Right ventricular adaptation and subclinical damage by echocardiography in heart transplantation recipients: insights from myocardial work index

Aim

Right ventricular (RV) dysfunction is an important cause of graft failure after heart transplantation (HTx) and a challenge for echocardiographic evaluation. We sought to evaluate the accuracy of the most novel echocardiographic tools for the assessment of RV remodelling and function in asymptomatic HTx recipients with and without rejection.

Methods

All patients underwent right heart catheterization with biopsy, cardiac magnetic resonance (CMR) and echocardiography in a row within the same day while fasting, irrespective of symptoms, as part of institutional follow up protocol dedicated to HTx recipients. Invasively measured systolic pulmonary artery pressure was used to calculate RV myocardial work index (MWI) from strain-pressure loops by using the custom software (EchoPAC BT204, Horten, Norway). Event timings were determined from pulmonic and tricuspid valve opening and closures. With the aim to generate full bull's eye map by automated function imaging, we computed RV LS data from the apical 4-chamber view 3 times, from 3 consecutive cycles substituting apical LV views. Other indices of RV function were measured according to the EACVI 2015 recommendations for chamber quantification. RV volumes and ejection fraction (EF) were quantified by CMR. Echocardiographic measurements were compared with CMR derived RV EF and biopsy findings as the reference for microstructural changes. We also evaluated by echocardiography organ donors as healthy controls.

Results

Sixty-one fully matching studies (echo, CMR, catheter, biopsy) were analyzed. Tricuspid systolic annular velocity (S'), peak systolic excursion (TAPSE) and longitudinal strain (LS) were significantly lower in healthy HTx recipients as compared to controls (p<0.001 for all). Whereas, RV volumes, EF and fractional area change (FAC) were not different between HTx recipients and healthy controls (Figure 1, EDV:end-diastolic volume). In the overall HTx recipients, only FAC (r=0.51, p<0.001) but not S', TAPSE, LS or MWI correlated with CMR derived EF. Biopsy defined subclinical rejections however were nicely mirrored by LS, and MWI (Figure 2), whereas other indices failed to reflect microstructural changes. In addition, MWI had higher accuracy than LS to discriminate biopsy findings. RV volumes, EF, FAC as well as TAPSE, S' were insensitive to subclinical myocardial damage.

Conclusion

RV adaptation in healthy HTx recipients is characterized by decreased longitudinal function but preserved overall RVFAC, EF, and volumes. MWI seems to be more reliable than other echocardiographic parameters to track subclinical RV myocardial damage due to rejection, while the RV EF remains preserved.

Funding Acknowledgement

Type of funding sources: None.

T1 mapping of the right ventricle in heart transplant recipients: how does it correlate with endomyocardial biopsy findings?

Aim

Noninvasive detection of cardiac allograft rejection is highly desirable. We sought to assess how right ventricular (RV) T1 mapping correlates with endomyocardial biopsy findings.

Methods

All patients underwent right heart catheterization with biopsy and cardiac magnetic resonance (CMR) irrespective of symptoms, as part of the institutional registry protocol dedicated to heart transplant (HTx) recipients. CMR studies were performed using a 1.5 T scanner and analyses by using a commercially available software (CMR42, Circle CVI, Calgary, Canada). Endocardial and epicardial borders were drawn on end-systolic and end-diastolic phases for ventricular function analysis. For T1 measurements, region of interests located at the RV free-wall were drawn manually on midventricular short-axis slices avoiding blood pool and epicardial fat. Extracellular volume (ECV) was calculated as ECV = (1 − hematocrit) × (ΔR1 myocardium/ΔR blood), where R1 = 1/T1. Late gadolinium enhancement (LGE) images were also obtained using a phase-sensitive inversion recovery segmented gradient echo sequence. Hyperenhancement was assessed semi-quantitatively as segmental (2–3 cm) or diffuse (>3 cm). Allograft rejection was determined based on the severity of inflammatory infiltrates and myocyte damage on pathological specimens according to the standardized International Society for Heart and Lung Transplantation (ISHLT) nomenclature.

