Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT

PURPOSE

This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated.

MATERIALS AND METHODS

In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system.

RESULTS

One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively.

CONCLUSIONS

In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Long-term assessment of clinical outcomes and disease progression in patients with corrected Tetralogy of Fallot

OBJECTIVE

Understanding changes of right ventricular (RV) geometry and function in repaired Tetralogy of Fallot (rToF) patients can improve decision-making for pulmonary valve replacement. Therefore, we aimed to assess the magnitude and clinical correlations of RV changes in rToF patients.

PATIENTS AND METHODS

Clinical and MRI data of rToF patients who underwent repeated cardiac magnetic resonance imaging (MRI) at two centers between December 2003 and September 2020 were analyzed together with anatomical factors, including RV outflow tract obstruction, pulmonary artery branch stenosis, and tricuspid regurgitation. Adverse cardiac events and/or NYHA class worsening were documented and correlated with MRI changes. QRS length was reported at each MRI.

RESULTS

Two-hundred-and-nineteen rToF patients (53% males, aged 20.2 ± 10.1 years) were enrolled. An increase of ventricular dimensions, except LVEDVi, and worsening of right and left ejection fractions were found over an average period of 5 years of follow-up. These changes were statistically significant but within 10% of the initial value. No significant changes were reported on a year-to-year basis, except in a small group of patients (6%) in whom no predictive factors were identified. Despite similar RV dimensions at the first examination, younger patients had a higher RV ejection fraction and a different annual rate of change of ventricular dimensions compared to older ones. Patients with arrhythmias (20%) were more frequently older and had larger RV dimensions but showed no significant correlations with MRI changes/years.

CONCLUSIONS

 Changes in RV dimensions and function occur rarely and very slowly in rToF patients. A small percentage of patients experience a significant worsening in a short time interval without any recognized risk factors. Arrhythmias appear to occur in a small percentage of cases in the late follow-up.

Role of MRI in early follow-up of patients with solid organ injuries: How and why we do it?

Trauma represents one of the most common causes of death or permanent disability in the population below 50 years. At present, non-operative treatment is the commonly adopted strategy in hemodynamically stable patients with solid organ injuries, when there are not concomitant bowel and mesenteric injuries requiring a prompt surgical approach, but it may require multiple imaging follow-up examinations, especially in the case of major injuries. No data are available about magnetic resonance imaging utilization in the early follow-up of trauma patients with solid organ injuries, particularly in liver and spleen trauma. We report our preliminary experience in this field.

Neonatal teeth: Importance of histological findings in management update

BACKGROUND

Presence of teeth in a newborn represents a rare finding and a disturbance of biological chronology of teeth. The aim of this paper is to report two cases with neonatal teeth histologically examined.

CASE REPORT

In this paper two cases of patients with neonatal teeth are reported and histological examinations of three extracted teeth are described. We report an exceptional finding in one of the neonatal teeth microscopically examined: a massive inflammatory infiltration in the pulp tissue similar to that in pulpitis.

RESULTS

The management of natal and neonatal teeth usually includes the extraction in case of ulceration on the tongue or severe tooth mobility to prevent accidental inhalation or feeding disturbances. The presence of an inflammatory infiltration of pulp tissue in one of teeth histologically examined suggests to review the indications for extraction considered to date.

CONCLUSION

The management of natal and neonatal teeth should consider the presence of an inflammatory infiltration of pulp tissue. An anamnestic interview is advisable in ordert to deeply investigate about possible behaviours of the child due to pain or discomfort.

P1336 Sometimes the heart could appear different if seen under a magnetic resonance scanner: misdiagnosed cases of isolated left ventricle apical hypoplasia and double chambered left ventricle

Introduction

Congenital heart diseases (CHD) are detected in 1% of children, often usually the first year of life; however, many defects are diagnosed later or remain undiagnosed. Both congenital and acquired disorders could affect the left ventricle (LV). First-line assessment includes echocardiography; nonetheless, because of intrinsic or technical limitations and artefacts, further investigation may be required. Cardiac Magnetic Resonance (CMR) is capable of providing anatomical and functional information without many of limitations and drawbacks of echocardiography. We describe CMR findings of misdiagnosed cases of two rare congenital LV abnormalities: isolated LV apical hypoplasia (ILVAH) and double-chambered LV (DCLV).

