A 22-year-old man was referred for palpitations. On transthoracic echocardiography, he was found to have a right ventricular outflow tract mass. Further cardiac imaging was conducted by means of transesophageal echocardiography, computed tomography, and cardiac magnetic resonance. Complete surgical resection of the tumor was achieved, and pathologic examination revealed the lesion to be a myxoma.
Cardiac tumors located in the right ventricular outflow tract are rare and can present unusual diagnostic and therapeutic challenges. Cardiac computed tomography and magnetic resonance are becoming more widely available and can be useful adjuncts in the management of such tumors.
Heart neoplasms; magnetic resonance imaging; myxoma/diagnosis/surgery; tomography, X-ray computed; ventricular outflow tract, right
We prospectively evaluated the hemodynamic performance of the SORIN Freedom SOLO aortic bioprosthesis, a stentless bovine pericardial valve designed for supra-annular implantation.
Forty patients (mean age, 71.68 ± 5.25 yr; 29 men) with severe aortic stenosis underwent aortic valve replacement from January 2008 through August 2009. Patients were evaluated by transthoracic echocardiography and clinical examination, both preoperatively and again at 6 and 24 postoperative months. Peak and mean transvalvular gradients, end-diastolic and end-systolic diameters, interventricular septal and posterior wall thicknesses, indexed volumes of ventricular mass, degrees of aortic regurgitation, and left ventricular ejection fractions were calculated echocardiographically. The valves were implanted with single polypropylene sutures. In the early postoperative period, 1 patient (2.5%) died of multiorgan failure.
The mean aortic cross-clamp time was 86.05 ± 34.2 min. Echocardiographic peak gradients were 84.54 ± 16.85 mmHg (preoperative), 29.59 ± 6.27 mmHg (6 mo postoperative), and 24.33 ± 4.67 mmHg (24 mo postoperative) (P < 0.001); left ventricular mass indices were 176.26 ± 39.98 g/m2 (preoperative), 139.21 ± 30.1 (6 mo postoperative), and 120.51 ± 23.88 g/m2 (24 mo postoperative) (P < 0.001). During follow-up, the maximum aortic insufficiency recorded was trace, and no valve dysfunctions were observed. Temporary thrombocytopenia was documented in all patients during early postoperative follow-up (lowest level at day 3); recovery to preoperative levels occurred by day 10.
The Freedom SOLO aortic bioprosthesis is an easy-to-implant valve with excellent hemodynamic performance. The thrombocytopenia appears to be a transient laboratory finding.
Aged; aortic stenosis/surgery; heart valve prosthesis implantation; heart valves/surgery; bioprosthesis; prosthesis design; thrombocytopenia/blood; treatment outcome
The bacterium Alcaligenes xylosoxidans is known to cause several nosocomial infections; however, it rarely causes endocarditis, which has a very high mortality rate. Early isolation of the infection source and prompt identification of the patient's antibiotic sensitivities are paramount if the infection is to be treated adequately.
We present what is apparently only the second documented case of the successful eradication of bioprosthetic valve endocarditis that was caused by pacemaker lead infection with Alcaligenes xylosoxidans. A 62-year-old woman with multiple comorbidities presented with endocarditis of a recently placed bioprosthetic aortic valve. The infection was secondary to pacemaker lead infection. She underwent antibiotic therapy, but an unusual pattern of antibiotic resistance developed. Despite initially adequate therapy, the infection recurred because of virulence induced by antibiotic resistance. Emergent, high-risk surgical treatment involved excising the infected valve and removing the source of the infection (the pacemaker leads). The patient eventually recovered after prolonged antibiotic therapy and close vigilance for recurrent infection. In addition to the patient's case, we discuss the features of this bacteremia and the challenges in its diagnosis.
