Idiopathic infantile arterial calcification: case report

Idiopathic infantile arterial calcificationI (IIAC) is a rare disorder characterized by calcium deposition in the internal elastica lamina of medium and large arteries and it has been defined in term of molecular genetics. It is usually fatal, approximately 85% of all patients die within the first months of life owing to ischemia of vital organs. Death from myocardial infarction usually occurs in the first 6 months. Calcification in a peripheral artery with electrocardiogram (ECG) changes of occlusive coronary artery disease suggests the diagnosis. It is caused by mutations in the ENPP1 gene localized on chromosome 6q22 and has OMIM number 208000. A case with fatal evolution at the end of the first month is presented.

Nosocomial infections in pediatric cardiac surgery, Italy

OBJECTIVE

To evaluate the incidence of nosocomial infection (NI) in pediatric patients who received cardiothoracic surgery and to identify possible associated risk factors.

DESIGN

Prospective observational study.

SETTING

The cardiac surgery and cardiac intensive care units at the Regina Margherita Children's Hospital, Turin, Italy.

PATIENTS

All patients who underwent surgery from July 20, 1998, to July 19, 1999, were enrolled, except patients with operative catheterization only.

METHODS

Clinical data were collected daily from July 20, 1998, to July 19, 1999. NIs were diagnosed according to US Centers for Disease Control and Prevention criteria.

RESULTS

104 patients were included in the present study, 80 (76.9%) of whom underwent extracorporeal circulation. The NI ratio was 48.1% (50/104); the percentage of patients with NI was 30.8% (32/104): 23.1% developed one infection, 7.7% two or more. The rate of NI was 2.17 per 100 days of hospitalization (50/2,304). The most common pathogen was Pseudomonas aeruginosa. Important risk factors were length of preoperative admission >5 days, total length of admission >10 days, open chest during postoperative phase, and cyanotic heart disease. There was a significant association between sepsis and central venous catheterization for 3 days or more. Rate of sepsis was 19 per 1,000 catheter days (16/852).

CONCLUSION

NIs represent a frequent complication for children who undergo heart surgery. Based on our data, we suggest decreasing the preoperative stay as much as possible. The higher NI incidence in patients with an open chest postoperatively suggests that an alternative antibiotic strategy should be considered for these patients.

[Endoscopic palliation of dysphagia due to anastomotic recurrences after esophageal surgery and total gastrectomy due to carcinoma]

BACKGROUND

Dysphagia is the main symptom of locally recurrent esophageal and gastric carcinoma and generally suggests extensive disease. The safety and efficacy of endoscopic palliation in patients who developed locally recurrent disease after surgery is evaluated.

METHODS

Twenty-six males and 12 females, with an average age of 63.5 years were included in the patients group. In 12 patients there was an esophago-gastric anastomosis, in 26 an esophago-jejunostomy, after total gastrectomy. Anastomotic recurrences were divided into predominantly polypoid (16 cases) and predominantly stenosing (22 cases). Three treatment modalities were employed: endoscopic dilation (6 cases), Nd-Yag laser therapy (16 cases) and prostheses (16 cases).

RESULTS

Successful endoscopic treatment was obtained in 33 out of 38 patients (86.8%). Major complications occurred in 5 patients (15%) with a mortality rate of 6%.

CONCLUSIONS

The endoscopic palliation is effective. Technically, endoscopic treatment is easier to perform, with better results, when dealing with polypoid rather than stenosing recurrences.

[Results of endoscopic Nd-Yag laser treatment of inoperable colorectal carcinoma]

Between November 1986 and December 1993, 94 patients underwent endoscopic laser therapy for inoperable colo-rectal cancers. According to the main clinical symptoms, tumors were divided into obstructing and bleeding; A Nd-YAG non contact laser was used at power setting of 70 to 100 watt. In 28 cases laser therapy was carried out after electrorection of the tumor and in 22 cases after dilation; in 41 cases it was associated with radiation therapy. In 90% of bleeding tumors and in 70% of obstructing tumors we achieved a good result in the short term. In 50% of bleeding tumors and in 65% of obstructing tumors the symptoms recurred after an interval of 8.2 and 6.1 weeks. The main survival period was 11.2 months for bleeding tumors and 7.4 months for obstructing tumors. Two patients with a small rectal cancer are free to neoplasia at 19 and 26 months after laser therapy.

