Coronary artery to right ventricle fistula in heart transplant recipients: a complication of endomyocardial biopsy.

In a series of 74 heart transplant recipients undergoing annual coronary angiography, a coronary artery to right ventricle fistula was observed in 4 patients, an incidence rate of 5.4%, which is much higher than the expected incidence of congenital coronary artery fistula (0.1% to 0.2%). A traumatic origin of the fistulas is unlikely because none of the heart donors had evidence of chest trauma. An endomyocardial biopsy-related etiology of the fistulas is postulated. All fistulas were located in the biopsy sampling area. Patients with a fistula underwent more biopsies before the diagnosis compared with patients without a fistula (20 +/- 11 versus 14 +/- 6, p = 0.05). At least one large arteriole (diameter greater than 0.16 mm) was found on pathologic examination of the biopsy specimens from each of the patients with a fistula (100%) but in only 2 (16.7%) (p less than 0.01) of 12 randomly selected patients without a fistula. The size of the fistula appears to be hemodynamically insignificant in all four patients, judging from angiographic size, normal intracardiac pressures and normal cardiac output values at rest. The diagnosis of a coronary artery to right ventricle fistula is possible and should be entertained at the time of coronary angiography of heart transplant recipients. The clinical significance of the finding is unclear. As long as endomyocardial biopsy remains the diagnostic method of identifying tissue rejection, prevention of the described complication is unlikely.

Usefulness and limitations of transesophageal echocardiography in the assessment of proximal coronary artery stenosis.

To assess the usefulness of transesophageal echocardiography in the evaluation of proximal coronary artery stenosis, 111 consecutive patients (mean age 61 years) who had intraoperative transesophageal echocardiography and coronary angiography within 1 week of surgery were studied. Transesophageal echocardiography visualized the entire length of the left main artery (0.2 to 2.2 cm, mean 0.93), 0.2 to 2.2 cm of the proximal left anterior descending artery and 0.1 to 3.4 cm of the proximal left circumflex artery in 103 patients (93%) and 0.1 to 4.6 cm of the proximal right coronary artery in 55 patients (49%). In the coronary artery segments visualized by echocardiography and compared with the corresponding angiographic segments, transesophageal echocardiography correctly identified 23 (96%) of 24 left main stenoses, 11 (78%) of 14 stenoses involving the left anterior descending artery, 6 (75%) of 8 left circumflex stenoses and all 7 stenoses (100%) of the right coronary artery. In all seven patients with ostial stenosis (left main artery in five and right coronary artery in two), the condition was correctly diagnosed by this technique. The sensitivity and specificity of transesophageal echocardiography in the overall evaluation of proximal coronary artery stenosis as customarily defined by angiography were 96% and 99% for the left main artery, 48% and 99% for the left anterior descending artery, 67% and 100% for the left circumflex artery and 37% and 100% for the right coronary artery, respectively. The distance of the stenotic lesion from the origin of the vessel by transesophageal echocardiography also correlated well with that measured by angiography (r = 0.63 to 0.99).(ABSTRACT TRUNCATED AT 250 WORDS)

Collateral flow in patients with acute myocardial infarction.

To assess the change in angiographically visualized collaterals in evolving acute myocardial infarction (AMI), coronary arteriograms from 53 patients obtained 6.2 +/- 0.2 hours after onset of AMI symptoms were compared with follow-up angiograms obtained 14 +/- 1 days later. Collaterals were graded according to intensity score and percent of distal infarct-related artery visualized. Collateral intensity score and the percent of distal infarct vessel visualized by collaterals at baseline were low, and there was a significant increase in both values at follow-up angiography. The group of 20 patients with occluded infarct vessels at follow-up study accounted for these increases. In 33 patients with patent infarct vessels at repeat angiography, collateral intensity score and percent of segment visualized were unchanged. Among the patients with occluded infarct vessels at baseline and subsequent improvement in left ventricular (LV) ejection fraction (EF), baseline collateral score and percent of segment visualized were significantly greater than in patients in whom LVEF did not improve. Thus, in patients with evolving AMI, (1) angiographically visible collaterals are not extensive within the early hours of AMI, (2) the extent of collaterals on follow-up angiography may not be representative of that on the day of AMI, (3) collaterals are considerably more common 2 weeks after AMI, especially in patients with occluded infarct arteries during follow-up, and (4) collaterals present at the time of AMI are associated with improved LVEF at 2 weeks.

Heparin and infarct coronary artery patency after streptokinase in acute myocardial infarction.