Alcaligenes/drug effects; anti-bacterial agents/therapeutic use; bacteremia/complications/diagnosis/drug therapy/etiology; endocarditis, bacterial/diagnosis/ultrasonography; gram-negative bacterial infections/complications/etiology; heart valve prosthesis; opportunistic infections/epidemiology; pacemaker, artificial/microbiology; treatment outcome
Fibromuscular dysplasia is a rare, nonatherosclerotic, noninflammatory vascular disease that typically affects women between the ages of 20 and 60 years. Although any artery can be affected, fibromuscular dysplasia most commonly affects the renal and carotid arteries. Fibromuscular dysplasia of the renal arteries usually presents with hypertension, while carotid or vertebral artery disease causes transient ischemic attacks, strokes, or dissection. Fibromuscular dysplasia of the brachial arteries is extremely uncommon. It can induce extremity ischemia, nerve compression, or both—causing coldness, discoloration, pain, ulceration or gangrene of the fingers, paresthesias, or paralysis.
We report a rare case of multivessel fibromuscular dysplasia manifested by acute stroke in association with type I aortic dissection, which progressed rapidly to ascending aortic false aneurysmal development that necessitated arch replacement. Outcomes of aortic arch replacement in this setting are currently unknown. Therefore, our case might well offer some insight.
Aneurysm, dissecting/complications/etiology/pathology; aortic aneurysm, abdominal; aortic aneurysm, thoracic; blood vessel prosthesis implantation; brachial artery/pathology; carotid artery diseases/pathology; differential diagnosis; fibromuscular dysplasia/diagnosis/etiology/therapy; interventional cardiology; radial artery/access; renal artery/pathology
Takotsubo cardiomyopathy is characterized by the development of transient focal wall-motion abnormalities that involve the apical and midventricular segments, in the absence of obstructive coronary artery disease. A variant, inverted takotsubo cardiomyopathy, was described in 2010. We report 3 cases in which each patient's transthoracic echocardiogram revealed the characteristic basal and midventricular segmental akinesis of this variant. This pattern is not associated with coronary artery distribution, and it therefore can be differentiated from coronary artery disease with the use of echocardiography, by evaluating the distribution and temporal changes of akinetic areas.
Cardiomyopathies/diagnosis/physiopathology; echocardiography; takotsubo cardiomyopathy/diagnosis; ventricular dysfunction, left/diagnosis
Aorto–left ventricular tunnel, characterized by extracardiac communication between the ascending aorta and left ventricle, is a very rare congenital condition. Although some affected infants remain asymptomatic until adulthood, most present with symptoms of heart failure during their first year of life. We report the case of an 11-year-old boy who had coexisting abnormalities: an aorto–left ventricular tunnel originating from the left coronary sinus, and an ascending aortic aneurysm. The patient underwent on-pump surgical correction and was in New York Heart Association functional class I status a year later. We also review the nature of this rare condition.
Aorta/abnormalities; aortic aneurysm/surgery; child; heart defects, congenital/diagnosis/pathology/surgery; heart ventricles/abnormalities; treatment outcome; ventricular function, left
Atherosclerosis is an inflammatory disease, and several inflammatory biomarkers, such as C-reactive protein, have been used to predict the risk of coronary heart disease. High white blood cell count is a strong and independent predictor of coronary risk in patients of both sexes, with and without coronary heart disease. A high number of white blood cells and their subtypes (for example, neutrophils, monocytes, lymphocytes, and eosinophils) are associated with the presence of coronary heart disease, peripheral arterial disease, and stroke. The coronary heart disease risk ratios associated with a high white blood cell count are comparable to those of other inflammatory markers, including C-reactive protein. In addition, other components of the complete blood count, such as hematocrit and the erythrocyte sedimentation rate, also are associated with coronary heart disease, and the combination of the complete blood count with the white blood cell count can improve our ability to predict coronary heart disease risk. These tests are inexpensive, widely available, and easy to order and interpret. They merit further research.
Atherosclerosis; biological markers/blood; complete blood count; coronary artery disease; coronary heart disease; inflammation; leukocyte count; white blood cell count
Isolated interrupted aortic arch, a congenital malformation, is very rarely reported in adults. Most adult patients have presented with type A interruption (interruption just beyond the left subclavian artery) and without an associated ventricular septal defect. Conventional surgical repair is typically a challenge because of the extent of collateral circulation in patients who have survived to adulthood. We describe the successful, single-staged, extra-anatomic ventral aortic repair of type A interrupted aortic arch in an 18-year-old man, and we discuss the pathogenesis of the so-called adult form of the condition.