Self-expanding metal stents for palliation of inoperable carcinoma of the esophagus and gastroesophageal junction

OBJECTIVES

Rapid palliation of malignant dysphagia is usually possible with endoscopic implantation of plastic prosthesis, but this device has a high rate of complications. Recently expandable metal stents have become available that may have a reduced complications rate.

METHODS

This report details our experience with 32 patients treated from September of 1992 through June of 1994. Twenty-three patients were treated primarily with the Ultraflex esophageal prosthesis, and five patients were treated with postoperative malignant stricture, three with failed laser therapy and one with postradiation therapy malignant stricturing. Implantation was successful in 30/32 patients (94%). No major bleeding or perforation followed placement. The dysphagia score improved dramatically from 3 to 0.5. Twenty-six patients had a follow-up of at least 30 days. No stent migration occurred. Food impaction was seen in three patients, tumor ingrowth in three, and overgrowth in one patient. The median survival was 6.2 months with a range of 1.8-11.3 months.

CONCLUSIONS

Expandable metal stents are effective and safe for palliation of malignant obstruction of the esophagus and gastro-esophageal junction. However, long term problems remain to be addressed, such as ingrowth by tumor, food impaction, and limitation of stent expansion by tumor rigidity.

Fontan repair for tricuspid atresia: experience with 50 consecutive patients

From April, 1975, to October, 1985, 50 patients (mean age, 5.3 years; range, 2.5 to 14 years) underwent a Fontan repair for tricuspid atresia or severe tricuspid stenosis. Fifty-six palliative operations had been performed previously in 43 patients. Twenty-nine patients received an atriopulmonary connection by direct anastomosis [19], interposition of an aortic homograft [7], or a porcine heterograft [3]. An atrium-subpulmonary chamber connection was performed in 21 patients (Björk modification, 10; Dacron tube, 10; valved conduit, 1). Eleven patients (22%) died early, 6 of whom did not meet the established criteria for a Fontan operation. One patient died 6 months postoperatively of superior vena cava thrombosis. Four patients were reoperated on successfully. At a mean follow-up of 28.8 months, 28 patients are in New York Heart Association Functional Class I and 9 are in Class II; 1 patient was lost to follow-up. Thirteen patients underwent control catheterization fifteen days to four years postoperatively (median right atrial pressure, 14 mm Hg). Exercise testing in 9 asymptomatic patients, performed after a mean interval of 33 months, showed a moderate impairment of cardiac performance. We conclude that in select patients, a Fontan repair appears to be a reliable procedure at medium-term follow-up.

Therapeutic considerations in congenital absence of the right pulmonary artery. Use of internal mammary artery as a preparatory shunt

Congenital unilateral absence of a pulmonary artery is rare. When present, it is usually associated with other cardiac malformations. In this communication an infant with coarctation of the aorta, ventricular septal defect and absent right pulmonary artery is reported. After correction of the first two defects, due to persistent respiratory difficulty, the infant had exploration of the right pulmonary hilum in hopes of finding a pulmonary artery remnant and re-establishing blood flow to that lung. A small hilar vessel supplying all three lobes of the right lung was found and as a first stage, to enhance pulmonary arterial growth, a palliative systemic to pulmonary artery shunt was performed utilizing a large internal mammary artery. This is the first report of a case in which the internal mammary artery is used in an infant to establish systemic to pulmonary arterial flow in congenital unilateral absence of a pulmonary artery.

Left ventricular outflow tract obstruction due to an aneurysm of the membranous septum in a patient with pulmonary atresia and ventricular septum defect - case report

Although the occurrence of subpulmonary stenosis resulting from displacement of an aneurysm of the membranous septum is well known, resultant subaortic stenosis has not been well documented. We present an unusual case of acquired pulmonary atresia with restrictive ventricular septal defect and associated severe subaortic resulting from an aneurysm of the membranous septum.