Coronary stenting through 4 French diagnostic catheter

A first case of coronary stent implantation through a 4 French diagnostic catheter is described.

Outcome in adult patients after arterial switch operation for transposition of the great arteries

BACKGROUND: The arterial switch operation (ASO) is currently the treatment of choice in neonates with transposition of the great arteries (TGA). The outcome in childhood is encouraging but only limited data for long-term outcome into adulthood exist. METHODS AND RESULTS: We studied 145 adult patients (age>16, median 25years) with ASO followed at our institution. Three patients died in adulthood (mortality 2.4/1000-patient-years). Most patients were asymptomatic and had normal left ventricular function. Coronary lesions requiring interventions were rare (3 patients) and in most patients related to previous surgery. There were no acute coronary syndromes. Aortic root dilatation was frequent (56% patients) but rarely significant (>45mm in 3 patients, maximal-diameter 49mm) and appeared not to be progressive. There were no acute aortic events and no patient required elective aortic root surgery. Progressive neo-aortic-valve dysfunction was not observed in our cohort and only 1 patient required neo-aortic-valve replacement. Many patients (42.1%), however, had significant residual lesions or required reintervention in adulthood. Right ventricular outflow tract lesions or dysfunction of the neo-pulmonary-valve were frequent and 8 patients (6%) required neo-pulmonary-valve replacement. Cardiac interventions during childhood (OR 3.0, 95% CI 1.7-5.4, P<0.0001) were strong predictors of outcome (cardiac intervention/significant residual lesion/death) in adulthood. CONCLUSIONS: Adult patients with previous ASO remain free of acute coronary or aortic complications and have low mortality. However, a large proportion of patients require re-interventions or present with significant right sided lesions. Life-long cardiac follow-up is, therefore, warranted. Periodic noninvasive surveillance for coronary complications appears to be safe in adult ASO patients.

Biostatistik

Wir lesen in einem Fachartikel, dass bei einer bestimmten Therapieform von 100 Behandelten nur halb so viele versterben wie bei einer anderen Form der Therapie. Ist dieser Unterschied statistisch gut abgesichert (statistisch signifikant)? Oder ist es möglich, dass er nur auf Zufall beruht? Es könnte z. B. sein, dass in der ersten Gruppe eine Person verstarb, in der zweiten jedoch zwei. In der ersten Gruppe starben damit tatsächlich nur halb so viele Menschen wie in der zweiten Gruppe. Wie stark unterscheidet sich der Therapieerfolg bei diesen beiden Behandlungsformen nun wirklich? Mit Hilfe der Statistik versuchen wir, über numerische Informationen Antworten auf solche Fragen zu erhalten. Statistik befasst sich mit dem Sammeln, Zusammenfassen, Darstellen und Interpretieren von Daten. Biostatistik ist der Zweig der Statistik, der diese Aufgaben in der Biomedizin und in Public Health übernommen hat. Wir lernen in diesem Kapitel die Grundprinzipien zur Zähmung der Variabilität kennen, d. h. wir erfahren, wie man trotz vorhandener statistischer Unsicherheit möglichst wahrheitsgemäße Schlussfolgerungen über Populationen und Patientengruppen ziehen kann. Statistik kommt dabei nicht ganz ohne mathematische Formeln aus. Sie wird daher von Vielen oftmals als schwierig oder unangenehm angesehen. Wir versuchen hier den mathematischen Formalismus auf das Nötigste zu beschränken. Schweizerische Lernziele: CPH 13–16

Transcatheter repair of iatrogenic left ventricular free-wall perforation

Left ventricular free-wall perforation can complicate catheter-based diagnostic or interventional procedures and may require immediate needle pericardiocentesis followed by surgical repair in about 20% of the cases. We describe the transcatheter closure of a left ventricular free-wall perforation as an option in the event of maintained access to the perforation site after defect creation.