Results

In all, 61 paired studies were evaluated. None of the patients had heart failure symptoms. We defined 3 subgroups: Group I; never rejected (n=23), group II; biopsy remarkable for rejection (n=19) and group III; history of past rejection(s) (n=19). RV volumes and ejection fraction (EF) did not differ between the groups. However, rejections were nicely mirrored by T1 time and particularly by ECV. Of note, T1 time and ECV improved but not completely normalized after resolution of rejection. Overall, T1 time (cut off 1060ms) and ECV (cut off 35%) were sensitive (84%, both) and had high negative predictive values (88% and 87%, respectively) but not specific (43% and 52% respectively) for discriminating rejection related subclinical RV damage. Their specificity slightly improved to 52 and 61% respectively, if patients with previous rejection were excluded (Figure 1). LGE did not discriminate rejection.

Conclusion

RV volumes and EF are insensitive to detect allograft rejection. Native T1 time and ECV of the RV, as a means of extracellular expansion, likely reflect interstitial fibrosis, oedema, and inflammation that are typical for, but not limited to allograft rejection. Hence, these parameters can help to exclude rejection but have limited standalone value for making the nonivasive diagnosis due to their low specificity. These results cannot be extrapolated to the left ventricle.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): University of Baskent

The prevalence and course of pulmonary hypertension and right ventricular dysfunction in patients undergoing orthotopic heart transplantation

BACKGROUND

Pulmonary hypertension (PHT) and right ventricular (RV) dysfunction are among the commonly observed and potentially serious complications following heart transplantation. RV dysfunction is reported to occur in as much as half of these patients. In this study, the authors sought to examine the prevalence and the course of these prognostically important complications.

METHODS

The records of 30 patients who had undergone orthotopic heart transplantation at our center were examined. Demographic and clinical variables were noted; RV dysfunction, pulmonary artery pressure on Doppler echocardiographic examination, and catheter findings were recorded.

RESULTS

The mean age of the study population was 31.3 years. On preoperative assessment, PHT was present in 21 (70%) patients. The average value of systolic pulmonary artery pressure was 44.5 ± 5.9 mm Hg. The mean value of pulmonary vascular resistance was 3.3 ± 1.8 hybrid reference unit (HRU). RV dysfunction was detected on postoperative assessment in 17 (56.7%) patients. The mean ischemia time was 216 ± 77 minutes; in 3 cases it exceeded 5 hours but in none of the cases did it reach 6 hours. Rejection was detected in 14 (46.7%) patients. Most of the patients received inotropic agents in the early postoperative period. When compared with preoperative values, on follow up at the end of the first year, a significant decrease in pulmonary artery pressure was observed (47.4 ± 4.8 vs 38.5 ± 7.5 mm Hg; P = .03), and the ratio of patients experiencing RV dysfunction decreased to 16.6% (n = 5).

CONCLUSION

The findings of this study indicate that RV dysfunction and PHT are common complications following heart transplantation and improve with appropriate management over time with monitoring.

Prognostic significance of biological apoptosis factors in gastric cancer

PURPOSE

Gastric cancer is a biologically heterogeneous disease containing many genetic and epigenetic alterations. In our study, the expression status of apoptosis-inducing p53 and apoptosis-inhibiting Bcl-2 in gastric cancer and their relation with prognosis, if any, was investigated.

METHODS

Patients that were being followed in our clinic and had histopathologically diagnosed gastric adenocarcinoma were included in this study. The p53 and bcl-2 expressions were investigated immunohistochemically and patients were grouped according to p53 and Bcl-2 expression as follows: group A: both p53 and Bcl-2 negative; group B: p53 positive and Bcl-2 negative; group C: p53 negative and Bcl-2 positive; group D: both p53 and Bcl-2 positive.

