“Head‐to‐toe” kissing balloon angioplasty during PCI of right coronary artery chronic total occlusion

New techniques involving the use of retrograde channels have enabled successful revascularization of chronically occluded arteries previously not amenable to standard strategies. We describe the use of a simultaneous antegrade and retrograde approach to perform bifurcation kissing balloon angioplasty which was not possible using a standard antegrade approach. As the balloons are oriented in opposite rather than identical directions, we have named this technique “Head‐to‐Toe Kissing.” © 2013 Wiley Periodicals, Inc.     

Enhancement of the anti-Salmonella immune response in CD154-deficient mice by an attenuated, IFN-γ-expressing, strain of Salmonella enterica serovar Typhimurium

Previously, we demonstrated that cell–cell communications via the CD40-CD154 pathway play a critical role in the induction of type 1 cytokine responses, including IL-12 and IFN-γ, which in turn greatly influence the response to Salmonella infections. Mice genetically deficient in the expression of CD154 exhibited markedly increased susceptibility to infection by an attenuated, double auxotrophic (aroA⁻aroD⁻) strain, designated BRD509, of Salmonella enterica Serovar Typhimurium. In the present study, we used a strain of Salmonella engineered to express murine IFN-γ, designated GIDIFN, in order to assess its potential to enhance the host's immune response in CD154-deficient animals. We demonstrate that infection of animals with GIDIFN results in markedly enhanced anti-bacterial response, as evidenced by the significant reduction in bacterial loads in target organs and decreased animal mortality. This was associated with a more robust proinflammatory cytokine response, including IL-6, IL-12, TNF-α and IFN-γ. In protection studies, GIDIFN strain was demonstrably superior than the BRD509 strain in affording protection against virulent Salmonella challenge in naïve CD154^−/− mice. Interestingly, however, infection with GIDIFN failed to correct the isotype switching defect in CD154^−/− mice, suggesting that the enhanced immunity triggered by GIDIFN strain occurs independently of humoral immune responses. These findings demonstrate that GIDIFN has immunopotentiating effects on the host's immune response and provide direct evidence for the utility of IFN-γ-expressing attenuated Salmonella in enhancement of immune responsiveness in immunodeficient hosts.     

Cardiac Papillary Fibroelastoma: Single-Institution Experience with 14 Surgical Patients

In general, treatment for symptomatic and asymptomatic cardiac papillary fibroelastoma is surgical resection—particularly of left-sided lesions, because of the risk of systemic embolization. However, few institutions have enough experience with these tumors to validate this approach. We present our institutional experience with papillary fibroelastoma and discuss our current approach.We searched our institution''s cardiac tumor database, identified all patients diagnosed with cardiac papillary fibroelastoma from 1992 through 2014, and recorded the clinical and pathologic characteristics of each case. We found 14 patients (mean age, 60.5 ± 12.3 yr) who had 18 lesions. Eleven patients (79%) were symptomatic; however, we could not always definitively associate their symptoms with a cardiac tumor. Most lesions were solitary and ≤1.5 cm in diameter; half involved the left side of the heart. All 18 lesions were surgically excised. There were no operative or 30-day deaths, and no patient needed valve replacement postoperatively. There was one late death; at one year, another 3 patients were lost to follow-up, and the others were alive without tumor recurrence.Because of the embolic risk inherent to intracardiac masses and our relatively good postoperative outcomes, we recommend the surgical resection of all left-sided papillary fibroelastomas in surgical candidates, and we discuss with patients the advisability of resecting right-sided lesions.     

Postoperative spinal adhesive arachnoiditis presenting with hydrocephalus and cauda equina syndrome

To our knowledge, the association between hydrocephalus and postoperative spinal adhesive arachnoiditis (SAA) has never been reported. Herein we describe an unusual case of a 45-year-old man with spinal adhesive arachnoiditis (SAA) who developed delayed-onset hypertensive hydrocephalus and cauda equina syndrome (CES) after multiple low-back surgeries. The patient's clinical presentation, imaging findings, surgical management, and the possible mechanisms are discussed in the light of the present literature.