Effects of Nd-YAG Laser iridotomy on anterior segment measurements in pigment dispersion syndrome and ocular hypertension.

PURPOSE: To compare the anterior segment optical coherence tomography (AS-OCT) measurements of eyes with pigment dispersion syndrome (PDS) and ocular hypertension (OHT) before and after neodymium:yttrium-aluminum-garnet (Nd:YAG) laser peripheral iridotomy (LPI). METHODS: A total of 23 eyes of 23 patients with PDS and OHT with features of PDS were included in this retrospective study. All of the eyes with PDS and OHT were examined by AS-OCT before and after Nd:YAG LPI. Anterior chamber depth, angle opening distance 500, angle opening distance 750, trabecular iris space 500, trabecular iris space 750 and scleral spur angle, iris bowing and iris shape were measured with AS-OCT by the same examiner. RESULTS: The differences in all parameters before and after Nd:YAG LPI were statistically significant. Iris configuration was concave in all eyes prior to iridotomy. After Nd:YAG laser iridotomy, the iris configuration became convex in 7 eyes, flat in 9 eyes and remained concave in 7 eyes. CONCLUSION: Nd:YAG laser peripheral iridotomy is an effective method for reversing the iris concavity and iris bowing in pigment dispersion syndrome.

A comparative evaluation of segmental analysis of macular layers in patients with early glaucoma, ocular hypertension, and healthy eyes.

PURPOSE: To compare macular layer thicknesses between early glaucoma, ocular hypertension, and healthy eyes and to evaluate the accuracy of spectralis optical coherence tomography (OCT) segmentation software in discriminating early glaucoma from ocular hypertension and healthy eyes. METHODS: OCT scans were performed using the standard macular and peripapillary retinal nerve fiber layer (pRNFL) protocols on the Spectralis-OCT. The following macular thickness parameters were compared in the inner and outer circles of the Early Treatment Diabetic Retinopathy Study: total macular thickness (MT), retinal nerve fiber layer (mRNFL), ganglion cell layer (mGCL), inner plexiform layer (mIPL), inner nuclear layer (mINL), outer plexiform layer (mOPL), outer nuclear layer (mONL) and ganglion cell complex (mGCC: sum of mRNFL, mGCL, and mIPL). Sectors and layers with the best area under the receiver operating characteristic curve (AUC) were determined and compared between groups. RESULTS: Of a total of 200 eyes included in this study, 64 eyes had primary open angle glaucoma, 69 had ocular hypertension, and 67 were healthy. Peripapillary RNFL was significantly thinner in the early glaucoma group (P<0.05). For the macular variables, there was a significant reduction in the MT, mGCC, mRNFL, mGCL, and mIPL thicknesses in the early glaucoma group; while there were no statistically significant differences between the ocular hypertension and control groups (P>0.05). For distinguishing early glaucoma from normal eyes, AUCs for mGCC, mGCL, and mRNFL were similar to the pRNFL; and for early glaucoma and ocular hypertension, AUCs for mGCC, mGCL mRNF and mIPL were comparable to the pRNFL. CONCLUSION: Macular segmentation can assist in the early diagnosis of glaucoma as a complementary study to pRNFL analysis.

Analysis of retinal microvasculature in Fuchs' uveitis syndrome. Retinal microvasculature in Fuchs' uveitis.

PURPOSE: The objective of this study is to quantitatively analyse the foveal microvasculature in eyes with Fuchs' Uveitic Syndrome (FUS), or Fuchs' Heterochromic Iridocyclitis (FHI), by Optical coherence tomography angiography (OCTA). METHODS: Thirty patients with FUS and 30 healthy volunteer patients (control group) were enrolled in the study. Vascular density (VD) in the superior and deep capillary plexuses (SCP, DCP) were reported and compared between eyes with FUS (FU), fellow eyes (FE) and the control group. RESULTS: Foveal VD and parafoveal VDs in all quadrants of the SCP were significantly lower in the FU group than the FE group and normal eyes (P<0.05). Foveal VDs in the DCP were similar between the three groups (P>0.05); however, parafoveal VDs in all quadrants of the DCP were significantly lower in the FU group than in the FE and control eyes (P<0.05). Foveal and parafoveal VDs in both the SCP and DCP were similar between fellow eyes and the control group. CONCLUSION: Fuchs' Uveitic Syndrome (Fuchs' Heterochromic Iridocyclitis) affects not only the anterior uvea and vitreous but also the retinal microvasculature. Analysis by OCT-A may enable us to understand the extent of this disease.

Surgical management of left main coronary artery aneurysm.

Aneurysmal dilatation of coronary arteries is characterized by abnormal dilatation of a localized or diffuse segment of the coronary arterial tree. Left main coronary artery aneurysms are rare coronary anatomic abnormalities. They rarely involve the left main coronary artery. Different strategies have been adopted, where the coronary artery aneurysms have been left as such, resected partially, isolated, reconstructed, ligated with a simultaneous bypass with internal mammary artery, or treated with vein grafts. We report a case of a successful ligation of aneurysm of the left main coronary artery and three simultaneous coronary artery bypass procedures (Fig. 1, Ref. 15).

