A congenital complex including muscular interventricular septal aneurysm in an adult: case report and review of literature

Muscular interventricular septum is an extremely rare location for congenital aneurysm. A 48-year-old patient with a muscular interventricular septum aneurysm coexisting with atrial septal defect, pulmonary stenosis and ventricular preexcitation is presented. Three-dimensional echocardiographic reconstruction of the lesion aided in a precise morphologic and quantitative assessment of the condition. The review of 10 previously reported patients with the entity is presented.     

Systemic Effects of Intracoronary Nitroglycerin during Coronary Angiography in Children after Heart Transplantation

Coronary spasm during coronary angiography for vasculopathy in children can be prevented by the intracoronary administration of nitroglycerin. We reviewed the anesthesia and catheterization reports and charts for pediatric transplant recipients who underwent angiography from 2005 through 2010. Correlation analysis was used to study the relation of post-injection systolic blood pressure (SBP) to nitroglycerin dose. Forty-one angiographic evaluations were performed on 25 patients (13 male and 12 female). Mean age was 9.9 ± 3.2 years (range, 3.3–16.1 yr). The mean total dose of nitroglycerin was 2.93 ± 1.60 µg/kg (range, 1–8 µg/kg).There was a significant drop between the baseline SBP (mean, 106 ± 21.6 mmHg) and the lowest mean SBP before nitroglycerin administration (78 ± 13.2, P <0.0001, paired t test). There was no significant additional change in SBP (mean after nitroglycerin administration, 80.7 ± 13.1 mmHg; P = 0.2). There was a significant drop in lowest heart rate between baseline (109 ± 16.5 beats/min) and before nitroglycerin administration (89 ± 14.3 beats/min; P <0.0001, paired t test). There was no significant additional change in heart rate (mean heart rate after nitroglycerin, 84 ± 17.7 beats/min; P = 0.09). There were 2 interventions for SBP before nitroglycerin and 2 after nitroglycerin. One child experienced a transient ST-T–segment change during angiography after nitroglycerin. In the highest dose range, the additional decrease in SBP was 7.2 mmHg (P=0.03). Routine intracoronary nitroglycerin administration in this dose range produced no significant changes in SBP or heart rate in children.Key words: Child, coronary angiography, coronary vasospasm/etiology, dose-response relationship, drug, heart transplantation/adverse effects, hemodynamics/drug effects, nitroglycerin/administration & dosage/therapeutic use, postoperative complications/therapy, retrospective studies, vasodilation/drug effectsAllograft coronary disease in children occurs with increasing frequency after transplantation, as a function of time. In a multicenter study,¹ the incidence of coronary artery disease in children 5 years post-transplant was 17% of all recipients. Coronary angiography remains the gold standard in the detection of vasculopathy in heart-transplant recipients.² Coronary artery spasm can complicate selective coronary angiography and result in myocardial ischemia. Coronary spasm can simulate the angiographic appearance of graft vasculopathy and cause diagnostic confusion.³ The spasm can arise from manipulation of the arterial wall by the catheter or from intraluminal injection of contrast material. In cardiac transplant recipients, coronary artery spasm has been reported in as many as 4.9% of coronary angiograms.³In adults, intracoronary nitroglycerin is routinely administered during coronary angiography to prevent coronary artery spasm.⁴ In children, however, safety and dosage guidelines for intracoronary nitroglycerin have not yet been firmly established. A dose of 3 µg/kg can be extrapolated by weight from the established adult dose of 200 µg; this dose was used in a study of children after the arterial switch operation and was shown to produce coronary vasodilation—with a small reduction in systolic blood pressure (SBP) and no noteworthy change in heart rate—in a control group of patients.^5,6We previously reported a case of coronary artery spasm during routine coronary angiographic monitoring in a 9-year-old boy who had undergone heart transplantation as an infant.⁷ After left main coronary artery injection of contrast material, the patient''s left anterior descending and left circumflex coronary arteries appeared to be diffusely narrow, and he developed marked ST-segment elevation, hypotension, and ventricular tachycardia. After cardiopulmonary resuscitation, he recovered uneventfully and displayed normal systolic function. Coronary angiography one month later, with the administration of intracoronary nitroglycerin before the injection of contrast material, revealed normal coronary artery diameter and was accomplished without complication.Since 2005, intracoronary nitroglycerin has routinely been used in pediatric transplant patients during biennial selective coronary angiographic monitoring at our institution. The purpose of the study is to report our experience with the routine use of intracoronary nitroglycerin for coronary angiography in children: its effects on blood pressure, on heart rate, and on the occurrence of arrhythmia and ST-segment elevation.     

Resolution of acute lower extremity deep vein thrombosis with rivaroxaban compared to warfarin

Journal of Thrombosis and Thrombolysis - Thrombosis resolution is an important component of treatment for deep vein thrombosis (DVT) and multiple anticoagulants are now available. It is unknown...     

Diagnostic value of Doppler ultrasound in the assessment of liver cirrhosis in children: Histopathological correlation

We have correlated flow abnormalities in the hepatic vasculature with histological findings in the liver to determine the accuracy of Doppler ultrasound in the diagnosis of liver cirrhosis in children. Eighteen children admitted for evaluation of unknown liver disease were examined prospectively and blindly with Doppler ultrasound prior to liver biopsy. Biopsy specimens showed established cirrhosis in 9 of 18, early cirrhosis in 5 of 18, and no cirrhosis in 4 of 18 children. Doppler studies were also performed on 20 control subjects. The portal vein velocity was decreased (p < 0.0005) and the arterio-portal velocity ratio was increased (p < 0.0005) in the established cirrhosis cohort relative to the controls. For the criteria of the established cirrhosis cohort, the sensitivities of the loss of the reverse flow component in the hepatic veins, the arterio-portal velocity ratio being greater than 3.0, the portal vein velocity being less than 20 cm/s, and the existence of focal flow acceleration in the hepatic veins were 100%, 78%, 67%, and 44%, respectively. The specificity of all of these criteria was 100%. The indicators were not useful in the diagnosis of early cirrhosis. © 1996 John Wiley & Sons, Inc.     

Impact of Surfactant and Calcium Sulfate Type on Air-Entraining Effectiveness in Concrete

The paper presents the evaluation of the influence of calcium sulfate on the air void microstructure in concrete and its action mechanism depending on the character of the air-entraining agent. Gypsum dehydration has been previously proven to negatively influence the air void structure of air-entrained concrete. Ettringite, nucleating from tricalcium aluminate and calcium sulfate, influences the adsorption and mode of action of anionic-based polycarboxylate ether admixtures. The authors suspected the admixture’s air-entraining mechanism was also affected by these characteristics. Gypsum dehydration was confirmed to influence the air void structure. In the case of the anionic surfactant, the content of air bubbles smaller than 300 µm was lower compared to cement with gypsum and hemihydrate. On the other hand, the content of air voids with a diameter up to 60 µm, which are the most favorable, was higher. The results obtained led to the conclusion that the mechanism of air entrainment was twofold, and in most cases occurred through the lowering of surface tension and/or through the adsorption of surfactant on cement grains. The adsorptive mechanism was proved to be more effective in terms of the total air content and the structure of the air void system. The results and conclusions of the study provide guidelines to determine the proper surfactant type to reduce the risk of improper air entrainment of concrete, and emphasize the importance of gypsum dehydration of cement in the process of air entrainment.