RESULTS

In 19 (51.4%) patients positive immunostaining with p53 was observed, while negative in 18 (48.6%). A significant relationship between the metastatic ability of the tumor and p53 expression was determined (p=0.004). In 78.6% of the metastatic tumors no p53 expression was observed, while in 69.6% of the non-metastatic tumors p53 expression was positive. No significant relationship was detected between p53 expression and survival. Positive immunostaining with Bcl-2 was observed in 9 (16.7%) patients, and negative in 45 (83.3%). No significant relationship was determined between the Bcl-2 expression and the depth of invasion, dissemination to lymph nodes and metastatic ability of the tumor. A borderline statistically significant relationship was determined between the Bcl-2 expression and survival (p=0.051). Group B patients showed a statistically significant survival difference compared with the other groups (p=0.022).

CONCLUSION

The results of this study suggest that concurrent evaluation of p53 and Bcl-2 in patients with gastric adenocarcinoma may have prognostic importance.

Newly diagnosed hyperglycemia and stress hyperglycemia in a coronary intensive care unit

AIMS

To determine prevalence of newly diagnosed hyperglycemia (NDH) among patients with acute coronary disease, inquire relationship of stress hyperglycemia (SH) with functional outcomes.

METHODS

Admission (APG) and first morning fasting plasma glucose (FPG) measurements were obtained, capillary glucose measurements (CGM) every 6-h within first day were performed-Group 1: Normoglycemics. Group 2: NDH cases: No known diabetes, APG>200mg/dl and/or FPG>126 and/or any of CGM>200. Group 2a: unrecognized glycemic disorder, HbA1c>6.0%. Group 2b: stress hyperglycemia, HbA1c<6.0%. Group 3: Recognized diabetes. Duration of ICU stays, APACHE-II scores were recorded. Logistic regression analysis was performed using ICU stay as dependent variable and age, groups, co-morbidities, problems in hospital, APACHE-II scores, CGMs were used as independent risk factors.

RESULTS

There were 255 (51.6%) in Group 1, 82 (16.6%) in Group 2; 37 (7.5%) cases in Group 2a, 45 (9.1%) in Group 2b and 157 (31.8%) in Group 3. Group 2b spent longer time in ICU, had higher APACHE-II scores (p=0.0001, p=0.0001). Regression analysis demonstrated SH as an independent risk factor for duration of ICU stay (OR: 2.8, 95% CI: 1.3-6.2).

CONCLUSIONS

Hyperglycemia was present in 48.4%; 16.6% had NDH, 9.1% had SH. Poor functional conditions of SH cases pointed that they need to be considered carefully.

A familial tendency for developing inguinal hernias: study of a single family

PURPOSE

Inguinal hernias are the most common abdominal wall rupture, and the predisposing factors to hernia formation include a familial tendency, connective tissue and lung diseases, smoking and prostatism. The aim of this study is to discuss the familial tendency for hernia in 5 members of a family of 11 people. To our knowledge, no other large family with inguinal hernias has been reported in the English literature.

METHODS

This study presents the surgical procedures and follow-up results of right inguinal hernias seen in 5 of 11 members from one family. Age, sex, body mass index (BMI), biochemical parameters, type of hernia and surgical procedure, and follow-up results were evaluated retrospectively.

RESULTS

This study included five patients (three males, two females) presenting with right direct inguinal hernias. The initial symptoms began at an average age of 18.2 years (range 15-22), and the mean BMI of the patients was 20.6 kg/m(2) (range 19.3-22.1). Three underwent hernia repairs with polypropylene surgical mesh and two with polyglactin-polypropylene composite mesh (Vypro II). The patients' blood vitamin C levels were lower than those of the other family members, while their 24-h urinary hydroxyproline levels were higher. The patients were followed for an average of 16.4 months (range 3-33 months). No complications developed during follow-up.

CONCLUSION

The occurrence of the same type of hernia in more than one family member and the altered biochemical results indicate that the hernias may have resulted from a familial connective tissue disease. In patients with hernias, if a familial tendency is suspected, a detailed examination for connective tissue diseases may help to confirm the diagnosis.