Symptomatic bilateral carotid artery stenoses 7 years after coronary artery bypass surgery in a young patient with familial hypercholesterolemia.

We present a patient suffering from homozygous familial hypercholesterolemia, who developed coronary artery disease in the age of 15 treated with three vessels coronary artery bypass grafting (CABG) operation. 7 years after CABG surgery symptomatic bilateral carotid artery stenoses were observed. Both internal carotid arteries were stented. The combination of pharmacologic therapy with life-long LDL-apheresis is the current treatment of choice.

A very rare anatomic variation of the left brachiocephalic vein: left retro-aortic brachiocephalic vein with tetralogy of Fallot.

An anomalous course of the left brachiocephalic vein behind the aortic arch was identified in a patient with tetralogy of Fallot. A 6-year-old male patient had been admitted to the hospital with a diagnosis of tetralogy of Fallot and patent foramen ovale. At the beginning of the operation the left brachiocephalic vein could not be found. The pericardium was opened longitudinally and there was no persistent left superior vena cava. After careful examination, the left brachiocephalic vein was found behind the aorta. Especially during open heart surgery this pathology is very important. We conclude that when the left brachiocephalic vein can not be found, the possibility of persistent left superior vena cava and retro-aortic left brachiocephalic vein should be borne in mind.

Use of sevoflurane during cardiopulmonary bypass decreases incidence of awareness.

BACKGROUND AND OBJECTIVE: The role of sevoflurane has not been studied in relation to awareness during anaesthesia. We observed the effect of sevoflurane on the incidence of awareness during cardiopulmonary bypass for open-heart surgery. METHODS: Fifty-nine patients of age >17 yr undergoing open-heart surgery with cardiopulmonary bypass were randomly assigned to two groups. In both groups, induction was with etomidate, dehydrobenzperidol and fentanyl; anaesthesia was maintained with sevoflurane, fentanyl and N20; vecuronium was used for muscular paralysis. Group 1 (30 patients) received dehydrobenzperidol and fentanyl during cardiopulmonary bypass; Group 2 (29 patients) received sevoflurane and fentanyl. Patients were given different auditory inputs during different phases of surgery. All patients were interviewed with standard questions 8 and 24 h postoperatively for evidence of explicit awareness. RESULTS: Five patients in the dehydrobenzperidol group gave a history of awareness (16.67%) as opposed to none in the sevoflurane group. The difference in the incidences of awareness was significant (P < 0.05), but no differences were found between the interviews conducted at 8 and 24 h. Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common.

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Chlamydia pneumonia seropositivity correlates with serum fibrinogen and lipoprotein a levels: any role in atherosclerosis?

The aim of the study is to determine the impact of Chlamydial seropositivity on atherosclerosis in a group of patient requiring coronary and/or carotid revascularization. A population of 30 diabetic patients (group 3) and 26 nondiabetic patients (group 2) with angiographically documented coronary and/or carotid artery disease were enrolled for the study. Volunteers from the relatives of hospital staff with no known disease (n=29; group 1) were included as the control group. Serum samples from the participants were assayed for cardiovascular risk factors including total serum cholesterol, triglyceride and lipoprotein levels, fibrinogen, Hb A1c levels and IgG titers for Chlamydia pneumonia (C. pneumonia). Chlamydial seropositivity was analysed further to determine a possible impact on atherogenesis. Serum LDL cholesterol levels revealed statistically significant difference between groups 1 and 2 (p=0.001). There was no difference between groups 2 and 3 regarding LDL cholesterol levels. There was no significant difference among the groups with respect to C. pneumonia seropositivity and the other atherosclerotic risk factors. Chlamydial seropositivity was found to be more frequent in males than in females (p=0.008). In the C. pneumonia seropositive group, serum fibrinogen and lipoprotein a levels were found to be significantly higher than the seronegative group (p=0.0001 and p=0.001, respectively). Other atherogenic risk factors were similar in the seropositive and negative groups. The causal role of Chlamydial infections in atherosclerotic plaque formation might be due to their influence on the serum fibrinogen and lipoprotein a levels.

Aprotinin reduces the IL-8 after coronary artery bypass grafting.

The effect of aprotinin, a protease inhibitor, on myocardial interleukin-8 (IL-8) production after ischemia-reperfusion injury was investigated. Twenty patients who had elective coronary artery bypass grafting were included in this study. Patients were randomly divided into two groups (n = 10 in each). Group A patients received high dose aprotinin (20,000 IU/kg as pretreatment followed by 7500 IU/kg for 6 h) and Group B patients received normal saline as a control. Serum IL-8 levels after the termination of cardiopulmonary bypass (CPB) showed a significant improvement in aprotinin treated group compared to control group (70 +/- 42.6 vs 360.71 +/- 87.9 ng/ml) (P < 0.005). Levels were also significantly higher at post-operative 24th hour in patients who did not received aprotinin (340.16 +/- 92.10 vs 96.13 +/- 34.33 ng/ml). However at post-operative 48th hour levels were again higher in control (untreated) group, but the difference was not statistically significant (78.8 +/- 34.4 vs 42.8 +/- 9.29 ng/ml). Aprotinin prevented the IL-8 release from myocytes in ischemia-reperfusion injury. The mechanism is highly dependent on anti-protease activity of aprotinin.

