Predictability of aortic dissection as a function of aortic diameter

The role of aortic diameter on the occurrence of type A dissection was investigated in 73 patients with dilated ascending aorta at the lime of pre-operative evaluation. Using transthoracic echocardiography for diagnosis and measurements, 54 patients were identified with type A dissection (group 1) and 19 without dissection (group 2). The true mean aortic diameters were identical (6·0±1·3 cm in group 1 and 6·4±1·4 cm in group 2; mean±SD; ns) as were the indexed aortic diameters (ratio of diameter/body surface area; 3·2±0·8 cm . m−12 and 3·4±0·7cm m−2 respectively; ns). However, the individual diameters showed a pronounced scatter in both groups (range from 3·6±11·0 cm). Of the 73 patients, 66 had surgery (47/54 with and 19/19 without dissection) and seven patients were treated medically. Emergency surgery was performed in 45/66 patients (all with acute type A dissection) andelective repair in 21/66 (19 without and two with chronic type A dissection). In-hospital mortality was 18% in the emergency group, 5% in the elective group and 57% in the medical group. It is concluded that patients with dilated ascending aorta have a substantial incidence of acute dissection. Their clinical course is unpredictable; acute dissection occurs in some, and in others the ascending aorta continues to enlarge without dissection. Because patients with dissection often arrive too late for elective repair andhave to be operated on as emergencies with a higher operative risk, we recommend elective surgery before the diameter of the ascending aorta has reached 6 c

Doppler-echocardiographic findings in a patient with persisting right ventricular sinusoids

The Doppler-echocardiographic features of persisting right ventricular myocardial sinusoids are presented. An 18-year-old patient with persisting right ventricular sinusoids had undergone comissurotomy for critical pulmonary artery stenosis at the age of 12 months. Follow-up catheterization at the age of 17 years revealed no signs of residual pulmonary artery stenosis, outflow tract obstruction or pulmonary hypertension. No shunt could be documented. High systolic velocity jets within the myocardial sinusoids were recorded by means of continuous-wave Doppler. Pulmonary artery blood flow velocity was recorded mainly consequent to atrial contraction and was reduced during right ventricular ejection period, thus reflecting impaired systolic and diastolic right ventricular functio

Severe Respiratory Insufficiency Complicating Epstein-Barr Virus Infection: Case Report and Review

We report a case involving a young adult who had life-threatening bilateral pneumonitis in the course of an acute Epstein-Barr virus (EBV) infection. Because of severe hypoxemia, the patient required mechanical ventilation and additional oxygenation by an intravascular oxygenator. The patient was treated with corticosteroids and survived without sequelae. Severe pulmonary involvement associated with EBV infection is a rare but potentially fatal complication of infectious mononucleosis. Similar cases reported in the literature are reviewed, and the therapeutic options for this particular complication are discusse

Telemedicine for cardiac surgery candidates

Background: Cardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms. Methods: Coronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images. Results: In 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P≪0.01. Conclusion: Initial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located center

Alloimmunity and nonimmunologic risk factors in cardiac allograft vasculopathy

Graft vasculopathy is an accelerated form of coronary artery disease that occurs in transplanted hearts. Despite major advances in immunosuppression, the prevalence of the disease has remained substantially unchanged during the last two decades. According to the ‘response to injury' paradigm, graft vasculopathy is the result of a continuous inflammatory response to tissue injury initiated by both alloantigen-dependent and independent stress responses. Experimental evidence suggests that these responses may become self-sustaining, as allograft re-transplantation into the donor strain at a later stage fails to prevent disease progression. Histological evidence of endothelitis and arteritis, in association with intima fibrosis and atherosclerosis, reflects the central role of alloimmunity and inflammation in the development of arterial lesions. Experimental results in gene-targeted mouse models indicate that cellular and humoral immune responses are both involved in the pathogenesis of graft vasculopathy. Circulating antibodies against donor endothelium are found in a significant number of patients, but their pathogenic role is still controversial. Alloantigen-independent factors include donor-transmitted coronary artery disease, surgical trauma, ischaemia-reperfusion injury, viral infections, hyperlipidaemia, hypertension, and glucose intolerance. Recent therapeutic advances include the use of novel immunosuppressive agents such as sirolimus (rapamycin), HMG-CoA reductase inhibitors, calcium channel blockers, and angiotensin converting enzyme inhibitors. Optimal treatment of cardiovascular risk factors remains of paramount importanc