Scar endometriosis in the abdominal wall: a predictable condition for experienced surgeons

PURPOSE

Endometriosis in surgical scars develops in 0.1% of those women who undergo Caesarean section or other obstetric surgery. Herein we analyse and discuss the clinico-pathological characteristics of 15 patients with scar endometriosis in the abdominal wall.

METHODS

Fifteen cases of scar endometriosis in the abdominal wall that were treated surgically in our department between 2003 and 2009 were examined retrospectively. Age, parity, complaint, medical or surgical history, pre/postoperative hormonotherapy, size of the mass, surgical procedure, follow-up and disease recurrence were analysed.

RESULTS

This retrospective study included 15 patients presenting with 17 postoperative abdominal wall masses. The mean age of the patients was 32.1 +/- 6.0 years (range, 23-48). Eleven of the patients had a painful mass that became bigger before menstruation, two had palpable masses only, and two were hospitalised because of a mass with persistent pain. The locations of the masses were as follows: eight were close to the right side and three were close to the left side; two were in the middle of the Pfanenstiel incision and two were in trocar tracts. The patients' surgical histories included Caesarean section in thirteen, bilateral laparoscopic ovarian cyst excision in one, and laparoscopic appendectomy in one.

CONCLUSIONS

If a patient presents with incision pain and a palpable mass after gynaecologic surgery, an incisional endometrioma should be considered. Surgical excision and hormone therapy are effective treatment approaches in these patients.

Castleman's disease as cervical mass: a report of three cases and review of the literature

Castleman disease is a rare disorder characterized by benign lymph node hyperplasia involving lymphatic tissue in the neck, mediastinum, abdomen and other areas. Disease was described for the first time in 1956 by Castleman. The etiopathogenesis of the disease is unknown. The disorder can be classified into three histopathological types: hyalin-vascular, plasma-cell and mixed. We report three cases of the Castleman's disease (hyaline-vascular type) in three female patients with unilateral swelling of the neck. None of the patients developed any local or distant recurrence in postoperative follow-up.

Surgery-related complications in cardiac transplantation patients

OBJECTIVE

The surgical techniques was first described by Lower and Shumway for cardiac transplantation have not changed for many years; they are still being commonly used worldwide despite recently presented alternatives. We sought to evaluate the surgical complications among our cardiac transplantation patients in whom we performed the standard technique.

PATIENTS AND METHODS

The standard biatrial anastomosis technique was used in 13 patients who have a mean follow-up of 18.6 (1 to 38) months. During the follow-up, echocardiographic assessment was performed to evaluate left and right atrial diameters, tricuspid and mitral valve regurgitation, interatrial septum, and suture lines. Elecotrocardiograms were evaluated for arryhthmia and pacemaker requirements in the midterm.

RESULTS

The mean left and right atrial diameters were measured as 40.5 (32 to 57) x 66.6 (48 to 78) and 37.9 (32 to 43) x 56.3 (48 to 69) mm, respectively. The jet area was calculated at less than 5 cm(2) for mitral and tricuspid valve regurgitation, which can be defined as "mild" regurgitation. There was no increase in the degree of regurgitation of both atrioventricular valves during the follow-up period. In one patient, a thrombus was detected in the suture line; there was a nonsignificant left to right shunt in another patient. A temporary pacemaker was indicated in two patients. Atrial fibrillation was detected in three patients, who responded to medical therapy. During the follow-up atrial fibrillation developed in one patient.

CONCLUSION

The cardiac transplantation operation using the standard technique may result in atrial dysfuntion due to deformation of atrial integrity and geometry. However, when we evaluated our results, we concluded that the standard surgical technique was a safe, simple, effective, and feasible method.

Dexmedetomidine during coronary artery bypass grafting surgery: is it neuroprotective?--A preliminary study

BACKGROUND

In the present study, we aimed to determine whether during coronary artery bypass grafting (CABG) surgery, dexmedetomidine has protective effects against cerebral ischemic injury.