Case report 1 (image A,B,D)

An 18 yrs girl diagnosed with dilated cardiomyopathy (DCM) was submitted to our CMR Lab for a functional assessment. After birth, deep Q waves in the inferior leads were noted on the ecg, and an echocardiographic examination showed a dilated and hypokinetic LV. At 1 year of age, she underwent cardiac catheterization that excluded coronary arteries anomalies and confirmed a reduced LV systolic function. A diagnosis of idiopathic DCM was formulated and she was initiated with anticongestive therapy. During the follow-up she felt well with normal exercise tolerance, longitudinal echocardiography did not show any substantial modification over the years. In 2018, a CMR study was performed. Surprisingly, the cardiac apex was formed exclusively by the right ventricle, wrapped around the LV. The LV appeared spherical and truncated inferiorly, and the apical portion was missing; LV volumes and ejection fraction were normal; regional akinesia and subendocardial late gadolinium enhancement (LGE) were evident at the inferior wall. These findings were consistent of ILVAH.

Case Report 2 (image C,E,F)

A 24 yrs old boy with prenatal diagnosis of LV diverticulum came to our observation for a CMR study. He was asymptomatic, particularly, no palpitations or syncope were referred, nor arrhythmias were detected during the follow-up; exercise tolerance was normal. CMR showed a coarse muscle band in the LV cavity, extending from the apex to the posterior papillary muscle, thus delimiting a contractile accessory chamber. LV volumes and global systolic function were normal. The LV accessory chamber presented a normal structured free lateral wall with a normal systolic thikening, except at the apical infero-lateral segment where it appeared thinned and akinetic and showed LGE with a subendocardial pattern. These findings were consistent of DCLV.

Conclusions

the LV could be affected by many diseases with different etiological, clinical and morphological features. Compared to other imaging diagnostic modalities, CMR allows better definition of LV morphology, function and tissue characterization, becoming essential for LV abnormalities diagnosis and follow-up.

Abstract P1336 Figure.

Correlation between cephalometric variables and obstructive sleep apnoea severity in children

AIM

Alterations in craniofacial growth have been associated with obstructive sleep apnoea in children. The main objectives of this study were to analyse the correlation between cephalometric variables and Obstructive Apnea/Hypopnea Index (OAHI) in order to investigate if craniofacial features may influence the severity of obstructive sleep apnoea and to study the correlation between upper nasopharyngeal width and maxillomandibular skeletal discrepancy in sagittal and vertical plane.

MATERIALS AND METHODS

Study Design: Correlations between cephalometric variables and obstructive sleep apnoea/hypopnea index and between upper airways space and maxillomandibular skeletal discrepancy were investigated. Forty-seven children with obstructive sleep apnoea diagnosed by overnight sleep study (polysomnography) underwent a lateral radiograph, orthodontic and ear-nose-throat examinations. Cephalometric analysis according to Kirjavainen has been performed to define skeletal and upper airways variables.

STATISTICS

Spearman's correlation analysis was performed between OAHI and all cephalometric variables. Pearson's correlation analysis was performed between cephalometric variables of upper airway space and cephalometric variables related to maxillomandibular discrepancy. Chi-square test was used to compare occlusal features with adenoidal and tonsillar hypertrophy. Kruskal-Wallis rank test was used to compare OAHI with occlusal variables and adenotonsillar hypertrophy.

RESULTS

The results show a positive correlation between OAHI and maxillomandibular discrepancy measured by ANB angle (rho=0.32; p=0.023). A significant correlation was found between upper nasopharyngeal width and vertical maxillomandibular skeletal discrepancy: 1) ad1-PNS were correlated to Mandibular Plane/Sella- Nasion angle (r=-0.36; p=0.012), Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007), and Posterior-Anterior Facial Height % (r=0.29; p=0.045); 2) ad2-PNS was correlated to Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007). No statistically significant differences were found in non-parametric tests between OAHI and occlusal variables or adenoidal and tonsillar hypertrophy.

