Right ventricular myxoma

We recently treated a patient with right ventricular myxoma and a clinical picture of pulmonary embolism and tricuspid valve obstruction who had successful removal of the tumor through the tricuspid valve via a right atriotomy.     

The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients.

This study analyzed the impact of prognostic variables of age, sex, histopathological diagnosis, extent of disease at diagnosis, and surgical intervention on well differentiated thyroid carcinoma and how surgical treatment, radioactive iodine, and radiotherapy influence the patients' outcomes. There have been 1599 patients with well differentiated thyroid cancer treated and followed at the University of Texas M.D. Anderson Cancer Center from 1948 to 1989. The median follow-up for all patients was 11.0 yr, with the maximum follow-up being 43 yr and the minimum follow-up being 1 yr. The patients were predominantly female (2.3:1), with papillary (81%) and intrathyroidal carcinomas (42%) at the time of diagnosis. Sixty-six percent of the patients had a total thyroidectomy, 7% received external radiotherapy, and 46% had radioactive iodine as part of the treatment of the original disease; the overall recurrence rate was 23%, and the death rate was 11%. This study showed that treatment with radioactive iodine was the single most powerful prognostic indicator for increased disease-free interval (P less than 0.001) and that its use significantly increased survival as well. No benefit was obtained from treatment with external radiotherapy. Children had the best overall survival, but of the adult patients, females who had intrathyroidal papillary disease treated with total thyroidectomy, who had been given radioactive iodine, and whose disease had been diagnosed between 20-59 yr of age had the best prognosis.     

Conduction defects in aortic valve disease

Serial electrocardiograms of 426 patients undergoing homograft replacement of the aortic valve were analyzed with respect to the presence or absence of conduction defects (CD) in an attempt to define more precisely their etiology and relationship to prognosis. The dominant lesion was aortic stenosis in 249 patients and aortic regurgitation in 177 patients. Preoperative CD were present in 69 patients (28 per cent) with aortic stenosis and in 43 patients (24 per cent) with aortic regurgitation. In those with aortic stenosis, calcification in the ventricular septum or impaired left ventricular function were common and could have been important etiological factors. In those with aortic regurgitation, impaired left ventricular function was the dominant feature. Coronary artery disease was present in a minority of patients in both groups. In patients with aortic stenosis, there were three early deaths (4.4 per cent) and 11 late deaths (15.9 per cent). In those with aortic regurgitation, there were four early deaths (9.3 per cent) and four late deaths (9.3 per cent). Of 275 patients with normal conduction throughout the pre- and postoperative period, there were 15 early deaths (5.4 per cent) and 13 late deaths (4.7 per cent). (Follow-up 3 to 84 months. Mean, 36 months). Reversal of CD following operation occurred in more than half of those patients with first-degree A.V. block regardless of the initial hemodynamic lesion and was associated with improvement in left ventricular function. Reversal of left anterior hemiblock (LAH) occurred in approximately 30 per cent of cases. Progression of LAH and the combination of left axis deviation with left bundle block (LBBB) were associated with a poor prognosis. Fresh CD following operation occurred in 19 patients within 1 month of surgery and in 20 patients beyond this period of time. In this group there were two early deaths (5.1 per cent) and four late deaths (10.3 per cent). Of 20 patients developing late conduction defects, six were associated with valve failure and the development of poor left ventricular function. In the remainder no apparent cause could be determined and this group may represent fibrosis occurring in the region of the conducting pathways.     

Detection of metastatic adrenal carcinoma using 131I-6-beta-iodomethyl-19-norcholesterol total body scans.

Adrenal and total body scintigraphs with 131I-6-beta-iodomethyl-19-norcholesterol were obtained in 5 patients who had had prior resection of adrenal cortical carcinoma. The results were compared with roentgenographic findings and liver, bone, and total body gallium-67 citrate scintigraphs. Metastatic lesions were detected with radiolabeled cholesterol in 4 of 5 patients, including 3 liver metastases, 2 bone metastases, and 1 lung metastasis. These lesions were also demonstrated by one or more of the other diagnostic modalities. All initial findings were negative in a fifth patient, who developed brain metastases within two months. The 6-methyl-analog of iodocholesterol makes it possible to detect metastatic adrenocortical carcinoma with total body scans. Whether or not this agent is "tumor specific" and will be of significant clinical utility will have to be determined more fully in a larger series of patients.     

