography. In one patient urethral fistula occurred and in two patients a fibrous diaphragm at the proximal end of the neourethra appeared. For the rest of the patients the neourethra lumen was stable, between 6 and 7mm at urethral ultrasonography control, the success rate being 88.89%.

CONCLUSION

The VO of BMG by the technique described, is a good solution for selected patients with PUS.

[Cajal interstitial cells identification]

Cajal interstitial cells are cells that are found in the abdominal digestive system wall, between neurons and smooth muscular tissue. They are considered to be pacemakers for slow intestinal waves. The paper discuss about the electron-microscopic identification of Cajal interstitial cells in the rat small intestine wall, cell morphology, placement of these cells in the muscular layer and the relation between Cajal interstitial cells and the components of the nervous plexus. Fragments of rat small intestine have been prepared for electron microscopy examination. Cajal interstitial cells have been found in different locations: in the circular muscular layer, around the nervous nodes and between the muscular layers (longitudinal and circular). The main morphologic characteristic of these cells is the aspect of cytoplasm, with numerous vacuoles and long extensions, some of them very thin, with a tendency to divide. Some Cajal interstitial cells form a network that surrounds the nervous nodes. Other form junctions with the muscular cells and with the interstitial neurons.

[White-Bland-Garland syndrome: the maximum natural development of the coronary anastomosis(II)]

The anomalous origin of the left coronary artery from pulmonary artery (White-Bland-Garland syndrome) is a very rare coronary malformation, having despite the great mortality in the early childhood, an adult form, characterized by minor symptoms and long course. This paradoxical situation is totally dependent to the complete development of the coronary anastomosis, allowing the right coronary flow to perfuse the left myocardium. The theory of the "terminal arterial perfusion" of the heart, still persistent in some monographs is meeting in this natural situation its strongest opponent argumentation. The coronary anastomosis, clearly visible by coronarography are large enough (in late stages) to inverse the flow in left coronary artery, filling the pulmonary artery. Is the coronary-pulmonary shunt, responsible for the majority of symptoms, in the 5th or 6th decades. The adult form of the White-Bland-Garland syndrome is indicative for the maximum result we may hope to reach using the new revascularisation method for ischemic heart disease: new vessels formation and enhancing the coronary anastomosis by growth factors administration therapy.

[Phenytoin influence on human metanephros]

The influence of Phenytoin on the human embryo is knowing to produce the fetal hydantoin syndrome. Even this syndrome is knowing to produce microcephaly, mental retardation, eyelid ptosis etc it is not mentioned the influence of Phenytoin on the human metanephros. This is the reason of our study, made on human embryos. Their mothers received during pregnancy Phenytoin. In one studied embryo we have remarked a malformation in the metanephros. Even we can not make a strong correlation between the malformation and the Phenytoin we consider that pregnant women should not use Phenytoin during pregnancy.

[Correlations between the type of distribution of the branches of the inferior mesenteric artery and the aspect of the mesocolon]

Emergence pattern of inferior mesenteric artery (IMA) branches leaded to description of 6 types of arterial distribution, each of them being correlated with a certain mesocolon aspect. The height of mesosigmoid depends on coalescence pattern and grade, and has a particular importance in terminal colic and retroperitoneal viscera's surgery. For each of the 6 types of distribution are described different ways of differential ligatures, for elongation and descending the colon, initially establishing the predominant collateral trunks. For practicing these ligatures we have to take count of preoperative paraclinic investigations, general and particular haemodynamic conditions and some intraoperatory parameters.

Esophageal porto-caval anasthomosis. Critical view of the hypothesis of F.C. Carvalho

The apparition and the breakage of esophageal varices et the level of cardioesophageal junction in the portal hypertension still represents a problem of pathological surgery. The presence of these varicose dilatations in this region is due to an important zone of porto-caval anastomoses. Angioarhitectonical study of lower abdominal esophagus represents a disputed problem in the specialty literature. The hypothesis of south American anatomist F. C. Carvalho (1966) looks to be the best model that could explain the appear of cardioesophageal varices. Studies realized in the past within the Anatomy Department of Medicine "Carol Davila" Bucharest tried to demonstrate the validity of Carvalho's theory, and the results of these researches are exposed in the present paper.