CONCLUSIONS

The present study shows a significant correlation between maxillomandibular discrepancy and the severity of OSA. Moreover, the reduction of nasopharyngeal width was correlated to maxillomandibular hyperdivergent growth pattern. These results support the presence of a correlation between sleep-disordered breathing and craniofacial features even if the cause-effect relation is still unclear. Based on these evidences, we suggest the importance of orthodontic evaluation in the management of paediatric OSA.

Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol

Objective:

To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol.

Methods:

All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS.

Results:

181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results.

Conclusion:

Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Multidisciplinary approach to the treatment of double bilateral upper permanent incisors in a young boy

BACKGROUND

A double tooth is a rare developmental anomaly referring to the fusion of two adjacent tooth buds or the gemination of a single bud.

CASE REPORT

This case report describes the multidisciplinary approach to an 11-year-old patient with two double upper permanent incisors. The clinical intraoral examination showed a mixed dentition with bilateral double maxillary central incisors, molar Class I malocclusion and palatal ectopy of two lateral upper incisors. Computed tomography of the upper dental arch revealed the presence of double central incisors with two distinct roots. The clinical choice consisted of an innovative treatment including surgical, endodontic, orthodontic and restorative treatments. This management protocol produced good aesthetic, healthy and functional results that were stable also two years post-treatment.

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

INTRODUCTION

Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique.

METHODS

We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated.

RESULTS

Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001).

CONCLUSIONS

MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients.

Unexpected histopathologic result of a wide surgical excision of a bleeding lesion of the skin: a case of Merkel cell carcinoma of the leg

BACKGROUND

Merkel cell Carcinoma is a very rare primary cutaneous tumor that often looks like an innocuous and asymptomatic nodule or plaque of the skin, but with a very fast growing. It is also called neuroendocrine carcinoma of the skin or trabecular cancer. The main treatment is based on a local excision followed by radiotherapy or chemotherapy. The most common site of presentation of this lesion is head and neck (40-60%.) and it often occur in older men with immunological system dysfunction like HIV patients, cancer, severe infections and immunosuppression for transplantation.

METHODS

The authors report a case of a bleeding Merkel Cell Carcinoma of the right leg in a 83 years old man with HCV infection, chronic kidney disease and diabetes mellitus type 2 that required local excision.

RESULTS

Lesion was entirely removed and then patient was sent to oncologists. After two months from surgical excision, healing process is regular and without complications.

CONCLUSIONS

This type of tumor can be misdiagnosed and, if bleeding, it can represent a serious surgical emergency.

Effects of simultaneous palatal expansion and mandibular advancement in a child suffering from OSA

This clinical report describes a child suffering from obstructive sleep apnoea (OSA) and class II skeletal malocclusion with maxillary contraction and anterior open bite. He presented moderate obstructive sleep apnoea with large impact on quality of life of patient and parents. He was treated using an innovative orthodontic device (Sleep Apnea Twin Expander) to simultaneously carry out palatal expansion and mandibular advancement. After orthodontic therapy, the OSA-18 questionnaire demonstrated an improvement of the main respiratory symptoms, while cardiorespiratory sleep study revealed a reduction in obstructive sleep apnoea events. Post-treatment, clinical assessment and cephalometric analysis showed a reduction of sagittal maxillary discrepancy and an extension of upper airway space. In conclusion, this case report suggests that orthodontic treatment might be a valuable alternative treatment in children with obstructive sleep apnoea related to craniofacial anomalies.

A biased random-key genetic algorithm for data clustering

Cluster analysis aims at finding subsets (clusters) of a given set of entities, which are homogeneous and/or well separated. Starting from the 1990s, cluster analysis has been applied to several domains with numerous applications. It has emerged as one of the most exciting interdisciplinary fields, having benefited from concepts and theoretical results obtained by different scientific research communities, including genetics, biology, biochemistry, mathematics, and computer science. The last decade has brought several new algorithms, which are able to solve larger sized and real-world instances. We will give an overview of the main types of clustering and criteria for homogeneity or separation. Solution techniques are discussed, with special emphasis on the combinatorial optimization perspective, with the goal of providing conceptual insights and literature references to the broad community of clustering practitioners. A new biased random-key genetic algorithm is also described and compared with several efficient hybrid GRASP algorithms recently proposed to cluster biological data.