Effect of cardiopulmonary bypass on plasma levels of lipoprotein (a) in hypercholesterolemic patients.

Increments of lipoprotein (a) (Lp (a)) concentration during cardiopulmonary bypass (CPB) have not been justified in the literature yet. We have investigated whether Lp (a) levels remain constant or increase during CPB and if high plasma levels of low density lipoprotein (LDL; containing apolipoprotein (apo) B) in hypercholesterolemic patients affect the assembly of Lp (a) (containing apoB: Apo (a)). In this study, the change in plasma lipid and lipoprotein levels of 40 patients with hypercholesterolemia and 40 patients who have normal cholesterol values were determined and compared during CPB, and in the postoperative early stage. In our study, lipid and lipoproteins, except Lp (a), showed a falling trend and paradoxically, Lp (a) statistically showed a significant rising trend, like the acute phase reactant in two groups (p=0.011 for LDL, p=0.016 for high density lipoprotein (HDL) and p<0.001 for the others, in 80 patients). Concentrations of Lp (a) in plasma increased more sharply in the hypercholesterolemic group than the normocholesterolemic group during CPB. This difference was significant at the 60th minute of cardiopulmonary bypass with a nonparametric test (p<0.05 Mann-Whitney U test). High density lipoprotein values showed more decline in the hypercholesterolemic group patients than in the normocholesterolemic group patients (p<0.05). In conclusion, lipoprotein (a) levels increased more pronounced in patients with hypercholesterolemia during CPB. On the other hand, high LDL levels in hypercholesterolemic patients accelerated Lp(a)formation in the acute phase.

A surgical approach on an emergency basis for removal of Wilms' tumor with intracardiac neoplastic extension.

Extension of Wilms' tumor through inferior vena cava into the heart two years after the completion of therapy, is a very rare clinical aspect. We successfully operated on a 7 year old girl who had a huge right atrial mass which filled the right ventricle and right ventricular out flow tract, on an emergency basis using cardiopulmonary bypass.

Isolated cardiac metastasis of osteosarcoma.

Osteosarcoma metastasis to the heart caused by tumor thrombosis is very rare. A 7-year-old girl with an osteosarcoma of the right humerus, refused the treatment, at first, then, 1 year later, referred to the hospital with metastasis to the heart. The mass invading the pulmonary arteries was successfully removed with open-heart surgery.

An alternative repair technique for aortic periprosthetic leakage.

In case of aortic periprosthetic leakage, there are several methods of repair. When valve replacement or refixation is not suitable an alternative repair technique, 'curtaining' with a Dacron patch to prevent leakage is presented.

Vascular hamartoma of the mediastinum: a case report.

Vascular hamartoma of the mediastinum is a rare benign vascular tumor. A 13-year-old girl presented with back pain, persistent coughing, palpitation, and angina pectoris. Preoperative investigations demonstrated an enlarging mass involving the superior mediastinum extending posteriorly (T6-T8). An encapsulated, 6x5x3 cm dark purplish mass adherent to the aortic wall was found. The main mediastinal mass was totally excised but limited resection was carried out in the paravertebral region. Microscopic examination revealed a vascular hamartoma.

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report.

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.

The effect of acute normovolemic hemodilution on homologous blood requirements and total estimated red blood cell volume lost.

BACKGROUND: Acute normovolemic hemodilution combined with retransfusion is one of the various techniques proposed to avoid homologous blood transfusion in cardiac surgery. The purpose of the present paper is to study the effect of the volume of autologous blood collected pre-cardiopulmonary bypass (CPB) on homologous blood requirements and total estimated red blood cell (RBC) volume lost in coronary artery bypass grafting (CABG) surgery. METHODS: Following induction of anesthesia, sequestration of one (5-8 ml/kg; Group I, n = 14) or two units (12-15 ml/kg; Group II, n = 14) of fresh autologous blood was performed under electrocardiographic and hemodynamic control. Group III (n = 14) was designated as the control group. Autologous blood was reinfused at the conclusion of CPB. RESULTS: The use of homologous blood in the study groups was significantly less than in the control group. High-volume phlebotomy did not make a significant difference in the requirement of the homologous blood, while causing a mild increase in the total estimated RBC volume lost. No significant differences could be demonstrated in preoperative, post-CPB and discharge hematocrit levels and postoperative blood drainage between the groups. CONCLUSION: Acute intraoperative hemodilution with high- and low-volume phlebotomy reduced the homologous blood requirements similarly regardless of the amount of phlebotomy.