Aortic intramural hematoma: aspects of pathogenesis 2011

Non-invasive tomographic imaging modalities have recently contributed to identifying aortic intramural hematoma, a variant form of classic dissection, which is characterized by the absence of an intimal tear and thus the absence of direct flow communication, and which represents an important disease entity in acute aortic syndrome. Clinical investigations have revealed that intramural hematoma has characteristic clinical features and that the natural remodeling process of hematoma is different from that of classic aortic dissection. These findings suggest that intramural hematoma is not just a precursor to aortic dissection, but may be a unique disease entity with a more favorable prognosis compared to aortic dissection. There is regional heterogeneity regarding the relative incidence of this hematoma, with higher incidence seen in Eastern countries. Due to favorable outcomes with medical treatment in Asian patients with type A intramural hematoma, a tailored or individualized approach based on risk stratification using initial clinical information and including imaging studies and timely surgical repair has been suggested in hemodynamically stable patients; however, these results need to be confirmed in other patient populations. The concept of a "micro-tear" which cannot be easily visualized using conventional imaging modalities has been raised: "echo-free space" on transesophageal echocardiography and "focal contrast enhancement" on ultra-fast computerized tomography have drawn many physicians' attention, and the possibility of a pathophysiologic link between classic aortic dissection and intramural hematoma has been discussed. Further investigations are needed to test whether intramural hematoma begins with an initial intimal tear and a different aortic status--characterized by a more rigid and non-compliant aorta associated with old age or long-standing hypertension--and results in an apparently absent intimal flap.     

Aortic intramural hematoma: an increasingly recognized and potentially fatal entity

Aortic intramural hematoma (IMH) is related to but is pathologically distinct from aortic dissection. In this potentially lethal entity, there is hemorrhage into the aortic media in the absence of an intimal tear. Although intimal disruption is not present, the prognosis is similar to that of classic aortic dissection; therefore, early diagnosis is critical. In this review, symptoms and prognosis of aortic IMH are discussed, as well as current diagnostic techniques and therapy.     

Aortic valve disease: Current recommendations

Aortic stenosis is a common valvular abnormality. Surgical valve replacement is the standard of care for symptomatic patients with severe aortic stenosis and is appropriate for certain asymptomatic patients. Statin therapy may slow progression of the disease. Contrary to conventional wisdom, vasodilator therapy may in fact be safe and effective in certain instances of severe aortic stenosis. Chronic aortic regurgitation is commonly treated with vasodilator therapy, which is certainly indicated for the asymptomatic patient with hypertension. Surgery is recommended for left ventricular dilatation, diminished ventricular systolic function, or symptoms.     

主动脉壁间血肿误诊为急性腹痛1例报告

在急性主动脉综合征中,主动脉壁间血肿（IMH）是潜在致命的急症之一。它的主要危险并发症是进展为主动脉夹层,导致主动脉破裂、形成主动脉瘤或者完全吸收,早期诊断和治疗至关重要。但是,并不是所有IMH患者都具有典型的临床表现,早期诊断困难,容易引起误诊。IMH仅以急性腹痛起病实属罕见,笔者报道了1例以急性腹痛起病的68岁老年男性患者,最初误诊为其他腹部疾病,后经影像学检查得以确诊。急诊医师对仅表现为急腹症的IMH肿应引起注意,以做到早期诊断和处理。     

Current therapeutic recommendations: infliximab for ulcerative colitis

Randomized, controlled studies have shown that infliximab, the chimeric anti-tumor necrosis factor alpha (TNF-alpha) antibody, is effective for the treatment of active and fistulizing Crohn's disease. Because infliximab is beneficial in patients with Crohn's disease, in whom other therapies have failed, it has been postulated that infliximab may also be helpful in patients with ulcerative colitis. Many investigators have studied the effectiveness of infliximab in ulcerative colitis, mainly in patients who are refractory to corticosteroids. Unfortunately, these studies have not yielded a conclusive answer to the efficacy of infliximab in inducing remission in patients with severe ulcerative colitis. However, some have reported excellent results and others less effective, with the overall data being inconclusive. The purpose of this review is to summarize the current literature on the use of infliximab in ulcerative colitis, as well as to provide insight into the possible mechanisms of why it may or may not work in these difficult-to-treat patients.     

肝肾综合征的诊断和治疗

肝硬化晚期易出现各种并发症,如上消化道出血、腹水、肝癌,1型肝肾综合征(hepatorenal syndrome, HRS),HRS的预后仍是最差的.     

Primary benign intramural intracavitary cardiac tumors--clinical, diagnostic and therapeutic aspects

10 cases of benign primary tumours of the heart (5 myxomas of the left atrium, 2 myxomas of the right atrium, 1 right-ventricular endothelioma of the endocardium, 1 left-ventricular pseudorhabdomyoma, 1 tumour of the interventricular septum) are described. The diagnostically decisive method was in 5 cases the heart catheterization with angiocardiography, furthermore in one case each the roentgenogram of the thorax, the echocardiography, the histology of embolic material, the operation as well as the autopsy. The echocardiography was available for 4 patients; in one case it was diagnostically decisive, delivered important additional informations in 2 patients and failed in one patient. With increasing propagation of the echocardiography, which in the opinion of the authors at least in all cases should be used before a planned invasive cardiological diagnosis, is to be reckoned with an improvement of the diagnosis of tumours of the heart and with an increase of the chances of a causal, namely the timely cardiosurgical therapy.     

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus： Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing difficulty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.