METHOD

Twenty-four patients, aged 50-70 years, undergoing CABG surgery were randomized into two groups of 12 patients each: those receiving dexmedetomidine (group D) and those not receiving it (group C). As basal blood samples from arterial and jugular bulb catheters were drawn, dexmedetomidine (1 microg/kg bolus and infusion at a rate of 0.7 microg/kg/h) was administered to patients in group D. Arterial and jugular venous blood gas analyses, serum S-100B protein (S-100B), neuron-specific enolase (NSE) and lactate measurements were performed after induction, 10 min after the initiation of cardiopulmonary bypass (CPB), 1 min after declamping, at the end of CPB, at the end of the operation and 24 h after surgery. Mann-Whitney U- and Wilcoxon's tests were used for statistical analyses.

RESULTS

No significant between-group differences were found regarding arterial and jugular venous pH, PO(2), PCO(2) and O(2) saturations. S-100B, NSE and lactate levels were also similar between groups D and C. During the post-operative period, there were no clinically overt neurological complications in any patient.

CONCLUSION

Cerebral ischemia marker (S-100B, NSE, lactate) patterns were as expected during CPB; however, there were no differences between the groups, which led us to believe that during CABG surgery dexmedetomidine has no neuroprotective effects. Future studies with larger populations are recommended to further establish the effects of this drug.

The impact of renal failure on survival following cardiac transplantation

OBJECTIVE

Renal failure after cardiac transplantation is a common and serious complication. In this study we investigated the incidence and effects of renal failure on survival among patients who underwent cardiac transplantation.

PATIENTS

Eight patients underwent cardiac and one patient combined cardiac and renal transplantation. The mean age of the patients was 33 +/- 11.6 years (range, 17 to 51). On preoperative echocardiographic evaluation, the mean ejection fraction was calculated as 19 +/- 3.11% (range, 16% to 24%). One patient had compensated renal failure and one patient, dialysis-dependent renal failure. Hemofiltration was routinely used during the operations. Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Early renal replacement therapy was performed in patients with acute renal failure.

RESULTS

The incidence of acute renal failure was 55.5% (5 patients). In the early postoperative and follow-up periods, the mean ejection fraction was 55 +/- 9.9% and 57 +/- 4.5%, respectively. The mean follow-up period was 21.3 +/- 8.8 (range, 6 to 33) months. In the early initiation period, the mean peak value of cyclosporine blood level was 479 +/- 201.8 ng/mL during the first month, 250 +/- 95.3 and after the third month, 195 +/- 43.7 ng/mL. The mean creatinine level at last follow-up was 1.27 +/- 0.4. One patient experienced a grade III-A rejection episode. One patient died due to coronary artery occlusive disease at 31 months after transplantation.

COMMENT

In our study we have observed that renal failure had no negative effect on patient survival. This can be explained by improved cardiac performance, keeping cyclosporine levels low finding and utilizing early renal replacement treatment.

Xenograft Transplantation in Congenital Cardiac Surgery at Baskent University: Midterm Results

OBJECTIVE

Xenograft valved conduits have been used in several cardiac pathologies. In this study we have presented our midterm results of pediatric patients pathologies who were operated with xenograft conduits.

PATIENTS AND METHODS

Between January 1999 and January 2005, 134 patients underwent open heart surgery with xenograft conduits. The conduits were used to establish the continuity of the right ventricle to the pulmonary artery or aorta, the left ventricle to the pulmonary artery, or aorta due to various types of complex cardiac anomalies. Patients were evaluated by transthoracic echocardiography (ECHO) at 6-month follow-ups. Cardiac catheterization was performed when ECHO demonstrated significant conduit failure.