Anastomosis, surgical; aorta, thoracic/abnormalities/surgery; collateral circulation; heart defects, congenital/complications; treatment outcome
May-Thurner syndrome, also called iliac vein compression syndrome, is a rare cause of left iliac deep vein thrombosis, which arises from pulsatile compression of the left common iliac vein by the right common iliac artery. The resultant endothelial damage and intraluminal spur formation can lead to iliac deep vein thrombosis and sudden-onset left-lower-extremity edema and pain. Patients typically present with May-Thurner syndrome in their 2nd to 4th decades of life. In chronic form, the syndrome can be debilitating because of venous claudication and stasis ulcers. Surgical approaches and endovascular interventions have been effective in the acute phase of the disease, and intravenous stents can resolve the manifestations of chronic venous compression. Anticoagulation alone is ineffective, and a consensus regarding the usage and duration of antiplatelet and antithrombotic therapy has not been established.
We present the case of a 68-year-old woman with a remote history of abdominal surgery who presented with left-lower-extremity edema and pain. Magnetic resonance venography of the pelvic veins yielded a definitive diagnosis of May-Thurner syndrome. Catheter-directed thrombolysis and intravenous stent placement resolved her symptoms, and she was discharged from the hospital on anticoagulative therapy. A year later, she had no residual pain or edema, and the affected veins were patent with normal phasic flow and normal responses to compression and augmentation.
Combined modality therapy; constriction, pathologic/complications/diagnosis/epidemiology/therapy; edema/etiology/pathophysiology; iliac vein/pathology/ultrasonography; lower extremity/blood supply; magnetic resonance angiography; peripheral vascular diseases/therapy/ultrasonography; thrombosis/therapy; treatment outcome; venous thrombosis/diagnosis/etiology/therapy
The aim of this study was to evaluate a new type of occluder for patent ductus arteriosus.
Patent ductus arteriosus was established in a canine model by anastomosing a length of autologous jugular vein to the descending aorta and the left pulmonary artery in an end-to-side fashion. Transcatheter closure of each patent ductus arteriosus was performed on 10 dogs, which were then monitored for as long as 6 months with aortography, echocardiography, and histologic evaluation.
Transcatheter closure with use of the novel pan-nitinol device was successful in all canine models. Postoperative echocardiography showed that the location and shape of the occluders were normal, without any residual shunting. Further histologic evaluation confirmed that the occluder surface was completely endothelialized 3 months after implantation.
Transcatheter patent ductus arteriosus closure with the pan-nitinol occluder can be performed safely and successfully in a canine model and shows good biological compatibility and low mortality rates.
Alloys/administration & dosage; biocompatible materials; disease models, animal; dogs; ductus arteriosus, patent/therapy; heart catheterization/instrumentation/methods; heart septal defects, ventricular/therapy; nitinol/chemistry; prosthesis design; prosthesis implantation/instrumentation/methods; septal occluder device; stainless steel/chemistry
Many complications have been reported after cardiopulmonary bypass. A common physiologic change during the early postoperative period after cardiopulmonary bypass is increased diuresis. In patients whose urine output is increased, postoperative diabetes insipidus can develop, although reports of this are rare. We present the cases of 2 patients who underwent on-pump coronary artery bypass grafting (with cardiopulmonary bypass). Each was diagnosed with diabetes insipidus postoperatively: a 54-year-old man on the 3rd day, and a 66-year-old man on the 4th day. Each patient recovered from the condition after 6 hours of intranasal therapy with synthetic vasopressin (antidiuretic hormone). The diagnosis of diabetes insipidus should be considered in patients who produce excessive urine early after cardiac surgery in which cardiopulmonary bypass has been used.