Penetrating cardiac injuries. Two case reports

INTRODUCTION

Penetrating cardiac injuries is still a diagnostic problem at this time. Their management requires immediate surgical intervention and excellent surgical critical care postoperatively.

PRESENTATION OF CASES

A 15-year old male patient was stabbed with a knife to the right chest. The chest radiograph showed an haemothorax and the angiography showed an intercostals artery and a right auricle injury. After an emergency operation the patient was released home in good condition after the toracotomy had healed. A 19-year old male patient was stabbed with a knife to the chest more than once. By a left toracotomy we sutured the lesion of the left ventricle with multiple single stitch in non-absorbable suture, we covered the suture with a sealant. The patient released home in 24 days.

DISCUSSION

Penetrating cardiac injuries is one of the leading cause of death from urban violence. To evaluate a thoracic trauma with cardiac injury it's clear the use of thorax X-ray and multislice angio-Tc scan. Echocardiography has clearly emerged for the diagnosis in patients haemodynamically stable. When the patient is haemodynamically unstable the emergency thoracotomy is mandatory.

CONCLUSION

Despite the high mortality of penetrating cardiac injuries new surgical and radiological tecniques may help surgeon to save this patients.

Oral parafunctions as risk factors for diagnostic TMD subgroups

The frequency of diurnal clenching and/or grinding and nail-biting habits was assessed in patients affected by temporomandibular disorders (TMDs) and in healthy controls in order to investigate the possible association between these oral parafunctions and different diagnostic subgroups of TMDs. The case group included 557 patients (127 men, mean age +/- SD = 34.5 +/- 15.4 years; 430 women, mean age +/- SD = 32.9 +/- 14.1 years) affected by myofascial pain or disc displacement or arthralgia/arthritis/arthrosis. The control group included 111 healthy subjects (55 men, mean age +/- SD = 37 +/- 15.2 years; 56 women, mean age +/- SD = 38.2 +/- 13.8 years). Multinomial logistic regression analysis was used to assess the association between oral parafunctions and TMDs, after adjusting for age and gender. Daytime clenching/grinding was a significant risk factor for myofascial pain (odds ratio (OR) = 4.9, 95% confidence interval (CI): 3.0-7.8) and for disc displacement (OR = 2.5, 95% CI: 1.4-4.3), nail biting was not associated to any of the subgroups investigated. Female gender was a significant risk factor for myofascial pain (OR = 3.8; 95% CI: 2.4-6.1), whereas the risk factor for developing disc displacement decreased with ageing. No association was found between gender, age and arthralgia/arthritis/arthrosis.

[Diaphragmatic rupture with intrathoracic hepatic dislocation. Two case report]

The authors show two cases of diaphragmatic rupture by blunt trauma with intra thoracic liver dislocation due to an accident on the street. The preoperative diagnosis has been based on the CT scan. The laparotomy, central for a patient and sub costal bilateral for the other one, gave the chance to repair the diaphragmatic defect directly and to deal with the associated lesions existing in both the casualties. No prosthetic material has been used and the reconstruction of the diaphragmatic defect has been conducted through a interrupted suture with non absorbable material. According to our experience the reparation of the diaphragmatic defect has always been conducted through a laparotomic approach and without using any prosthetic material. We repute that in these cases the laparotomic approach is the best one, which permits not only the reparation of the diaphragmatic defect but also the correct management of the related lesions which could be present. Usually we use a interrupted suture with non absorbable material for minor lesions and a continuous one, double layered if possible, for the major ones.

[Retroperitoneal abscess by suppurative psoas. Case report]

A 51 years old male was admitted to our Emergency Department because a severe pain in the right lumbar area irradiating to homolateral thigh, with fever. Abdomen and pelvis TC scan revealed a big retroperitoneal abscess. An urgent laparotomy was performed. It showed a huge retroperitoneal purulent collection extending caudally to right thigh and all around urinary bladder. The fluid collections were drained and a sample was sent for biological examination. There was the evidence of enterococcus faecalis and specific antibiotic treatment was done. The patient was discharged after 33 days in good general conditions. The aim of this study is to emphasize the difficulty in clinical diagnosis of this pathology due to the lack specific symptoms and signs, and the occasional difficulty to find the original cause of the condition. Moreover we remark the utility of CT scan and of selective collection drainage.