Comparison of management patterns and clinical outcomes in patients with atrial fibrillation in Canada and the United States (from the analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management [AFFIRM] database)

Little is known about differences in practice patterns or outcomes in the management of patients who have atrial fibrillation in Canada compared with those in the United States (US). We evaluated the effect that the country of enrollment may have on the management patterns and clinical outcomes in patients who participated in the AFFIRM study. Three thousand four hundred patients came from the US and 660 from Canada. In the US, patients were more likely to have a history of coronary artery disease (39% vs 35%, p = 0.03), hypertension (72% vs 67%, p = 0.01), or congestive heart failure (24% vs 18%, p = 0.0002). More US participants were <65 years of age (25% vs 19%, p = 0.003). Although at randomization the use of warfarin was comparable, during follow-up Canadians were more likely to be treated with warfarin and to be therapeutically anticoagulated. Mortality rate at 5 years was higher in US patients (24% vs 16%, p = 0.001), and the composite end point (death, disabling stroke, major bleeding, cardiac arrest, or anoxic encephalopathy) was also higher in US patients (30% vs 22%, p = 0.0005). Even after adjusting for known differences in baseline characteristics, the risk of death was lower in Canada (hazard ratio 0.70, p = 0.02). In conclusion, in the AFFIRM study, US subjects were more likely to have preexisting cardiovascular diseases despite being younger (<65 years old) than those in Canada. Effective warfarin therapy was more commonly employed in Canada. After correcting for the known differences in baseline characteristics, Canadian patients who had atrial fibrillation had a lower mortality risk.     

sICAM-1 correlates with myocardial ICAM-1 expression in dilated cardiomyopathy

BACKGROUND: Dilated cardiomyopathy (DCM) is etiopathogenically linked to intramyocardial inflammation, which is reflected by ICAM-1 abundance. We investigated whether soluble ICAM-1 (sICAM-1) levels in the sera of DCM patients are associated with intramyocardial ICAM-1 expression. METHODS: Immunohistochemically detected ICAM-1 expression was quantified semiquantitatively in endomyocardial biopsies from DCM patients (n=45; n=17 females; age: 48+/-15 years) and from n=12 donor hearts (controls) by a human observer (baseline vs. enhanced expression) and quantitatively by a digital image analysis (DIA) system. The DIA-measured qualities were area fraction (AF), surface-volume ratio (SVR) and integral optical density (ID). The sICAM-1 levels of the DCM patients and n=12 healthy volunteers (controls) were measured by ELISA (means of duplicate measurements). Intramyocardial ICAM-1 expression and sICAM-1 levels were compared in these DCM patients. RESULTS: Of the DCM patients, n=24 (53%) demonstrated statistically higher sICAM-1 levels compared to controls (>198 ng/ml). By semiquantitative and quantitative DIA evaluation, endothelial ICAM-1 abundance was present in n=25 (56%) of the DCM biopsies. sICAM-1 correlated significantly (P<0.001) both with the semiquantitatively assessed and the DIA-measured ICAM-1-AF, the ICAM-1-SVR and the ICAM-1-ID. The positive predictive value of sICAM-1 measurements for intramyocardial ICAM-1 abundance was 96%, and the negative predictive value was 71%, with a receiver operating characteristic area under the curve of 0.93. Furthermore, sICAM-1 levels correlated with intramyocardial T-lymphocytic (CD2+/CD3+) infiltrates (P<0.03). CONCLUSIONS: Measurement of non-invasively obtained sICAM-1 reliably reflects intramyocardial ICAM-1 expression and may therefore serve as a non-invasive marker of inflammatory activity in DCM.