Anticoagulant therapy is frequently used after thrombolytic agents in the treatment of acute myocardial infarction (AMI) although it is unclear that such therapy will prevent subsequent infarct vessel reocclusion. The role of duration of heparin therapy in maintaining infarct artery patency was studied retrospectively in 53 consecutive AMI patients who received streptokinase therapy and underwent coronary angiography acutely and at 14 +/- 1 days. Of the 39 patients with initial infarct vessel patency, patency at follow-up angiography was observed in 100% (22 of 22) of those who received greater than or equal to 4 days of intravenous heparin but in only 59% (10 of 17) of those patients who received less than 4 days of heparin (p less than 0.05). Of the 14 patients not initially recanalized after streptokinase, patent infarct-related arteries at follow-up angiography were found in 3 of 8 (38%) treated with greater than or equal to 4 days of heparin therapy but in none of the 6 patients treated for less than 4 days (difference not significant). No significant difference in hemorrhagic complications was noted between the short- and long-term heparin treatment groups. Thus, greater than or equal to 4 days of intravenous heparin therapy after successful streptokinase therapy in AMI is more effective in maintaining short-term infarct vessel patency than a shorter duration of therapy and it may maintain the short-term patency of the infarct vessel in those patients who later spontaneously recanalize.

Can chest CT decrease the use of preoperative bronchoscopy in the evaluation of suspected bronchogenic carcinoma?

BACKGROUND: Fiberoptic bronchoscopy (FOB) is frequently used to diagnose and stage bronchogenic carcinoma (BC). However, the value of FOB in diagnosis/staging BC presenting as a pulmonary nodule or mass (PNM) is controversial. Since chest CT is usually obtained in these patients, it may be used in patient selection for preoperative FOB. OBJECTIVE: Evaluation of the role of chest CT in determining the predictive value of FOB in diagnosing/staging a PNM, by comparing the results of CT and bronchoscopy. DESIGN: Retrospective review of chest CTs and medical records. PATIENTS: Consecutive patients with BC between 1992 and 1994 who had diagnostic FOB and CT in our institution, but without radiographic evidence of (1) pulmonary atelectasis, (2) endobronchial tumor or narrowing of the central airways, and (3) the PNM abutting the central airways. RESULTS: Sixty-four patients met the selection criteria. The size of the PNM ranged from 1.5 to 10 cm; the size was < or = 4 cm in 62 patients. FOB provided a diagnosis in 22 patients. Bronchoscopy detected endobronchial lesions in 11 patients (17%); 3 had lesions in more than one lobe. In three patients, the PNM was <3 cm. The radiographically undetected endobronchial tumor increased the tumor stage in only two patients. The "CT bronchus" sign had a positive and negative predictive value of 75% and 68%, respectively. CONCLUSIONS: (1) In this study, CT failed to detect endobronchial tumor in 11 of 64 patients (17%). Because of the implications of a new staging system, more studies are necessary before abandoning staging FOB. (2) The CT bronchus sign has a very high positive and negative predictive value in the use of diagnostic FOB and should be used to guide the method of biopsy of a PNM.

Renal, hemodynamic, and electrocardiographic effects of low versus high osmolality contrast agents on the transplanted heart.

The effects of low and high osmolality ionic contrast agents on the transplanted heart were studied in 75 consecutive patients. Renal function remained unchanged 24 hours after coronary angiography in both groups. Hemodynamic changes were transient and more pronounced after administration of the high osmolality agent; ECG changes and cineangiography quality were similar after both agents. The manyfold increase in cost of the low osmolality contrast agents may not be justified for use in stable patients after heart transplantation.

Validation of thermography in the diagnosis of reflex sympathetic dystrophy.

OBJECTIVES: To examine the validity of several thermogram-derived indices of autonomic functioning in the diagnosis of reflex sympathetic dystrophy (RSD). DESIGN: A series of chronic pain patients were classified diagnostically based on thermogram results using discriminant function analysis, and validity measures (e.g., sensitivity, specificity) were used to determine the accuracy of computerized thermographic pixel analysis in discriminating RSD from other pathology. SETTING: The study was conducted at the Rush Pain Center, a multidisciplinary outpatient pain clinic. PATIENTS: A series of 46 chronic pain patients referred for suspected sympathetically mediated pain. INTERVENTIONS: All patients underwent computerized thermographic examination under a baseline condition after acclimating to a climate-controlled room, immediately after a cold challenge was applied to the contralateral uninvolved extremity (4 degrees C for 90 s) and 20 min after the cold challenge. OUTCOME MEASURES: Temperature during the three experimental periods, degree of temperature asymmetry between affected and nonaffected limbs during the three periods, response to cold challenge, and recovery following cold challenge were measured. RESULTS: Temperature asymmetry accurately discriminated between RSD and non-RSD patients, with the most accurate asymmetry measures obtained at baseline. Responses to cold challenge and actual temperature values did not discriminate between RSD and non-RSD pain patients. CONCLUSIONS: Thermography can be a useful component of RSD diagnosis. In situations where sensitivity and specificity are equally important, an asymmetry cutoff of 0.6 degree C appears optimal. If specificity (i.e., accurately ruling out non-RSD cases) is more important, a cutoff of 0.8 degree C or 1.0 degree C may be considered as well.

Comparison of epidural butamben to celiac plexus neurolytic block for the treatment of the pain of pancreatic cancer.

