Atrial compartment operation for atrial fibrillation: to isolate the left atrium or not?

BACKGROUND: The atrial compartment operation was designed to convert atrial fibrillation (AF) to sinus rhythm with intentional preservation of the electrical connection between adjacent atrial compartments. However, incidental left atrial isolation was observed in some patients. This study compared the long-term clinical outcomes of left atrial isolation for AF with those with right and left atrial connection. METHODS: Twenty patients with mitral valve disease and chronic AF who underwent atrial compartment operation with successful sinus conversion were studied. Left atrial isolation was documented by local electrogram recording. When there were no signs of electrical connection between the left atrium and the rest of the heart, either during sinus rhythm or during stimulation from various atrial compartments, left atrial isolation was confirmed. All patients were followed by electrocardiogram and echocardiogram serial recordings. Clinical signs and symptoms of cardiac performance and thromboembolism were also examined. RESULTS: Seven patients showed an isolated left atrium and 13 patients had electrical connection between the right and left atria. The age, gender, AF duration, and underlying disease were not different between the two groups of patients. During a mean follow-up period of 66 +/- 15 months, none of the patients with left atrial isolation showed recurrence of AF, although one experienced paroxysmal atrial flutter. However, 8 of the 13 patients with right and left atrial connection experienced recurrent atrial flutter/fibrillation (6 atrial flutter and 5 AF) (p = 0.058). The propensity for recurrent atrial flutter/fibrillation in these patients may be related to the conduction delay between the two atrial compartments, measured at 142 +/- 48 ms. At the end of the follow-up period, all patients with left atrial isolation remained in normal sinus rhythm without antiarrhythmic drugs. Of the patients who had right and left atrial connection, 2 developed sustained AF and 1 developed atrial flutter. Patients with left atrial isolation showed a decreased transmitral "A" flow compared with those with right and left atrial connection. Postoperative left atrial diameter and clinical functional class did not differ between patients with and without left atrial isolation. The incidence of embolization observed in both treatment groups did not differ significantly: 14% (1/7) in patients with left atrial isolation and 8% (1/13) in patients with right and left atrial connection (p > 0.05 between the groups). CONCLUSIONS: Left atrial isolation confers a better arrhythmia outcome but at the expense of poorer mechanical performance as compared with preserved electrical connection between the two atria. Nonetheless, all patients remain at risk for systemic embolization. Therefore, modifications of current surgical incisions for AF are needed.     

Transcatheter closure of traumatic ventricular septal defect: an alternative to surgical repair?

A 19-year-old man with multiple-system injuries including a serious head injury and two poorly tolerated traumatic ventricular septal defects, was admitted to our hospital. Transcatheter closure of the cardiac defects was attempted instead of surgical repair because the required anticoagulation for cardiopulmonary bypass could precipitate intracranial bleeding. The two ventricular septal defects were successfully closed with Amplatzer devices, but the patient remained in hemodynamically unstable condition and subsequently died. Transcatheter closure of traumatic ventricular septal defect is an alternative to surgical repair, although it remains a hazardous procedure and requires experienced anesthesia management.     

Incarcerated hernia: to reduce or not to reduce?

Purpose  Before the advent of general anesthesia, taxis (hernia reduction) was the treatment of choice of incarcerated hernia but, over the years, its use subsided in favor of urgent herniorrhaphy. The role of taxis for incarcerated hernias in a growing geriatric population must be reexamined. Methods  We attempted taxis in 101 adult patients diagnosed with anterior abdominal wall incarcerated hernia. Following successful taxis, patients were hospitalized for a 24-h period of observation to obviate any complications of taxis. Upon their discharge, the patients were advised to follow with an elective hernia repair. Unsuccessful attempts at taxis were followed by emergency surgery. The gender of the patient, type of hernia, time lapse since incarceration, and signs of intestinal occlusion were recorded and mortality and morbidity rates were calculated. Results  Taxis was successful in 60.3% of cases. No taxis-related complication was observed, even though the mean delay in presentation since incarceration was 12 h. Mortality and morbidity within the taxis group were null. Conclusion  Taxis is a feasible and safe maneuver pending an eventual surgical treatment. By offering better conditions at a later repair, the mortality and morbidity may be considerably lowered. Further studies are needed in order to elucidate various aspects of this two-stage treatment of incarcerated hernia.     

Erectile dysfunction: to prescribe or not to prescribe?

Even with the help of modern pharmacology, treatment of erectile dysfunction often remains complex, and requires taking into account the social, psychological, and behavioral dimensions of the disorder. This brief report presents a case study highlighting this complexity.     

Cyclic supraventricular tachycardia in the parturient: to treat or not to treat?

Cardiac arrhythmias are more common in pregnant women than in non-pregnant women. In the asymptomatic pregnant patient with a stable fetus, watchful waiting might be the best strategy. Herein, we describe the first reported case of a pregnant patient who developed cyclic supraventricular tachycardia during labor. No treatment was prescribed, with a good maternal and fetal outcome.     

