Antiphospholipid antibodies and intracardiac thrombosis. A case report

The antiphospholipid syndrome (APS) has been associated with multiple cardiac abnormalities. The present report describes a case of right ventricle thrombus in a 51-year-old woman with a history of autoimmune haemolytic anemia and antiphospholipid antibodies. Transthoracic echocardiography demonstrated the presence of a right ventricle mass, mimicking a myxoma. She underwent open heart removal of the mass and was started on indefinitely anticoagulant therapy. At 2 years follow-up she was free of symptoms.     

Emergency management of spontaneous coronary artery dissection

Six cases of spontaneous coronary arteries dissection are reported. In one patient, triple vessel spontaneous coronary artery dissection was identified. Another patient presented spontaneous left main coronary artery dissection. In one case we found the spontaneous dissection of the left anterior descending artery associated with distal aortic arch dissection. These conditions are very rare and may present a surgical dilemma. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention is safe and effective. Early recognition of left main coronary artery dissection or three-vessel dissection is essential because urgent coronary artery bypass grafting may be life saving.     

Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure?

BACKGROUND AND OBJECTIVES: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. PATIENTS AND METHODS: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. RESULTS: CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. CONCLUSIONS: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Analysis of role-play in medical communication training using a theatrical device the fourth wall

Background  

Communication training is a central part of medical education. The aim of this article is to explore the positions and didactic functions of the fourth wall in medical communication training, using a role-play model basically similar to a theatrical performance.     

Total Arterial Myocardial Revascularization Using New Composite Graft Techniques for Internal Mammary and/or Radial Arteries Conduits

Abstract Background: Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We present five new surgical configurations for TAMR. Methods: Between December 1998 and July 1999,34 patients with triple vessel disease underwent TAMR. All patients were in CCS 111 or IV. Sketelonized internal mammary arteries (IMAs) were used. The surgical techniques for TAMR consisted of Y or T composite grafts constructed between the in situ RlMA and free LIMA graft or radial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA graft in two configurations. Twenty-six (76%) patients underwent contrast-enhanced TTE color Doppler before and a after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography. Results: Overall, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperative day 2. Another patient (2.9%) undergoing the right Y graft technique using IMAs and RA suffered pe-rioperative AM1 due to RA conduit vasospasm. Contrast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 ± 0.2 in the LIMA stem, and in the RlMA stem, a CFR of 2.3 ± 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs, we found only anomalous flow dynamic parameters of RIMA, suggesting a partial graft closure. The angio-graphic examination revealed a free LIMA graft closure. At 6 ± 2.4 months after operation 33 patients were alive and free of angina. The IMAs stem evaluation by TTE color Doppler at follow-up revealed a 2.45 ± 0.1 mm LIMA diameter and 2.6 ± 0.2 mm RlMA diameter, which was more than early postoperative data of P < 0.001 and P < 0.007, respectively. Conclusion: These data indicate that TAMR in young patients perhaps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the “nontouch” principle and should be taken into consideration in patients with a heavily calcified aorta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasive test, which allows assessment of IMA patency and CFR evaluation. The flow reserve of the IMAs seems to be adequate for multiple coronary anastomoses.     

Effects of a group-based counselling programme on diabetes-related stress, coping, psychological well-being and metabolic control in adults with type 1 or type 2 diabetes

This study was designed to determine whether participation in a group-based counselling programme would result in reduced diabetes-related stress, improved coping and psychological well-being as well as achieving glycaemic control closer to an acceptable level. Effects of the programme were evaluated implementing an experimental design with a sample comprising 63 Norwegian adults with both types of diabetes aged between 25 and 70. At the 6-month follow-up, results indicate that the group-based counselling programme tested in the present study has the potential to reduce diabetes-related stress and self-blame as well as to improve coping in adults with diabetes. Moreover, results suggest that the programme can help participants to achieve more acceptable HbA1c levels as well. The present study indicates that this group-based counselling programme is feasible in the sense of suggesting that cognitive restructuring and problem-solving approaches in groups may be useful in helping people adjust to diabetes.     

