Coronary stenting for coronary artery narrowing in a heart transplant recipient

Transplant atherosclerotic coronary disease remains the leading cause of death in heart transplant recipients. We report the first case of coronary stent implantation in a heart graft for epicardial focal stenosis. Due to the lower rate of restenosis after stenting in the native coronary artery, we suggest that coronary stenting be considered an acceptable, first intention therapeutic option instead of angioplasty alone whenever possible.     

Long-term follow-up of elderly patients with severe aortic stenosis treated by balloon aortic valvuloplasty. Importance of haemodynamic parameters before and after dilatation

Early and late prognosis after percutaneous balloon aortic valvuloplasty (PBAV) was assessed in 38 consecutive elderly patients (mean age, 78.5 +/- 6.1 years). Significant valve opening was achieved in 35 patients. The hospital mortality was 8% (three patients); two other patients died within the first month and three underwent aortic valve replacement. At 2 years follow-up, there were 10 additional deaths (seven cardiac deaths) and five patients had symptom recurrence managed by aortic valve replacement (3) or repeat PBAV (2). Overall, six patients underwent surgery without untoward events and six had repeat PBAV. Only two out of six patients with repeat PBAV had sustained improvement; one was referred to surgery and the remaining three died soon after the second PBAV. One- and 2-year survival were respectively 72 and 62% and percentage of survivors with persistent improvement 68 and 41%. Although aortic valve area after PBAV was associated with outcome, predictors of poor long-term prognosis were primarily related to the pre-operative haemodynamic status. Patients with pulmonary resistances greater than 400 dynes cm-1 s-5 had the poorest outcome (chi 2 = 18.4-P less than 0.0001). Overall, signs of heart failure were predictors of poor long term follow-up. These data indicate that long-term success of PBAV is mainly related to the left ventricular dysfunction noted prior to intervention.     

Isolated tricuspid valve stenosis caused by infective endocarditis in an adult: Report of a case

We report herein the case of a 42-year-old man in whom dyspnea on exertion was found to be caused by isolated tricuspid stenosis. Two-dimensional echocardiogram showed thickening of the tricuspid valve with a markedly enlarged right atrium. A color-flow Doppler examination-revealed severe tricuspid stenosis without regurgitation and a Doppler-derived tricuspid diastolic pressure gradient of 23 mmHg. At the time of surgery, the patient was noted to have a stenotic tricuspid valve with thickened leaflets, fused commissures, and almost normal chorda tendineae. The valve leaflets were teased apart to the scattered specimen, and tricuspid valve replacement was successfully performed. Microscopic examination of the specimen demonstrated infective endocarditis. Isolated acquired tricuspid stenosis is extremely rare and, to our knowledge, this is the first case of infective endocarditis being involved as the primary cause.     

The Impact of Small Bowel Resection on the Incidence of Stomal Stenosis and Marginal Ulcer After Gastric Bypass

Background: Stomal stenosis (SS) and marginal ulcer (MU) are reported to occur in 9-20% and 2-13%, respectively, of patients undergoing gastric bypass for morbid obesity. It is hypothesized that decreasing tension on the gastrojejunostomy by performing limited small bowel resection (SBR) would decrease ischemia, thereby decreasing the likelihood of SS and MU. Methods: A retrospective review of 150 consecutive gastric bypass patients operated by one surgeon from 1993 to 1996 was performed. The incidence of SS and MU was compared in patients with and without SBR. Results: The overall rate of SS was 24.0% and that of MU was 9.3%: the incidence of both was 2.0%. The incidence of SS in patients without SBR was 26.9% and with SBR was 19.6%. The incidence of MU in patients without SBR was 8.9% and with SBR was 9.8%. Neither result was statistically significant by Fisher's exact test. Conclusion: There is a trend towards a decrease in the incidence of SS in gastric bypass patients with concomitant SBR although this did not reach clinical significance.     

Value of spiral CT in hemodynamically stable patients following blunt chest trauma

Introduction: Features of spiral CT (SCT) — fast scanning, dynamic injection of contrast allowing optimal vessel opacification, and supplemental multiplanar imaging — promises to provide increased accuracy in the diagnosis of acute and non acute thoracic vascular disease. Recent work demonstrating the cost effective triage of hemodynamically stable patients after blunt chest trauma for angiography based on dynamic CT findings has prompted an investigation into the accuracy of SCT in this clinical setting. Methods: A retrospective review of all patients seen in the emergency department over the period of one year for aortic, thoracic, or blunt chest trauma evaluation was performed (74 patients) and all SCT scans available were reviewed and data reformatted for optimal delineation of pathology using maximum intensity projection and multiplanar reformation. The accuracy and predictive positive and negative values of SCT were calculated with respect to angiography, surgical, and/or clinical follow up evaluation. Results: Twenty three (31%) patients went directly to angiography owing to mediastinal widening on chest film and hemodynamic instability, of which four were positive and required emergent surgery. Seven hemodynamically stable patients (9%) had noncontrast SCT owing to mediastinal widening on chest film, all of which had angiography with none having great vessel trauma. Fourty four hemodynamically stable patients (60%) had contrast enhanced SCT (ceSCT), of which five (11%) were abnormal and underwent angiography, four of these were positive for aortic damage, one for a subclavian artery laceration. Of the remaining 39 patients who had normal ceSCT; five had angiography, all of which were normal. Of the remaining 34 patients that had normal ceSCT none had adverse outcome on clinical follow-up, minimum of 12 months. Conclusion: The predictive positive value for aortic trauma of ceSCT in blunt trauma is 80%, with a predictive negative value of 100%, indicating that it is feasible for SCT to be a first line exam in blunt chest trauma in the future.     