Amino-terminal fragment of pro-brain natriuretic hormone identifies functional impairment and right ventricular overload in operated tetralogy of Fallot patients

To evaluate the relationship between plasma concentration of amino-terminal fragment of pro-brain natriuretic peptide (NT-proBNP), functional capacity, and right ventricular overload in survivors of tetralogy of Fallot (TOF) repair, we prospectively studied 70 operated TOF patients (44 males, 21 +/- 1 years old; mean +/- SEM) who underwent, during the same day, echocardiography, cardiac magnetic resonance imaging, neurohormonal characterization (plasma NT-proBNP, catecholamines, plasma renin activity, and aldosterone assay), and cardiopulmonary exercise testing. Forty-eight age- and sex-matched healthy volunteers served as the control group. Compared to controls, maximal workload and peak oxygen consumption (VO2/kg) were lower in operated TOF patients (p < 0.001), whereas NT-proBNP concentration was elevated (p < 0.001). No difference was found among the other neurohormones. In operated TOF patients, NT-proBNP showed a significant positive correlation with right ventricular (RV) end systolic and end diastolic volumes and RV systolic pressure, and it showed a negative correlation with peak VO2/kg and RV ejection fraction. From multivariable analysis, NT-proBNP concentration was found to be an independent predictor of peak VO2/kg, RV end systolic volume, and RV systolic pressure. These results show an association among RV overload, decrease in functional capacity, and cardiac natriuretic peptide expression in operated TOF patients. NT-proBNP plasma assay may be a useful tool for diagnostic purposes and for decision making in this setting.

On some optimization problems in molecular biology

In the last two decades, the study of gene structure and function and molecular genetics have become some of the most prominent sub-fields of molecular biology. Computational molecular biology has emerged as one of the most exciting interdisciplinary fields, riding on the success of the ongoing Human Genome Project, which culminated in the 2001 announcement of the complete sequencing of the human genome. The field has currently benefited from concepts and theoretical results obtained by different scientific research communities, including genetics, biochemistry, and computer science. It is only in the past few years that it has been shown that a large number of molecular biology problems can be formulated as combinatorial optimization problems, including sequence alignment problems, genome rearrangement problems, string selection and comparison problems, and protein structure prediction and recognition. This paper provides a detailed description of some among the most interesting molecular biology problems that can be formulated as combinatorial optimization problems and proposes a new heuristic to find improved solutions for a particular class of them, known as the far from most string problem.

[Conservative treatment of the digestive fistulas: personal experience]

OBJECTIVE

The authors, thanks to experience obtained in an Unit for the treatment of digestive fistulas, discuss the possibility of a conservative treatment for the anastomotic fistulas.

MATERIAL AND METHODS

From 2000 to 2003 were treated thirty-five patients with post-anastomotic gastroenteric fistulas marked according to their localization, way end output (51.5% high, 42.8% moderate and 5.7% low). The treatment is based on an aspiration system, sometimes integrated with an irrigation system. A semi-permeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic, polymer covered with a self-adherent surgical sheet. This system create a vacuum chamber equipped with a subathmospheric pressures between 262.2 and 337.5 mmHg (350-450 mmbar), integrated with a continuous irrigation using antibiotic solutions or 3% lactic acid.

RESULTS

The AA. obtained the resolution in 30 patients (85.7%), 3 patients needs the surgery (8.6%), 2 died, one for sepsis and the other one for malnutrition. The mean time for the closure was 45 days (from 20 to 90). A part of digestive external fistulas goes to spontaneous resolution so comes the idea that the creation of particular condition is the basis of their closure.