Cardiopulmonary bypass/adverse effects; coronary artery bypass; diabetes insipidus/diagnosis/drug therapy/etiology; diuresis; natriuretic agents/blood; postoperative complications/diagnosis/drug therapy/etiology; time factors; treatment outcome; vasopressin/therapeutic use
Reports have suggested that the use of a dangerously tainted form of marijuana, referred to in the vernacular as “wet” or “fry,” has increased. Marijuana cigarettes are dipped into or laced with other substances, typically formaldehyde, phencyclidine, or both. Inhaling smoke from these cigarettes can cause lung injuries.
We report the cases of 2 young adults who presented at our hospital with respiratory failure soon after they had smoked “wet” marijuana cigarettes. In both patients, progressive hypoxemic respiratory failure necessitated rescue therapy with extracorporeal membrane oxygenation. After lengthy hospitalizations, both patients recovered with only mild pulmonary function abnormalities.
To our knowledge, this is the first 2-patient report of severe respiratory failure and rescue therapy with extracorporeal oxygenation after the smoking of marijuana cigarettes thus tainted. We believe that, in young adults with an unexplained presentation of severe respiratory failure, the possibility of exposure to tainted marijuana cigarettes should be considered.
Formaldehyde/ adverse effects/toxicity; lung diseases/chemically induced; marijuana smoking/adverse effects/complications/epidemiology; phencyclidine abuse; respiration, artificial/methods; respiratory distress syndrome, adult/etiology/therapy; respiratory insufficiency/chemically induced; street drugs/adverse effects; substance abuse detection; substance-related disorders/complications/diagnosis/prevention & control
Tumor thrombus arising from osteosarcoma is rare. We report the case of a 20-year-old man with proximal humerus osteosarcoma, accompanied by an extensive intravascular tumor thrombus extending into the heart. Our review of the literature found 14 previous reports on osteosarcoma with tumor thrombus. The combination of positron emission tomography and computed tomography is very useful in differentiating tumor thrombus from vascular thrombus, thereby avoiding unnecessary anticoagulation therapy. This same imaging combination can also be used to evaluate the response to treatment. Surgical resection of the tumor thrombus is highly recommended. The effect of tumor thrombus on survival is still unknown.
Bone neoplasms/complications; chondrosarcoma; humerus/pathology; neoplasm invasiveness; osteosarcoma/diagnosis/pathology/therapy; positron-emission tomography; thrombosis; tomography, x-ray computed; vascular neoplasms
We sought to determine whether preoperative statin treatment is more effective in reducing, after cardiac surgery with cardiopulmonary bypass, systemic inflammatory response and myocardial damage markers in patients who have elevated preoperative interleukin-6 levels than in patients who have normal preoperative interleukin-6 levels.
The study involved a prospective cohort of 164 patients who underwent coronary and valvular surgery with cardiopulmonary bypass. There were 2 study groups: group A (n = 60), patients with elevated preoperative interleukin-6 levels; and group B (n = 104), patients with normal preoperative interleukin-6 levels. Each group was subdivided according to whether patients were (group 1) or were not (group 2) treated preoperatively with statins. Accordingly, the subdivided study groups were A1 (n = 40), A2 (n = 20), B1 (n = 56), and B2 (n = 48). The plasma levels of proinflammatory interleukin-6 were measured 1, 6, 24, and >72 hours after surgery.
The baseline, operative, and postoperative morbidity and mortality characteristics were similar in all groups. Group A1 had significantly lower levels of interleukin-6 and troponin I than did group A2 at all postoperative time points. Group B1 had significantly lower levels of interleukin-6 than did group B2 postoperatively. There were no significant differences in troponin I levels between groups B1 and B2.
We conclude that, in patients with preoperative activation of the inflammatory system, preoperative treatment with statins is associated with lower postoperative interleukin-6 and troponin I levels after cardiac surgery with cardiopulmonary bypass.
Anticholesteremic agents/therapeutic use; biological markers; coronary artery bypass/adverse effects; inflammation mediators; interleukin-6/blood; postoperative complications/blood; systemic inflammatory response syndrome/prevention & control; statin treatment; troponin/blood