Surgical technique of laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis

We report herein a new method of performing laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, using refined surgical techniques. The pyloric tumor was immobilized by grasping the first portion of the duodenum and the anterior wall of the stomach, and electrocoagulation was used prior to incising the pyloric tumor to minimize bleeding during the procedure. Although this technique has been applied in only two patients so far, we present the details herein. We believe that with technical and instrumental refinements, the speed and safety of laparoscopic pyloromyotomy will improve and it will become an alternative to open surgery in pediatric patients.     

Value of Doppler ultrasound for the diagnosis of renal artery stenosis in children

To evaluate the reliability of Doppler ultrasonography (US) in identifying children with renal artery stenosis (RAS) among those with hypertension, we compared Doppler US results in 22 hypertensive children (mean age 8.9±4.3 years), with (13 cases) and without RAS at angiography, and in 33 normotensive children (mean age 8.8±4.7 years). We observed 2 false-negatives and 2 false-positives with Doppler US. Of the 2 false-negative diagnoses, 1 had RAS on an accessory renal artery located behind a normal upper polar artery and the other was observed in a patient with bilateral multiple stenosis of the very distal segments of renal arteries. The 2 false-positive diagnoses were due to sinuous left renal artery and to technical reasons, respectively. In another patient, Doppler US showed a tight RAS, while arteriography was normal. RAS was subsequently confirmed by a second arteriography. Peak systolic velocity values of Doppler US were significantly higher in patients with proven angiographic RAS (3.44±0.66 m/s) than in hypertensive patients with normal renal arteries at angiography (0.99±0.35 m/s, P <0.0001) and normotensive healthy children (1.04±0.23 m/s, P <0.0001). With the use of multiple views, and the experience acquired with practice, false-negatives or false-positives due to the geometry of the renal artery can be avoided. Nevertheless, very distal stenosis can be missed by Doppler US. Received October 30, 1995; received in revised form April 16, 1996; accepted May 14, 1996     

Non-invasive variant of Gorlin formula can be used to identify severe aortic stenosis

Summary. In recent years the continuity equation has been established as a valuable non-invasive method for calculating aortic valve area. The continuity equation cannot be used if there is calcification or sub-valvular stenosis in the left ventricle-outflow tract, because the area of the outflow trace is not circular in those cases. The authors have tested the value of a non-invasive variant of the Gorlin formula, as an alternative method of identifying severe aortic stenosis. They examined 32 consecutive patients with aortic stenosis with both methods. Seventeen patients had severe stenosis (valve area^0–7 cm²), calculated by the continuity equation. The other 15 patients had moderate stenosis (valve area 0–7–1–0 cm²). Using the non-invasive variant of the Gorlin formula, the authors were able to identify 16 of the 17 cases with severe stenosis, thus showing that the method is useful for identifying severe aortic stenosis. (P<0–001 by x²-test).     

Percutaneous transhepatic stenting by wallstents of portal vein and bile duct stenoses caused by immunoblastic sarcoma in a liver transplantation

Posttransplant lymphoproliferative disorders are infrequent tumors related to chronic immunosuppressive therapy. We present a liver transplant recipient who developed such a tumor in the porta hepatis that provoked obstruction of the entire portal triad. Treatment consisted of systemic chemotherapy, percutaneous dilatation, and placement of Wallstent endoprostheses across both biliary and portal vein stenoses. The patient died 3 weeks later of pneumonia and sepsis. At necropsy, the tumor was completely necrosed and the prostheses in both the common bile duct and the portal vein were patent.     

氟骨症性椎管狭窄症的手术治疗

１９８７～１９９０年手术治疗氟骨症性椎管狭窄症１００例。包括颈椎９例，胸椎８例，腰、骶椎８３例。术后随访１～４年，复查结果：临床治愈９３例（９３％）：显效３例（３％）、有效３例（３％）、无效１例（１％）。手术原则是彻底减压，因氟骨症具有椎骨及其骨周组织严重退变、异化和骨化的临床病理特点，故在胸、腰椎减压术后，一般不影响其稳定性，在颈椎施行双开式或单开式椎管扩大加植骨融合术，则可收减压、稳定及防止或减少椎板间隙瘢痕狭窄的效果。