[Anterior jugular vein cavernoma in a forthcoming rupture stage: a case report]

The Authors present a very rare case of left anterior jugular vein cavernoma anterior jugular vein cavernoma in an over-seventy-year-old woman. The patient was visited already in a complicated status occurring as an increasing lateral neck mass. The case is so interesting for several reasons: for the peculiar lesion that belongs, in fact, to the uncommon group of the cavernous hemangiomas; for the exceptional localization on the anterior jugular vein; for the old age of the patient; last, but not least, for the unusual presentation of the forthcoming rupture. A speed healing without complications has been achieved thanks to the immediate diagnosis (it is important to suspect the lesion!), to the imaging techniques and to the surgical approach performed in emergency.

Tetralogy of fallot with left heart hypoplasia, total anomalous pulmonary venous return, and right lung hypoplasia: role of magnetic resonance imaging

We report a rare case of tetralogy of Fallot with total anomalous pulmonary venous return, left heart hypoplasia, right lung hypoplasia, and left ocular-mandibular synchinesia (Marcus-Gunn phenomenon), correctly diagnosed by cardiovascular magnetic resonance imaging and successfully operated by modified Glenn anastomosis.

[Primary anastomosis in the neoplastic colonic obstruction]

The authors report their own experience on the treatment of large bowel obstruction caused by a neoplastic stenosis. During a 36-month period 110 operations for emergency large bowel obstructions were performed: 59 (53.6%) underwent primary anastomosis without colostomy (28 right colectomy, 16 left colectomy, 9 sub-total and 6 total colectomy). Total group post-operative mortality was 2.9% as a result of cardio-pulmonary complications. Morbidity was 19.8%, included a 3% of anastomotic leak underwent surgical treatment. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel obstructions.

[Abdominal lymphoma with abscess and thoracic perforation: en-bloc resection]

The authors compare a rare case of acute onset Gastric Lymphoma with that present in the literature. The patient, a white 67 year-old man, was admitted to hospital in severe general condition. On CT scan an opacity of the pleura and a subtotal collapse of the left lung associated with a mass infiltrating the diaphragm, the gastric fundus and pancreas were seen. After 48 hours from the admission an operation was performed. The abdominal mass infiltrating the stomach, the spleen and the left thorax was resected en-bloc by laparotomy. A Boulau drainage was inserted. The histology showed an high malignant, diffused, big cell lymphoma. The patient was discharged 23 days later after a regular postoperative course. Surgery can be necessary, sometime curative in gastric lymphomas while long term result and quality of life could be improved by chemotherapy.

Transcatheter closure of atrial septal defects with the STARFlex device: early results and follow-up

BACKGROUND

The STARFlex (SF) device is a CardioSEAL (CS) double-umbrella device that has been modified by the addition of a self-centering mechanism comprised of nitinol springs connected between the two umbrellas and a flexible core wire with a pin-pivoting connection. This paper compares the results of atrial septal defect (ASD) closure with CardioSEAL and STARFlex devices.

PATIENTS AND METHODS

Between December 1996 and March 2000, 117 patients underwent ASD closure with CardioSEAL (n = 79) and STARFlex (n = 38). The mean age (17 years), weight (49 kg), and ASD size (15 mm) were similar in the two groups. The procedures were performed under general anesthesia with both fluoroscopic and transesophageal echocardiographic monitoring.

IMMEDIATE RESULTS

The devices were successfully implanted in all patients. Ten patients had multiple ASDs. A single device was used in four patients (CardioSEAL in three, STARFlex in one), while a simultaneous placement of two CardioSEAL (one patient) or two STARFlex (five patients) were performed in six patients. The results are summarized as follows: [table: see text] Follow-Up Results: On follow-up clinical exam, electrocardiograms, chest X-rays, and echocardiograms were obtained at 1, 6, and 12 months. [table: see text] During follow-up there were no deaths, endocarditis, rhythm disturbances, or other complications. Arm fractures were observed almost exclusively with large CardioSEAL devices (40 mm, less frequently with 33 mm), and only in one 33-mm STARFlex device. There were no clinical complications related to fractures.

CONCLUSIONS

The STARFlex device seems to offer better results than the CardioSEAL, with significantly lower rates of residual shunts and arm fractures.

