Detection of posterior myocardial infarction by body surface mapping: A comparative study with 12 lead ECG and VCG

To examine the diagnostic ability of body surface mapping in posterior myocardial infarction (PMI), mapping was performed in 11 patients with PMI proven by left ventriculography and T1-201 myocardial perfusion imaging (PMI group) and in 44 normal subjects (N group). Map data was analysed by the following methods: (1) potential departure maps at 10, 20, 30, 40 and 50 msec after the onset of QRS; each map indicates the area of decreased potential out of the normal range at the time. (2) AQRS departure map which indicates the area of decreased time-integral value of QRS out of the normal range. True positive (TP) in the PMI group and false positive (FP) in the N group were calculated for each method, and were compared with those of various criteria for PMI with standard 12-lead electrocardiogram (ECG) and Frank lead vectorcardiogram (VCG). The potential departure maps and the AQRS departure map had high TP (10/11 and 8/11) and low FP (0/44 and 0/44). The diagnostic ability of mapping is considered to be higher than that of ECG and VCG. Mapping, especially the departure map technique, is a sensitive and specific method to detect posterior infarction.     

Clinical outcome of combined immunotherapy with low-dose interleukin-2 and interferon-α for Japanese patients with metastatic renal cell carcinoma who had undergone radical nephrectomy: a preliminary report

Background The objective of this study was to evaluate the clinical outcome of combined immunotherapy with interferon-α (IFN-α) and low-dose interleukin-2 (IL-2) for Japanese patients with metastatic renal cell carcinoma (RCC) who had undergone radical nephrectomy. Methods This study included 13 patients who were diagnosed as having metastatic RCC following radical nephrectomy. These patients received a subcutaneous injection of IFN-α (6 × 10⁶ IU per day) three times per week and an intravenous injection of IL-2 (1.4 × 10⁶ IU per day) twice per week. Tumor response was evaluated every 16 weeks, and as a rule, this weekly regimen was repeated 50 times in patients with evidence of objective response or stable disease. Results One of the 13 patients dropped out because of severe toxicity; hence, 12 patients were evaluable, with a median follow-up period of 18 months after the start of this combined therapy. Six patients (50.0%) achieved objective responses, with 1 complete response (CR), while only 2 (16.7%) demonstrated progressive disease. The median duration of response in the 6 responders was 13.5 months. Toxicity associated with this combined immunotherapy was limited to WHO grade 1 or 2 in these 12 patients. All patients were alive at last follow-up, and 2 remain disease-free after 1 additional patient showed a CR following surgical resection of the remaining metastatic disease. Conclusion Our preliminary experience suggests that long-term, repeated treatment with IFN-α and low-dose IL-2 is feasible in Japanese patients with metastatic RCC who have undergone radical nephrectomy. Although it will be necessary to accumulate data from a larger number of patients with a longer follow-up period, the combined immunotherapy tested in this study may become the preferred therapy for Japanese patients with metastatic RCC.     

Tuberculin reactivity in adults after 50 years of universal bacille Calmette-Guerin vaccination in Taiwan

We aimed to assess whether tuberculin reactivity in adults is affected by bacille Calmette-Guerin (BCG) vaccination after 50 years of universal BCG vaccination with 80-95% coverage. A community-based study on tuberculin reactivity in 619 participants was conducted in February 2000 in Keelung city, Taiwan. Information on BCG vaccination policies and annual risk of infection (ARI) in the underlying population was extracted from consecutive national prevalence surveys relating to the period 1952-1997. Compared with the expected ARI estimate, the standardized morbidity ratio of positive tuberculin response for vaccination in infancy was 2.2 (95% CI 0.3-15.5) for those aged <10 years. The corresponding figures for older age groups ranged from 3.6 (95% CI 2.2-5.9) for those aged 10-12 years to 0.7 (95% CI 0.5-0.9) for those aged 57-67 years. This suggests that the effect of BCG vaccination on positive tuberculin response in adults aged >30 years is probably negligible irrespective of age at vaccination or revaccination and that the tuberculin skin test can be used to diagnose TB in control programmes in countries with moderate or high incidence of TB.     

Can an early peri-anastomotic LITA stenosis be reversible?

Peri-anastomotic graft stenosis is a possible complication of coronary artery bypass graft operations. Early failure of myocardial revascularization may result from graft stenosis with inherent difficulties in perioperative diagnosis and subsequent management. We report the case of a 58-year-old man who experienced early preanastomotic left internal thoracic artery bypass stenosis that progressively resolved during a 2-year period without reoperation or interventional angioplasty. Although the mechanisms underlying graft stenosis remain unclear, this case emphasizes the role of repeated coronary angiography in the choice of treatment.     

Heparin-induced thrombocytopenia associated with bilateral adrenal hemorrhage after coronary artery bypass surgery

Heparin-induced thrombocytopenia (HIT) is a well-recognized syndrome associated with thrombosis and multiple potential clinical sequelae. We report a case of bilateral adrenal hemorrhage, a known but rare complication of heparin-induced thrombocytopenia complicating a routine coronary artery bypass surgery. Thrombocytopenia, abdominal pain, and signs of adrenal insufficiency in the context of heparin treatment should raise suspicion of this unusual complication.     

Intraoperative fracture of the right coronary artery: recognition and management

We describe the recognition and management of two patients who developed intraoperative fracture of the right coronary artery (RCA). Both patients had a calcified RCA without a hemodynamically significant stenosis. Compression of the right atrioventricular groove during the surgical procedure resulted in fracture of the RCA, leading to ventricular arrhythmias and hemodynamic instability. Coronary bypass grafting without cardioplegic arrest was used for definitive diagnosis and treatment. Both patients made a rapid and uneventful recovery.     

Reinforcement of saphenous vein graft with ePTFE graft for axillocoronary bypass grafting

Arteriosclerosis in the ascending aorta is widely accepted as a strong risk factor for the occurrence of stroke after coronary artery bypass grafting (CABG). The aortic no-touch technique, with a variety of modifications, has been used to reduce the risk of post-CABG stroke. Saphenous vein grafts (SVGs) have been used for axillocoronary bypass grafting, a modification of the aortic no-touch technique. However, kinking or compression often occurs with SVGs. We report here the successful application of an 8-mm expanded polytetrafluoroethylene graft, of the external bead support type, that was used to cover an SVG during axillocoronary bypass grafting.     

How to tailor A "pi" graft for complex myocardial revascularization: a variant of the mammary loop technique

We present a new pattern for tailoring the “π” graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a “Y” graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a “π” graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis.