Internal Mammary to Pulmonary Artery Fistula Presenting as Early Recurrent Angina after Coronary Bypass

A 50-year-old man developed recurrent angina 1 year after coronary artery bypass surgery. The patient was found to have a large fistula involving branches of the internal mammary artery graft and the left pulmonary artery. In the absence of another clear cause for the patient's symptoms, we speculated that our patient's angina and abnormal stress nuclear study were due to coronary steal. In patients with a history of coronary bypass grafting, fistula formation between graft and native vessels should be considered as a possible cause of early recurrent angina.

Vector electrocardiographic alterations after percutaneous septal ablation in obstructive hypertrophic cardiomyopathy: possible anatomic causes

OBJECTIVE: Analyze the dromotropic disturbances (vector-electrocardiographic), and the possible anatomic causes, provoked by selective alcohol injection in the septal branch, for percutaneous treatment, of obstructive hypertrophic cardiomyopathy. METHODS: Ten patients with a mean age of 52.7 years underwent percutaneous septal ablation (PTSA) from october 1998; all in functional class III/IV). Twelve-lead electrocardiogram was performed prior to and during PTSA, and later electrocardiogram and vectorcardiogram according to Frank's method. The patients were followed up for 32 months. RESULTS: On electrocardiogram (ECG) prior to PTSA all patients had sinus rhythm and left atrial enlargement, 8 left ventricular hypertrophy of systolic pattern. On ECG immediately after PTSA, 8 had complete right bundle-branch block; 1 transient total atrioventricular block; 1 alternating transient bundle-branch block either right or hemiblock. On late ECG 8 had complete right bundle-branch block confirmed by vectorcardiogram, type 1 or Grishman. CONCLUSION: Septal fibrosis following alcohol injection caused a predominance of complete right bundle-branch block, different from surgery of myotomy/myectomy.

Treatment of delayed rupture of the left ventricle after mitral valve replacement

Rupture of the left ventricle following mitral valve replacement is a catastrophic complication with deadly consequences. We report here the case of a 75-year-old man who underwent elective mitral valve replacement for severe mitral regurgitation. Delayed type 1 rupture of the left ventricle developed 3 hours postoperatively in the intensive care unit. A salvaging maneuver was used, which gained time, allowing reoperation and successful intraventricular repair.

Improvement in left ventricular dysfunction after surgical correction of mitral regurgitation

OBJECTIVE: To evaluate whether left ventricular end-systolic (ESD) diameters <FONT FACE=Symbol>&pound;</FONT> 51mm in patients (pt) with severe chronic mitral regurgitation (MR) are predictors of a poor prognosis after mitral valve surgery (MVS). METHODS: Eleven pt (aged 36&plusmn;13 years) were studied in the preoperative period (pre), median of 36 days; in the early postoperative period (post1), median of 9 days; and in the late postoperative period (post2), mean of 38.5&plusmn;37.6 months. Clinical and echocardiographic data were gathered from each pt with MR and systolic diameter <FONT FACE=Symbol>&sup3;</FONT>51mm (mean = 57&plusmn;4mm) to evaluate the result of MVS. Ten patients were in NYHA Class III/IV. RESULTS: All but 2 pt improved in functional class. Two pt died from heart failure and infectious endocarditis 14 and 11 months, respectively, after valve replacement. According to ejection fraction (EF) in post2, we identified 2 groups: group 1 (n=6), whose EF decreased in post1, but increased in post2 (p=0.01) and group 2 (n=5), whose EF decreased progressively from post1 to post2 (p=0.10). All pt with symptoms lasting <FONT FACE=Symbol>&pound;</FONT> 48 months had improvement in EF in post2 (p=0.01). CONCLUSION: ESD <FONT FACE=Symbol>&sup3;</FONT>51mm are not always associated with a poor prognosis after MVS in patients with MR. Symptoms lasting up to 48 months are associated with improvement in left ventricular function.