Lack of effects of recombinant human growth hormone in a child with a complex cardiovascular malformation and dilated cardiomyopathy

Recent studies have suggested the beneficial effects of GH treatment in patients with dilated cardiomyopathy. We have treated with recombinant human growth hormone (rhGH) a 6-year-old female with a complex congenital heart defect (severe tricuspid hypoplasia and malposition of the great arteries), who developed a progressive dilated cardiomyopathy of unknown etiology. rhGH treatment (0,1 U/kg/day, for 3 months) did not improve cardiac function, nor clinical symptoms, although we have no clear explanations for this. However, a trial with rhGH may be offered to children with dilated cardiomyopathy and waiting for heart transplantation.

Rapid reversal of dilated cardiomyopathy following removal of neuroblastoma

Reported is a child with dilated cardiomyopathy, in whom medical therapy resulted in a mild improvement of cardiac function. Metabolic studies suggested the presence of a catecholamine-secreting tumour; and an adrenal neuroblastoma was identified and surgically removed. Following surgery, there was progressive and complete normalization of cardiac function. Although very rare, neurogenic tumours may be involved in the development of a dilated cardiomyopathy in the infant and child.

Mechanical valves in the pulmonary position: a reappraisal

OBJECTIVES

To evaluate midterm results of mechanical valves in pulmonary position in patients with pulmonary regurgitation and right ventricular dysfunction as an alternative to bioprostheses.

PATIENTS

Mechanical valves (six tilting disc valves and two bileaflet valves) were implanted in eight patients previously operated on for tetralogy of Fallot (n = 7) and truncus arteriosus (n = 1), with severe right ventricular dysfunction caused by massive pulmonary regurgitation.

RESULTS

All patients survived prosthesis implantation and are currently well. At follow-up (3 months to 9 years), they do not show signs of valve failure, and right ventricular function has dramatically improved in all but one, who still shows moderate ventricular hypokinesia.

CONCLUSION

After operative correction of congenital heart defects in selected patients who show severe dysfunction of the right ventricle caused by pulmonary regurgitation/stenosis, mechanical valves may represent an alternative to bioprosthetic valves. The selection of the valve type is still a matter of debate. However, according to literature data, complications seem to have occurred only in patients with bileaflet mechanical valves in the pulmonary position, whereas no thromboembolic episodes or valve failure is reported in subjects with tilting disc valves in the right ventricular outflow. Tilting disc valves might perform better in the right ventricular outflow than bileaflet valves.

Idiopathic right pulmonary artery aneurysm with pulmonary valve insufficiency

A case of idiopathic right pulmonary artery aneurysm with pulmonary valve insufficiency simulating a mediastinal teratoma occurred in an asymptomatic 13-year-old boy. The key to correct diagnosis was pulmonary angiography. The patient was successfully treated with surgery.

[The surgical treatment of fixed aortic subvalvular stenosis]

Over the past 5 years, 45 patients (11 adults and 33 children) have undergone operations for discrete and fixed subaortic stenosis. The resection of the subvalvular membrane or the fibromuscular collar was the procedure of choice. 28 patients underwent myectomy and/or myotomy. None patients died during operations. No significant symptoms and gradients remained after operation. We conclude that in the surgical management of fixed discrete subaortic stenosis myectomy and myotomy in addition to membranectomy produces better relief of the left ventricular outflow obstruction than do membranectomy alone.

[Percutaneous closure of interatrial defect using the buttoned double-disk prosthesis]

BACKGROUND

Surgical repair is the procedure of choice for atrial septal defect correction. Even though surgical mortality is low (< 1%), morbidity is significant (anesthesia, thoracotomy, cardiopulmonary bypass, longer hospitalization and intensive care unit monitoring). Transcatheter methods to occlude atrial septal defects have been in development during the last two decades. We report our experience in Italy with the Sideris buttoned double-disk device.

METHODS

From March 1992 to April 1993, 14 patients aged 20 months to 52 years, weight 10 to 82 kg, underwent transcatheter atrial septal defect occlusion with the Sideris buttoned device. The buttoned device is a miniaturized two disk device introduced through small venous sheaths (8-9 F). The diameter of atrial septal defects by echocardiography varied between 9 and 23 mm, while the balloon stretched diameter of the defects varied between 13 and 24 mm. The devices selected were 19 +/- 4 mm larger than the stretched diameter of the defect, but less than the total length of the septum (33-56 mm) by echo.