Rupture and Migration of an Endovascular Stent in the Brachiocephalic Trunk Causing a Vertebral Steal Syndrome

Delayed stent fracture has been observed in many different arteries and may represent a risk factor for restenosis. We describe the case of a delayed rupture of an endovascular brachiocephalic trunk stent. The complete fracture allowed a fragment to migrate distally and tilt, resulting in a hemodynamic pattern similar to that of a prevertebral stenosis with complete inversion of the homolateral vertebral blood flow. The induced vertebral steal syndrome as well as the risk of cerebral embolism was corrected by an aortobrachiocephalic bypass and resection of the ruptured sten

Endoscopic access closure for direct implantation of valved stents

OBJECTIVES: The off-pump trans left ventricular approach provides an alternative option for insertion of stented aortic valves of any size for endovascular replacement. One of the key steps in this procedure is the repair of the ventricle after catheter withdrawal. This study evaluates the reliability of a new device for sutureless and quick repair of the left ventricle access. METHODS: The Amplatz-nitinol occluder consists of two square heads that squeeze the ventricle wall between them thus sealing the ventricular defect. In four adult pigs weighing 55 kg, left thoracoscopy was performed to open the pericardium and visualise the cardiac apex. Following a heparin injection (100 U/kg) under ICUS and fluoroscopic control, we inserted a 30 F sheath into the epigastric area through the cardiac apex up into the left ventricle thus simulating the approach for an off-pump aortic valve replacement. The sheath was then removed and the ventricle closed with the occluder. Animals were followed-up for three hours; the haemodynamics and pericardial bleeding were recorded. The animals were then sacrificed and the gross anatomy of the heart was examined. RESULTS: The device was successfully deployed in four animals in less than one minute. ACT was above 200 seconds in all cases. All animals survived the procedure with a mean arterial pressure of 50 +/- 15 mm Hg. Bleeding during deployment was 80 +/- 20 ml and over a 3 hour period was 800 +/- 20 ml. Examination of the gross anatomy examination demonstrated the correct positioning of the device. CONCLUSIONS: The occluder is easy to use and the procedure is feasible and reproducible. However, the occluder design requires technical improvements in order to reduce bleeding before it can be used clinically

Prevention and therapy of leg ischaemia in extracorporeal life support and extracorporeal membrane oxygenation with peripheral cannulation.

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) have been around for a long time, but it is only in recent years, with the advent of acute respiratory distress syndrome consecutive to influenza A (H1N1) infection, that these life-saving technologies have seen a broader application. Although the results of ECLS and ECMO are perceived as generally encouraging, there are still disturbing complications related to peripheral cannulation in general and, more specifically, to cannulation in the groin. The present review was designed to assess the magnitude of this latter problem, i.e. leg ischaemia related to ECLS and ECMO, in the literature and to identify strategies for possible therapies and, more importantly, prevention. The search strategy selected identified seven original articles with more than twenty patients, totalling 407 patients who underwent veno-arterial ECMO, and one large review dealing with all kinds of complications. For the original reports, the number of cases with veno-arterial support ranged from 21 to 143, with, as far as available, frequency of ischaemic complications between 11% and 52%, a reported range of surgical intervention between 9% and 22%, and a leg amputation rate from 2% to 10%. It appears that the number of reports dealing with lower extremity ischaemia during ECMO increases in parallel with the number of reports about ECMO. Strategies for early detection of peripheral ischaemia, interventions for efficient reperfusion, and measures for prevention including new concepts with smaller and eventually bidirectional arterial cannulas are discussed

Valve replacement in octogenarians: increased early mortality but good long-term result

Between January 1983 and December 1990, 20 patients aged 80 years or older underwent valvular surgery. The patients' ages varied from 80 to 87 years (mean, 82 ± 1.5 years). The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective, two urgent, and three emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. Six patients (30%) had an uneventful hospital stay, and the other 14 (70%) experienced several post-operative complications. The operative mortality rate was 15± (three patients). All patients before operation were in NYHA (New York Heart Association) class III and IV and all survivors remained in NYHA class I or II. The survivors have been followed from 6 to 70 months (mean 20 ± 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement in octogenarians can be performed, despite the high rate of post-operative complications, with increased but acceptable mortality. Long-term results are goo