Prognostic value of technetium-99m-labeled single-photon emission computerized tomography in the follow-up of patients after their first myocardial revascularization surgery

OBJECTIVE: To assess the prognostic value of Technetium-99m-labeled single-photon emission computerized tomography (SPECT) in the follow-up of patients who had undergone their first myocardial revascularization. METHODS: We carried out a retrospective study of 280 revascularized patients undergoing myocardial scintigraphy under stress (exercise or pharmacological stress with dipyridamole) and at rest according to a 2-day protocol. A set of clinical, stress electrocardiographic and scintigraphic variables was assessed. Cardiac events were classified as "major" (death, infarction, unstable angina) and "any" (major event or coronary angioplasty or new myocardial revascularization surgery). RESULTS: Thirty-six major events occurred as follows: 3 deaths, 11 infarctions, and 22 unstable anginas. In regard to any event, 22 angioplasties and 7 new surgeries occurred in addition to major events, resulting a total of 65 events. The sensitivity of scintigraphy in prognosticating a major event or any event was, respectively, 55% and 58%, showing a negative predictive value of 90% and 83%, respectively. Diabetes mellitus, inconclusive stress electrocardiography, and a scintigraphic visualization of left ventricular enlargement were significant variables for the occurrence of a major event. On multivariate analysis, abnormal myocardial scintigraphy was a predictor of any event. CONCLUSION: Myocardial perfusion tomography with Technetium-99m may be used to identify high-risk patients after their first myocardial revascularization surgery.

Assessment of factors that influence weaning from long-term mechanical ventilation after cardiac surgery

OBJECTIVE: To analyze parameters of respiratory system mechanics and oxygenation and cardiovascular alterations involved in weaning tracheostomized patients from long-term mechanical ventilation after cardiac surgery. METHODS: We studied 45 patients in their postoperative period of cardiac surgery, who required long-term mechanical ventilation for more than 10 days and had to undergo tracheostomy due to unsuccessful weaning from mechanical ventilation. The parameters of respiratory system mechanics, oxigenation and the following factors were analyzed: type of surgical procedure, presence of cardiac dysfunction, time of extracorporeal circulation, and presence of neurologic lesions. RESULTS: Of the 45 patients studied, successful weaning from mechanical ventilation was achieved in 22 patients, while the procedure was unsuccessful in 23 patients. No statistically significant difference was observed between the groups in regard to static pulmonary compliance (p=0.23), airway resistance (p=0.21), and the dead space/tidal volume ratio (p=0.54). No difference was also observed in regard to the variables PaO2/FiO2 ratio (p=0.86), rapid and superficial respiration index (p=0.48), and carbon dioxide arterial pressure (p=0.86). Cardiac dysfunction and time of extracorporeal circulation showed a significant difference. CONCLUSION: Data on respiratory system mechanics and oxygenation were not parameters for assessing the success or failure. Cardiac dysfunction and time of cardiopulmonary bypass, however, significantly interfered with the success in weaning patients from mechanical ventilation.

Predictive factors of complications after coronary stent implantation

OBJECTIVE: To analyze the predictive factors of complications after implantation of coronary stents in a consecutive cohort study. METHODS: Clinical and angiographic characteristics related to the procedure were analyzed, and the incidence of major cardiovascular complications (myocardial infarction, urgent surgery, new angioplasty, death) in the in-hospital phase were recorded. Data were stored in an Access database and analyzed by using the SPSS 6.0 statistical program and a stepwise backwards multiple logistic regression model. RESULTS: One thousand eighteen (mean age of 61&plusmn;11 years, 29% females) patients underwent 1,070 stent implantations. The rate of angiographic success was 96.8%, the rate of clinical success was 91%, and the incidence of major cardiovascular complications was 7.9%. The variables independently associated with major cardiovascular complications, with their respective odds ratio (OR) were: rescue stent, OR = 5.1 (2.7-9.6); filamentary stent, OR = 4.5 (2.2-9.1); first-generation tubular stent, OR = 2.4 (1.2-4.6); multiple stents, OR = 3 (1.6-5.6); complexity of the lesion, OR = 2.4 (1.1-5.1); thrombus, OR = 2 (1.1-3.5). CONCLUSION: The results stress the importance of angiographic variables and techniques in the risk of complications and draw attention to the influence of the stent's design on the result of the procedure.