RESULTS

Pulmonary-to-systemic flow ratio varied between 1.5 to 4.0. Mean pulmonary artery pressure varied between 10 and 24 mmHg (mean value 17 +/- 3.5 mm Hg). The relationship between different atrial septal defect measurements (echo, shunt flow, stretched diameter) was statistically analysed: transthoracic echo diameter had a good correlation with the balloon stretched diameter (r = 0.63, p < 0.001). The atrial septal defect was occluded in 12 patients (86% success rate). There was one early "unbuttoning" which was surgically corrected with success. The other patient underwent surgical correction 3 months later because of unsuitability for transcatheter closure. Minimal residual shunt detected by color flow mapping at 1 month follow-up was seen in 4 patients (33%). No complications occurred in any of our patients.

CONCLUSIONS

This initial experience with the Sideris buttoned double-disk device demonstrated that transcatheter closure of atrial septal defect is feasible and effective. It can be accomplished through small introducing sheaths. Further clinical trials are justified. This method could become the procedure of choice for the correction of small ASDs.

Infundibular septal defect with severe aortic regurgitation: a new surgical approach

Aortic regurgitation associated with prolapse of an aortic cusp and an infundibular septal defect is caused by the lack of anatomical support for the aortic annulus by the conal septum. This fact is taken into consideration in the new surgical approach that we performed in 5 children 3 to 16 years of age with infundibular ventricular septal defect and severe aortic regurgitation. The ventricular septal defect is closed by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed in the aortic wall. In all 5 patients, all clinical signs of aortic insufficiency disappeared, and only minimal aortic regurgitation could be demonstrated by color Doppler mapping.

[Total anomalous pulmonary venous drainage: is a surgical correction possible on the sole basis of echocardiography?]

Between April '83 and August '89, 33 patients with total anomalous pulmonary venous drainage were studied at the department of Cardiology in Bergamo. There were 18 males and 15 females, aged between three days and 8 months (average: two months). In this study only cases of isolated total anomalous pulmonary venous drainage were taken into consideration. The patients underwent echocardiographic examination with ATL MK 600, Vingmed 700, ATL Ultramark 9 with 3.5; 5; 7.5; MHz transducers; in the last three years the echocardiographic examination was integrated by continuous and pulsed wave Doppler and, in the last year, by color Doppler. The morphologic diagnosis was routinely established by means of the sequential approach method. A common feature in all types of total anomalous pulmonary venous drainage was the impossibility of defining the connections of the pulmonary veins with the left atrium. Furthermore, patients had a volume overload of the right heart, and atrial septal defects of various sizes. The site of anomalous drainage of the pulmonary veins was assessed by means of multiple cuts from subcostal, precordial and suprasternal windows. The echocardiographic diagnosis was exact and complete in 29 cases (87.9%), and in four cases it was incomplete but basically correct (12.1%). The anatomical findings were confirmed during cardiac surgery in 32 cases and by autopsy in one case of supracardiac total anomalous pulmonary venous drainage in a critically ill patient, who died before surgery. Of the 32 patients who underwent surgical correction, 20 (62.5%) had only an echocardiographic diagnosis, which resulted correct in all cases. The majority of patients with isolated TAPVD can be confidently diagnosed by means of echocardiography, thus, avoiding preoperative catheterization.

Aortopulmonary window coexisting with tetralogy of Fallot: echocardiographic diagnosis

Aortopulmonary window coexisting with tetralogy of Fallot (TF) was prospectively diagnosed by two-dimensional (2D) echocardiography and Doppler in an 18-month-old boy; the diagnosis was confirmed by cardiac catheterization and angiocardiography. Surgical correction was performed, but the patient died in the operating room from right ventricular dysfunction. The autopsy showed an adequate surgical repair, but the histologic examination of the lungs demonstrated severe pulmonary vascular disease, which was presumed to be the cause of death.