Atrial septal defect as an uncommon cardiovascular malformation with Turner’s syndrome

Cardiovascular malformations are frequently observed in Turner’s syndrome. Bicuspid aortic valve and coarctation of aorta are commonly associated with Turner’s syndrome while an atrial septal defect is unusual. Here report a rare case of artrial septal defect with Turner’s syndrome.     

Urinary tract infections: to prophylaxis or not to prophylaxis?

Urinary tract infections, with or without reflux, are the most frequent reason for long-term antibacterial prophylaxis in infants and children. When one is considering the use of prophylaxis in these children, what is clear from existing published data? Up to 2006 there were a small number of poor quality studies, with no reliable evidence of the effectiveness of antibiotics in preventing recurrent symptomatic urinary tract infections (UTIs). Since then, four randomised controlled studies, to assess the benefits, or lack thereof, of antibiotic prophylaxis, have been published. None has demonstrated a clear benefit. The following conclusions can be drawn: antibiotic prophylaxis is not indicated for children following a first febrile UTI if no or mild grade I or II reflux is present; for higher grade reflux there is no definite conclusion.     

Internal thoracic artery: to skeletonize or not to skeletonize?

The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique.     

Good MRI images: to Gad or not to Gad?

Gadolinium-based magnetic resonance imaging (MRI) contrast agents (Gad-CA) were formerly considered as alternatives to X-ray-employed iodinated media. Although originally thought to be nonnephrotoxic and proven to be nonhazardous in a healthy population, the Gad-CA safety issue is progressively more controversial in the high-risk group of end-stage renal disease (ESRD) patients. Recently, Gad-CAs have not only been blamed for harmless side effects such as dizziness or nausea but also for much more severe complications such as acute renal failure, pancreatitis, or even the development of so-called “nephrogenic systemic fibrosis” in patients with renal failure, culminating in the prohibition of gadodiamide (Omniscan) administration in ESRD patients and, due to renal-organ immaturity, in newborns and infants up to 1 year old. This editorial is written to give insights into the molecular structure of Gad-CAs as well as into the potential biochemical pathomechanisms underlying the aforementioned severe clinical manifestations. Furthermore, a review about the latest literature on Gad-CA nephrotoxicity is provided. Potential risk factors are mentioned and strategies to avoid deterioration of renal function are presented. Cases with Gad-CA-associated adverse events should be adequately documented and reported appropriately. MRI professionals should collaborate closely with their colleagues from other medical specialties to identify patients with adverse events.     

The gastric cardia: to be or not to be?

The origin and biologic significance of cardiac gastric mucosa are controversial. Traditionally, it has been considered native mucosa and part of normal foregut development. It has been recently suggested that cardiac mucosa is present only as a metaplastic response to gastroesophageal reflux disease and therefore always abnormal. We evaluated the esophagogastric junction in 100 pediatric autopsy samples to determine the existence, characteristics, and length of pure cardiac mucosa at different ages. No patient had a history of gastroesophageal reflux disease. Cardiac mucosa immediately distal and contiguous to the esophageal squamous mucosa was identified in all 100 samples, varying in length from 0.1 to 3 mm; the mean length was 1 mm. There was an inverse correlation between patient age and length of cardiac mucosa; gender had no influence on measured length. Three patients had mild to moderate histologic esophagitis; two had gastritis. No metaplastic features or Helicobacter pylori were identified. These findings support the concept that there is a normal, variably narrow developmental zone at the esophagogastric junction covered by cardiac mucosa and is present at birth. When cardiac type mucosa is found in biopsy material, it does not necessarily represent evidence of a mucosal metaplastic response to gastroesophageal reflux disease.     

Tetralogy of Fallot: to patch or not to patch?

Angiograms of 11 patients with Tetralogy of Fallot were reviewed before and after total repair, and analyzed with respect to growth of the pulmonary valve annulus. At the operation none of the patients was more than 5-years-old, none received a transannular patch and all were asymptomatic at the last visit. The radiologic diameter of the pulmonary valve annulus was compared to the descending thoracic aorta at the level of the diaphragm. Preoperative ratio averaged 1.09 +/- 0.22 and increased postoperatively to 1.35 +/- 0.20 (p less than 0.02). A "catch-up" growth of small annuli could be demonstrated.     

Nonmalignant lesions in breast core needle biopsies: to excise or not to excise?

Large core needle biopsies using stereotactic mammography or ultrasound guidance are now commonly performed as the initial diagnostic approach to nonpalpable breast lesions. Although the subsequent management of patients with invasive cancer, ductal carcinoma in situ, and most benign lesions diagnosed on core needle biopsy specimens is straightforward, certain nonmalignant lesions pose dilemmas with regard to the most appropriate clinical management following core needle biopsy. The purpose of this article is to review the available data regarding several nonmalignant breast lesions, which when encountered in core needle biopsy specimens raise repeated management questions. These include atypical ductal hyperplasia, lobular neoplasia (atypical lobular hyperplasia and lobular carcinoma in situ), papillary lesions, radial scars, fibroepithelial lesions, mucocele-like lesions, and columnar cell lesions.