Off-pump total arterial myocardial revascularization according to the right Y-graft configuration

OBJECTIVES: The aims of this study were as follows: 1) to evaluate the early outcome of the off-pump total arterial myocardial revascularization according to the right y-graft (lambda-graft) configuration and 2) to compare baseline flow and maximum flow between patients undergoing on-pump and off-pump right y-graft (RYG) construction. METHODS: Between December 1998 and January 2001, 47 patients (Group I) and 20 patients (Group II) with three vessel disease underwent on-pump and off-pump coronary artery bypass graft (CABG) respectively according to the RYG configuration. The mean age was 55.5 +/- 4.7 years and 55 +/- 6.4 years in Groups I and II, respectively. The RYG was constructed employing both internal mammary arteries (IMAs) only, in 21 and 8 patients in Groups I and II, respectively, presenting proximal-middle third stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA). The modified RYG configuration employing both IMAs and radial artery (RA) was performed in 26 and 12 patients in Groups I and II, respectively, presenting middle-distal third stenosis of the LAD and distal stenosis of the RCA or posterior descending artery stenosis. Postoperatively all patients underwent transthoracic echo color-Doppler (TTECD) contrast enhanced (by Levovist) before and after adenosine provocative testat one week and three months after operation. RESULTS: There were no hospital deaths. The mean mechanical ventilation was significantly different in Group I versus Group II patients, 18 +/- 4.4 hours versus 13 +/- 5.7 hours, respectively (p = 0.041). The mean intensive care unit stay was 1.5 +/- 0.6 days in Group I and 1 +/- 0.4 days in Group II (p = 0.033). There were no differences between Groups I and II regarding the IMA diameter, mean velocity, and mean flow. At follow-up time, 6 +/- 2.4 months after the surgical procedure, all patients were alive and free of angina. The coronary flow reserve (CFR) at LIMA main stem was significantly higher at three months when compared to the values at one week after the surgical procedure within the same group, (LIMA)CFR (three months) = 2.37 +/- 0.6 versus (LIMA)CFR (one week) = 2.07 +/- 0.4 (p = 0.005) in Group I and (LIMA)CFR (three months) = 2.4 +/- 0.4 versus (LIMA)CFR (one week) = 2.06 +/- 0.3 (p = 0.004) in Group II. Similarly, the CFR at RIMA main stem were significantly higher at three months when compared to the values at one week after the surgical procedure: (RIMA)CFR (three months) = 2.47 +/- 0.7 versus (RIMA)CFR (one week) = 2.1 +/- 0.5 (p = 0.004) in Group I and (RIMA)CFR (three months) = 2.48 +/- 0.5 versus (RIMA)CFR (one week) = 2.08 +/- 0.4 (p = 0.008) in Group II. CONCLUSION: The flow dynamic data, almost identical between patients undergoing off-pump and on-pump total arterial myocardial revascularization (TAMR) according to the RYG configuration, demonstrate that this technique can be applied with excellent results without the employment of cardiopulmonary bypass in selected coronary artery disease patients.     

Restoration of patency after apparent occlusion of the λ-graft's right branch

The “string sign” is a physiological and reversible response of the internal mammary artery (IMA) anastomosed to a moderately stenotic coronary artery. We describe a patient who presented postoperatively with a string sign phenomenon of the right branch of the λ-composite graft. The graft regained full patency 32 months after the surgical procedure with progression of the native coronary artery stenotic lesion. This case demonstrates that under specific conditions, such as the progression of native coronary artery disease, a no-flow composite graft employing IMAs can only regain patency and functional status in the same way as in situ IMAs. These findings confirm that the IMA remains the conduit of choice not only for its long-term patency, but also for its physiological adaptation characteristics. Received: July 2, 2001 / Accepted: August 17, 2001     

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

INTRODUCTION: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function. MaTERIALS AND METHOD: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. RESULTS: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.