Iatrogenic atrial septal defect, erosion of the septum primum after device closure of a patent foramen ovale as a new medical entity

Iatrogenic atrial septal defects are described in 2 patients. They occurred after implantation of Amplatzer occluders to close a patent foramen ovale. While device erosions to the extra-atrial space have been described, erosion induced atrial septal defects are a new medical entity. They may be fairly common in the situation of an atrial septal aneurysm whipping the rim of the device incessantly. They are clinically silent and benign and require echocardiography for detection. A second device solved the problem in the cases described.

Instant percutaneous closure of patent foramen ovale in patients with acute myocardial infarction and normal coronary arteries

Two young women with angiographically normal coronary arteries suffered an acute myocardial infarction. Both were found to have a patent foramen ovale (PFO), the likely pathway of a paradoxical embolus causing the infarction. The PFOs were diagnosed and closed percutaneously with an Amplatzer PFO Occluder during the emergency coronary angiography.

Treatment of femoro-acetabular impingement: preliminary results of labral refixation

BACKGROUND: Recent advances in the understanding of the anatomy and function of the acetabular labrum suggest that it is important for normal joint function. We found no available data regarding whether labral refixation after treatment of femoro-acetabular impingement affects the clinical and radiographic results. METHODS: We retrospectively reviewed the clinical and radiographic results of fifty-two patients (sixty hips) with femoro-acetabular impingement who underwent arthrotomy and surgical dislocation of the hip to allow trimming of the acetabular rim and femoral osteochondroplasty. In the first twenty-five hips, the torn labrum was resected (Group 1); in the next thirty-five hips, the intact portion of the labrum was reattached to the acetabular rim (Group 2). At one and two years postoperatively, the Merle d'Aubigné clinical score and the Tönnis arthrosis classification system were used to compare the two groups. RESULTS: At one year postoperatively, both groups showed a significant improvement in their clinical scores (mainly pain reduction) compared with their preoperative values (p = 0.0003 for Group 1 and p < 0.0001 for Group 2). At two years postoperatively, 28% of the hips in Group 1 (labral resection) had an excellent result, 48% had a good result, 20% had a moderate result, and 4% had a poor result. In contrast, in Group 2 (labral reattachment), 80% of the hips had an excellent result, 14% had a good result, and 6% had a moderate result. Comparison of the clinical scores between the two groups revealed significantly better outcomes for Group 2 at one year (p = 0.0001) and at two years (p = 0.01). Radiographic signs of osteoarthritis were significantly more prevalent in Group 1 than in Group 2 at one year (p = 0.02) and at two years (p = 0.009). CONCLUSIONS: Patients treated with labral refixation recovered earlier and had superior clinical and radiographic results when compared with patients who had undergone resection of a torn labrum. Although the results must be considered preliminary, we now recommend refixation of the intact portion of the labrum after trimming of the acetabular rim during surgical treatment of femoro-acetabular impingement.

Modified complete synovectomy prevents recurrence in synovial chondromatosis of the hip

Synovial chondromatosis of the hip is a rare disorder with few published reports regarding treatment and outcomes, and therefore, selecting the optimal surgical treatment is difficult. We reviewed eight patients with monoarticular synovial chondromatosis of the hip who had joint débridement and a modified total synovectomy performed through a surgical hip dislocation with a trochanteric flip osteotomy. Patients were evaluated for recurrence of disease, progression of osteoarthritis, clinical outcomes, and subsequent reoperations. The minimum followup was 4 years (mean, 6.5 years). At final review, no patient had recurrence of disease. Two patients had progression of osteoarthritis requiring total hip arthroplasties at 5 and 10 years after the initial surgical intervention. These patients did not show recurrent disease on histologic examination of the synovial membrane at the time of the arthroplasty. The six patients with preserved joints were followed up for a mean of 6.2 years. The mean Merle d'Aubigné and Postel score in this group was 16.5 points (range, 15-18 points) at the latest followup. There were no major or minor complications related to this treatment. Our midterm results suggest that open débridement with modified total synovectomy is an effective treatment that prevents recurrence of disease and provides substantial pain relief. Surgical hip dislocation allows safe and complete access to the joint for débridement and synovectomy with no added morbidity.

Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher-Langenbeck approach

OBJECTIVE: To describe the advantages and surgical technique of a trochanteric flip osteotomy in combination with a Kocher-Langenbeck approach for the treatment of selected acetabular fractures. DESIGN: Consecutive series, teaching hospital. METHODS: Through mobilization of the vastus lateralis muscle, a slice of the greater trochanter with the attached gluteus medius muscle can be flipped anteriorly. The gluteus minimus muscle can then be easily mobilized, giving free access to the posterosuperior and superior acetabular wall area. Damage to the abductor muscles by vigorous retraction can be avoided, potentially resulting in less ectopic ossification. Ten consecutive cases of acetabular fractures treated with this approach are reported. In eight cases, an anatomic reduction was achieved; in the remaining two cases with severe comminution, the reduction was within one to three millimeters. The trochanteric fragment was fixed with two 3.5-millimeter cortical screws. RESULTS: All osteotomies healed in anatomic position within six to eight weeks postoperatively. Abductor strength was symmetric in eight patients and mildly reduced in two patients. Heterotopic ossification was limited to Brooker classes 1 and 2 without functional impairment at an average follow-up of twenty months. No femoral head necrosis was observed. CONCLUSION: This technique allows better visualization, more accurate reduction, and easier fixation of cranial acetabular fragments. Cranial migration of the greater trochanter after fixation with two screws is unlikely to occur because of the distal pull of the vastus lateralis muscle, balancing the cranial pull of the gluteus medius muscle.

[Examination of urine in the child]

The examination of urine in children can be very complex, due to the difficulty to obtain clean urine specimens in infants and toddlers. Clean catch is an easy system to obtain urine but patience is needed. Transurethral catheterization or suprapubic aspiration is useful in infants and toddlers with sign of pyelonephritis. Urine bag specimens are not useful in the diagnosis of urinary tract infection because of the high rate of false positive cultures. The 24 hours urine collection is frequently replaced by a spot urine and the ratio of the measured substances with the urine creatinine are calculated. Urine microscopy is needed for the evaluation of pathological results in the dipstick testing: confirm that red urine is due to haematuria by demonstration of red blood cells on urine microscopy, dysmorphic cells and red-cell casts are pathognomonic of glomerular bleeding, white-cell casts signify glomerular inflammation and bacteria are easily seen in unstained urine. A urine culture is pathologic if the colony count exceeds 10(4) in the transurethral catheterization or clean void. In the suprapubic aspiration is any number of colony pathologic. Urate crystals in the urine of infants may cause a pink discoloration to nappies. Urine screenings are not very useful and should be performed only at the age of 5 years or by sexual-active adolescents.

Myoblast-seeded biodegradable scaffolds to prevent post-myocardial infarction evolution toward heart failure

OBJECTIVE(S): Even though the mechanism is not clearly understood, direct intramyocardial cell transplantation has demonstrated potential to treat patients with severe heart failure. We previously reported on the bioengineering of myoblast-based constructs. We investigate here the functional outcome of infarcted hearts treated by implantation of myoblast-seeded scaffolds. METHODS: Adult Lewis rats with echocardiography-confirmed postinfarction reduced ejection fraction (48.3% +/- 1.1%) were randomized to (1) implantation of myoblast-seeded polyurethane patches at the site of infarction (PU-MyoB, n = 11), (2) implantation of nonseeded polyurethane patches (PU, n = 11), (3) sham operation (Sham, n = 12), and (4) direct intramyocardial myoblast injection (MyoB, n = 11). Four weeks later, the functional assessment by echocardiography was repeated, and we additionally performed left ventricular catheterization plus histologic studies. RESULTS: The ejection fraction significantly decreased in the PU (39.1% +/- 2.3%; P = .02) and Sham (39.9% +/- 3.5%; P = .04) groups, whereas it remained stable in the PU-MyoB (48.4% +/- 3.1%) and MyoB (47.9% +/- 3.0%) groups during the observation time. Similarly, left ventricular contractility was significantly higher in groups PU-MyoB (4960 +/- 266 mm Hg/s) and MyoB (4748 +/- 304 mm Hg/s) than in groups PU (3909 +/- 248 mm Hg/s, P = .01) and Sham (4028 +/- 199 mm Hg/s, P = .01). Immunohistology identified a high density of myoblasts within the seeded scaffolds without any migration toward the host cardiac tissue and no evidence of cardiac cell differentiation. CONCLUSIONS: Myoblast-seeded polyurethane scaffolds prevent post-myocardial infarction progression toward heart failure as efficiently as direct intramyocardial injection. The immunohistologic analysis suggests that an indirect mechanism, potentially a paracrine effect, may be assumed.