RESULTS

Hospital mortality was observed in 28 patients (20.1%), and 13 patients died upon follow-up (9.7%). Mean follow-up was 24.6 +/- 4 months (range, 13 to 85 months). Among 93 survivors 20 patients (21.5%) were reoperated due to conduit failure. The main reasons for conduit failure were stenosis (n=13), valvular regurgitation (n=2), or both conditions in 5 cases. Mean pulmonary gradient before conduit re-replacement was 47.7 +/- 30.1 mmHg. The 1-, 3-, and 6-year actuarial survival rates were 95 +/- 2%, 91 +/- 3%, and 86 +/- 5%. The 1-, 3-, and 6-year actuarial freedom rates from reoperation were 95 +/- 1%, 90 +/- 3%, and 86 +/- 4%. An increased gradient between the pulmonary artery and the right ventricle and prolonged cardiopulmonary bypass times were observed to be significant risk factors for reoperation. There was no mortality among reoperated patients.

CONCLUSION

Xenograft conduits should be closely followed for calcification and stenosis. Conduit stenosis is the major risk factor for reoperation. In these patients, reoperation for conduit replacement can be performed safely before deterioration of cardiac performance.

Our Experience in Cardiac Transplantation in Baskent University

Recently cardiac transplantation has an important place in treatment of end-stage cardiac failure. In Turkey between 2003 and 2005 at 10 centers 64 cardiac transplantations were performed including five at our facility. Herein we have presented our results. All patients were men of mean age 34.2 +/- 10.7 (17 to 44) years. Upon preoperative echocardiography their mean ejection fraction was 18% +/- 3.27% (17% to 23%). Pulmonary vascular resistance was 4.47 wood unit in one patient and in one case, there was Rh incompatibility between donor and recipient. We used HTK solution for protection of donor hearts. Mean ischemia time was 251.2 +/- 62.7 minutes (155 to 314). Mean aortic clamping time was 84 +/- 4.7 minutes (80 to 90). In all patients we performed a biatrial anastomosis technique. Hemofiltration was used to prevent hemodilution during operation. In the postoperative period four patients had acute renal dysfunction; one, a minor cerebrovascular accident; two, reoperated because of bleeding; one, cholestasis; one, temporary atrio-ventricular block; and one, mediastinitis. Mean follow-up time was 15.6 +/- 19.7 months (2 to 50). Neither early nor late mortality has occurred. All patients are in New York Heart Association class I. In all cases we used triple immunosuppressive therapy. In the follow-up period the mean number of cardiac biopsies per patient was 4.2 +/- 3.03 (2 to 8). Two cases had cardiac catheterization. As a complication of cardiac biopsy, pericardial tamponade developed in one patient; in another one we observed a right ventricular aneursym after cardiac biopsy. Cardiac transplantation was performed with low mortality and morbidity rates in end-stage cardiac failure patients with longer life expectancy and higher life quality. Unfortunately in our country, because of difficulties to find donor hearts, cardiac transplantations were small in number. For better results, we need a larger series.

Evaluation of the Potential Role of Echocardiography in the Detection of Allograft Rejection in Heart Transplant Recipients

PURPOSE

Our objective was to determine the most relevant systolic and diastolic echocardiographic parameters to detect left ventricular (LV) dysfunction associated with allograft rejection among heart transplant recipients.

PATIENTS AND METHODS

Seven consecutive recipients underwent serial echocardiographic studies with two-dimensional spectral Doppler and tissue Doppler (TD) according to our institutional protocol. Results were compared with clinical status and endomyocardial biopsies (EMB) whenever available.

RESULTS

The time since transplantation was 22 to 850 days. Patient no. 2 had a biopsy-proven acute rejection at the 11th week which was associated with decreased TD velocities, ejection fraction (EF), and stroke volume (SV), as well as increased pericardial effusion and posterior wall thickness. Interestingly, changes in TD parameters preceded those in EF and SV. However, similar but less remarkable changes in TD velocities, EF, SV, pericardial effusion, and posterior wall thickness also occurred during other events, such as systemic infection and immediate postoperative hemodynamic compromise despite no rejection. A biopsy performed 7 months later in a patient with a previous rejection episode due to a relatively low EF and SV as well as increasing pericardial effusion with normal TD velocities revealed no rejection.