Kawasaki disease: involution of giant coronary aneurysms after prolonged anti-inflammatory treatment

The patient is a 5-year-old male with Kawasaki disease, whose involution of giant aneurysms of the left coronary arteries was surprising after a prolonged period of treatment, which lasted 80 uninterrupted days and comprised anti-inflammatory drugs associated with anticoagulation agents. The distal diameters of the anterior interventricular, the diagonal, and the circumflex arteries normalized by the end of the treatment. A residual giant aneurysm localized at the beginning of the anterior interventricular artery did not cause ischemia. Continuation of the medication for a prolonged period was recommended.

Aneurysmal dilation of the reimplant segment of the visceral vessels after thoracoabdominal aneurysm correction

We present a case of aneurysmal dilation of the aortic residual segment, involving abdominal vessels in corrective surgeries for thoracoabdominal aortic aneurysm, through the identification of risk groups for recurrent dilation, aiming at using a specific operative technique with a branched graft, to prevent aneurysm relapse.

Right ventricular structure and function as possible determinants of surgical outcome 30 years after repair of tetralogy of Fallot

OBJECTIVE: To identify the variables that may be involved in the persistence of symptoms (functional class II, III, or IV vs. I) in patients being followed up for 30 years after surgical repair of tetralogy of Fallot. METHODS: Fifty-three patients (27 women), who underwent corrective surgery for tetralogy of Fallot between 1960 and 1970, were studied. Their ages ranged from 7 months to 26 years. At the end of follow-up, 13 patients were asymptomatic and the remaining were in functional class II (N=24), III (N=15), and IV (N=1). To differentiate asymptomatic from symptomatic patients, the following variables were analyzed: age at surgery, need for widening the pulmonary ring and trunk, need for a second (2nd OP) or 3rd operation, residual defect of the interventricular septum, residual regurgitation of the pulmonary valve, systolic gradient through the right ventricular outflow tract, right ventricular dilation or hypertrophy (RVH), cardiothoracic index (CTI), right and left ventricular ejection fraction (RVEF/LVEF), and arrhythmias. RESULTS: The univariate analysis showed an association between the presence of symptoms and the 2nd OP (P=0.03), an increase in the CTI (P=0.0001), moderate to severe RVH (P=0.002), and dilation (P=0.0003). In the logistic regression model, the combination of the 2nd OP (P=0.008), the RVH (P=0.002), and the reduction in RVEF (P=0.01) determined the presence of symptoms. CONCLUSION: Despite the surgical treatment, right ventricular remodeling and performance were the major determinants in the late follow-up of tetralogy of Fallot.

A curious herbal :containing five hundred cuts, of the most useful plants, which are now used in the practice of physick engraved on folio copper plates, after drawings taken from the life /by Elizabeth Blackwell. To which is added a short description of ye plants and their common uses in physick.

1737 v. 1 #1010

A curious herbal :containing five hundred cuts, of the most useful plants, which are now used in the practice of physick engraved on folio copper plates, after drawings taken from the life /by Elizabeth Blackwell. To which is added a short description of ye plants and their common uses in physick.

1739 v. 2 #1011

Darwin and after Darwin. An exposition of the Darwinian theory and a discussion of post-Darwinian questions, by George John Romanes ...

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Darwin and after Darwin. An exposition of the Darwinian theory and a discussion of post-Darwinian questions, by George John Romanes ...

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Darwin and after Darwin. An exposition of the Darwinian theory and a discussion of post-Darwinian questions, by George John Romanes ...

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