Bilateral post-traumatic acetabular dysplasia

Traumatic disruption of the acetabular triradiate cartilage is an infrequent injury. When it occurs in early childhood, it may lead to growth changes in acetabular morphology. The morphology of this kind of acetabular dysplasia is uniform and differs significantly from that seen in classic developmental dysplasia of the hip. We present a case of bilateral post-traumatic acetabular dysplasia, which to our knowledge has not been reported. The morphology and the symptoms of impingement and periacetabular osteotomy of the hip joint are discussed.

Comparison of six radiographic projections to assess femoral head/neck asphericity

Early radiographic detection of femoroacetabular impingement might prevent initiation and progression of osteoarthritis. The structural abnormality in femoral-induced femoroacetabular impingement (cam type) is frequently asphericity at the anterosuperior head/neck contour. To determine which of six radiographic projections (anteroposterior, Dunn, Dunn/45 degrees flexion, cross-table/15 degrees internal rotation, cross-table/neutral rotation, and cross-table/15 degrees external rotation) best identifies femoral head/neck asphericity, we studied 21 desiccated femurs; 11 with an aspherical femoral head/neck contour and 10 with a spherical femoral head/neck contour. To radiographically quantify femoral head asphericity, we measured the angle where the femoral head/neck leaves sphericity (angle alpha). The aspherical femoral head/neck contours had a greater maximum angle alpha (70 degrees ) compared with the spherical head/neck contours (50 degrees ). The angle alpha varied depending on the radiographic projection: it was greatest in the Dunn view with 45 degrees hip flexion (71 degrees +/- 10 degrees ) and least in the cross-table view in 15 degrees external rotation (51 degrees +/- 7 degrees ). Diagnosis of a pathologic femoral head/neck contour depends on the radiologic projection. The Dunn view in 45 degrees or 90 degrees flexion or a cross-table projection in internal rotation best show femoral head/neck asphericity, whereas anteroposterior or externally rotated cross-table views are likely to miss asphericity. Level of Evidence: Prognostic study, level II-1 (retrospective study).

[Femoroacetabular impingement: trigger for the development of coxarthrosis]

Femoroacetabular impingement (FAI) is frequent; the estimated prevalence ranges between 10 and 15%. Our 10-years experience strongly suggests that FAI leads to osteoarthritis. Isolated acetabular or femoral abnormalities are rare, even though in women acetabular and in men femoral abnormalities predominate. Normal radiographs do not exclude the presence of FAI. Symptoms are related to the degree of deformity and occur earlier in the presence of activities requiring high levels of motion. The majority of patients with FAI are under the age of 40 years.In contrast to impingement in total hip replacement, the natural hip is under much higher constraint, not allowing to escape from impingement-induced shear forces by subluxation or complete dislocation. FAI-induced shear forces due to an aspherical femoral head/neck (cam type) are therefore high, causing outside-in damage with cleavage lesions of the acetabular cartilage by forced flexion and internal rotation. The cartilage of the femoral head remains initially intact, which cannot be explained by the classic concept of osteoarthritis. After the femoral head has migrated into the acetabular cartilage defect, vertical forces contribute to the further course of osteoarthritis. Tears between the labrum and cartilage, as seen by MRI, are not avulsions of the labrum from the cartilage but rather outside-in avulsions of the cartilage from the labrum. In acetabular overcoverage (pincer type) the labrum is the first structure to fail and acetabular cartilage damage develops thereafter.The treatment of FAI in patients under the age of 40 years is aimed at joint preservation. The clinical result is worse in the presence of significant cartilage damage. Therefore, early appreciation of FAI and timely therapeutic intervention as well as professional and athletic adjustment are important if osteoarthritis is to be prevented.