CONCLUSIONS

These data suggest that echocardiographic findings, although not specific for acute rejection, may play a potential role as a screening test to exclude rejection in heart transplant recipients.

Low-Dose Histidine-Tryptophan-Ketoglutarate Solution for Myocardial Protection

The effect of histidine-tryptophan-ketoglutarate (HTK) solution for myocardial protection has been shown in experimental and clinical studies using long ischemic times and high dosages. In our study we compared myocardial protection in isolated coronary bypass with a short period of ischemia using low dosage HTK and cold crystalloid cardioplegia. Each group contained 21 coronary artery disease patients. Cardioplegic solutions were administered antegrade in 10 to 15 mL/kg in one shot. This dosage of HTK was lower than that mentioned in the literature. We measured malondialdehyde, lactate, creatine kinase, creatine kinase-MB, and troponin-I levels. Aortic clamping time in the HTK group 33.9 +/- 8.2 minutes, versus 36.2 +/- 11.3 minutes in the crystalloid cardioplegia group (P > .05). Levels of creatine kinase and malondialdehyde were lower in HTK group at 24 hours and 2 minutes, respectively. Lactate levels were lower in the crystalloid cardioplegia group at 2 minutes in the coronary sinus serum sample, but there were no statistically differences among ischemic serum markers in both groups. Only intervals between aortic clamping and cardiac arrest were statistically meaningful (HTK 63.3 +/- 14.7 seconds versus crystalloid cardioplegia 53.6 +/- 15.6 seconds, P = .044). Our study shows that use of low-dose HTK for short clamping time operations is as successful for myocardial protection as crystalloid cardioplegia. Longer times for fibrillation can be explained with the low levels of potassium in HTK solution, but this length did not cause a biochemical or clinical difference.

Pulmonary arteriovenous fistula in the newborn: a case report of Rendu-Osler-Weber syndrome and a review of the literature

In most instances, congenital arteriovenous fistula is only one manifestation of a more widespread abnormality; 60% of patients also have hereditary hemorrhagic telangiectasis (Rendu-Osler-Weber syndrome). Among those with congenital pulmonary arteriovenous fistula, the diagnosis is made during infancy in only 15% of patients. We present a case of pulmonary arteriovenous fistula in a newborn and review the literature. This rare condition of newborns can be treated with different surgical procedures. Only 17 cases of newborn pulmonary arteriovenous fistula/have been reported, and only two of those had associated Rendu-Osler-Weber syndrome. The results of surgical procedures were good in most of these cases. We treated our case with lobectomy successfully.

The role of pulmonary artery anatomy in repair of tetralogy of Fallot

Pulmonary artery anatomy is the key factor that determines the type of surgical treatment required in tetralogy of Fallot. Despite the fact that routine primary repair is now done on infants, inadequate pulmonary artery size can dictate the need for staged surgical repair in even the oldest age groups. From October 1986 to October 1998, 361 patients at our clinic underwent surgery to correct tetralogy of Fallot. A total of 292 cases were treated with primary repair, 69 surgeries were palliative, and 30 of these 69 underwent corrective surgery. The Nakata index was used as a pulmonary artery index (PAI), and PAI< 200 was the criterion for requirement of two-stage repair. Of the 30 patients that underwent staged repair, the Blalock-Taussig shunt (BTS) procedure was used in 24; the remaining six patients had right ventricular outflow tract reconstruction (RVOTR). The mean age of all the palliative surgery patients was 3.4 years (range 6 months to 11 years), and of those who received corrective surgery was 5.5 years (range 2-12 years). These patients' PAI values were 181 +/- 37.5 mm2/m2 and 359 +/- 130.7 mm2/m2, respectively. The period between the two operations ranged from two months to four years. Mortality rates were 2.8 percent for palliative surgery as a whole, 4.1 percent for primary repair, and 16.6 percent for staged repair. Our policy with regard to corrective surgery for tetralogy of Fallot is to do primary repair regardless of a patient's age and weight, except in cases where the pulmonary artery anatomy is appropriate for the patient's body size.

Two discrete masses of leiomyomatosis in a patient, one extending to the right atrium

Leiomyomatosis extending to the right side of the heart through the inferior vena cava (IVC) is an extremely rare neoplasm. Although it is pathologically classified as a benign neoplastic formation, its growth and recurrence rate makes its extirpation mandatory. In this case report, we describe a 57-year-old woman who presented with leiomyotosis extending from the IVC to the right atrium (RA). This patient had presented with uterine leiomyoma three years previously. The patient died in the operating theatre from hemostatic problems after surgical complications arising from the unexpected presence of a second tumor.

Loss of nocturnal decline of blood pressure in patients with nasal polyposis

The objective of this study was to assess the blood pressure pattern in patients with nasal polyposis. Twenty-seven patients with nasal polyposis (18 males and 9 females), ranging in age from 15 to 72 years (mean 37.1 years) were eligible for inclusion in the study. All patients were hospitalized overnight before surgery. After the basal blood pressure measurements were taken, non-invasive ambulatory blood pressure monitoring was carried out. Oxygen saturation was measured via a finger probe and venous blood sampling was taken for catecholamine level during the full night. All measurements were repeated 4 months after nasal surgery. Mean values for nocturnal decline in blood pressure and heart rate before surgery were less marked than those measured after surgery. Mean decline values (+/- SD) were; 4.6 +/- 2.4 mmHg for systolic blood pressure, 5.8 +/- 3.8 mmHg for diastolic blood pressure, and 7.9 +/- 3.9 beats/min for heart rate before surgery, 9.3 +/- 2.8 mmHg, 8.5 +/- 4.1 mmHg and 10.4 +/- 4.3 beats/min after surgery (p < 0.01), respectively. Whereas mean and minimum SaO2 (%) significantly increased (p < 0.01), catecholamine levels decreased (p < 0.05 for adrenaline, p < 0.01 for noradrenaline) after surgery. A correlation was found between BMI and blood pressure as well as between duration of obstruction and blood pressure. Patients who snored had higher blood pressure values than those who did not. Our data show that in cases of nasal polyposis, hypoxia, hypercapnia, snoring, and sleep disorders may develop and persons with nasal polyposis and snoring have an increased risk of hypertension and loss of nocturnal decline in blood pressure.

Anatomic correction in transposition of the great arteries with unusual coronary pattern and side-by-side location

Switch operation is the treatment of choice in infants with transposition of the great arteries. The anatomic correction restores the left ventricle to its normal systemic function. In complete transposition, however, the diverse spectrum of coronary pattern influences the surgical outcome. We describe a successful arterial switch operation without LeCompte manoeuvre in a neonate with unusual coronary artery anatomy and side-by-side great arteries.

The diagnostic value of tuberculostearic acid in tuberculous pleural effusions

Tuberculostearic acid (TBSA) (10-methyloctadecanoic acid) is a structural component of mycobacteria and is not normally present in human tissues. The detection of this fatty acid in various clinical specimens, such as sputum, bronchial aspirate, pleural fluid and cerebrospinal fluid, is a rapid, sensitive and specific test for the diagnosis of tuberculosis. As rapid diagnostic methods are also needed in tuberculous pleurisy, this study was planned on 21 patients with pleurisy. The methods of gas chromatography, mass spectrophotometry combined with selected ion monitoring were used. The patients were divided into two groups: 11 with tuberculous effusion and 10 with nontuberculous patients. In the tuberculous group, TBSA was detected in 6 of the 11 patients, whereas in the nontuberculous group it was detected in 12 of the 10 patients. The sensitivity of the test was 54%, the specificity was 80%, the positive predictive value was 75%, the negative predictive value was 61%, and the efficacy was 66%. Therefore, tuberculostearic acid cannot be considered to be more useful than conventional methods in the diagnosis of tuberculous effusions, due to low sensitivity and high cost.