OBJECTIVE: To compare pain relief in metastatic pancreatic cancer patients between neurolytic celiac plexus block (NCPB) and epidural 5% butamben suspension (EBS), a material-based delivery system of a local anesthetic that produces a long-lasting differential nerve block. DESIGN: Open-label patient-selected parallel groups. SETTING: Urban tertiary care medical center. PATIENTS: Twenty-four adult patients with metastatic pancreatic cancer experiencing pain uncontrolled by systemic opioids who were referred to a multidisciplinary pain clinic for interventional therapy. INTERVENTIONS: Antecrural NCPB-block with ethanol and epidural 5% butamben suspension injections. MEASURES: Subjective global pain relief assessments on a 0-100% scale were made weekly for 4 weeks and then monthly. Change in opioid use postintervention. RESULTS: Eight patients had a single NCPB and three patients had two NCPB. Four of the former and two of the latter had successful pain relief defined to be a more than 75% reduction in pain when compared with pretreatment maintained for more than 4 weeks or until death (if less than 4 weeks). Thirteen patients received EBS in divided doses. Eleven patients received a cumulative EBS dose of 5 grams, one patient received a cumulative EBS dose of 2.5 grams, and one patient received a cumulative EBS dose of 8.75 grams. Nine of the eleven patients and each of the other two patients had successful pain relief. The overall incidence (85% EBS vs. 55% NCPB), the duration of successful pain relief, and the percent reduction in opioid use did not differ between the two groups. There were no serious complications. CONCLUSION: EBS appears to be a safe and effective alternative to NCPB in the treatment of pancreatic cancer pain.

Nerve blocks with 5% butamben suspension for the treatment of chronic pain syndromes.

BACKGROUND AND OBJECTIVES: Butamben is a non-water-soluble local anesthetic that can be prepared as an aqueous suspension for nerve blocks. This report describes the use of 5% butamben suspension for the treatment of chronic pain of cancer and noncancer origin. METHODS: The clinical courses of 75 consecutive patients were analyzed following 5% butamben nerve blocks (35 epidural blocks only, 33 peripheral nerve blocks only, and 7 had both epidural and peripheral nerve blocks). Epidural blocks were performed as a series of four with additional blocks offered if needed. Peripheral nerve blocks were done as a single block with repeat injections if needed. Injection volumes varied between 15 and 25 mL for epidural injections and 5 and 20 mL for peripheral nerve blocks. Successful therapy was defined as a -75% reduction in subjective pain assessments for -4 weeks or until death. Daily opioid requirements were also recorded. RESULTS: Fifty-four of the 75 patients (72%) were successfully treated. This included 48 of 67 cancer patients (71.6%) and 6 of 8 noncancer patients (75%). Median duration of pain relief was 12 weeks (range, 1-96) in the cancer patients and 10 weeks (range, 6-166) in the noncancer patients. Mean reduction in opioid requirements in successfully treated cancer patients was 74+/-5%. Pain on epidural injection occurred in half of the patients and was the most prevalent complication of treatment. Five patients had signs of intravascular injection. There were no serious long-term sequelae. CONCLUSIONS: When used as described in this report, 5% butamben suspension appears to be effective for treatment of chronic pain of both cancer and noncancer origin and has a low incidence of adverse sequelae.

Anomalous origin of posterior descending artery from left anterior descending artery with unusual intraseptal course.

The posterior descending artery (PDA) arises from the right coronary artery (RCA) in approximately 85% of people; only in from 10 to 15% does it arise from the circumflex artery. We report an unusual case of origin of the PDA from a branch of the left anterior descending artery (LAD). The PDA passed through the interventricular septum before it reached the posterior interventricular groove.

Needle-track metastasis after transthoracic needle biopsy.

Metastasis along the needle track (NTM) after a transthoracic needle biopsy (TNB) is considered a very rare complication. A survey of the membership of the Society of Thoracic Radiology and a review of the English-language literature were conducted to assess the incidence of this complication and its predisposing factors and natural history. A questionnaire was sent to all radiology departments in the United States and Canada that had a senior member of the Society of Thoracic Radiology. The total number of TNB between 1978 and 1993 and occurrences of NTM were elicited. If an NTM was encountered, information on the size of the nodule, proximity to the pleura, histology, size of the biopsy needle, and the interval between biopsy and NTM and outcome of the patient was elicited. The incidence of NTM was estimated using binomial proportions. Results of the literature survey were tabulated to provide similar information. One hundred sixty-five questionnaires were mailed and 75 responses were received. Approximately 68,346 TNB were reported. Five departments reported a total of eight NTM, resulting in an incidence of 0.012%. The average interval between TNB and NTM was 2.6 months. There were no predictable risk factors. The outcome was known in only 11 patients; 4 patients died by the time of reporting (2 after 14 months and 1 each after 6 and 9 months). From the results of this survey, the incidence of NTM after TNB is approximately 0.012%. This small risk is random and unavoidable.

Intrapulmonary teratoma: a case report and review of the literature.

Intrapulmonary teratomas are rare; only 30 cases have been reported in the world literature. These tumors are thought to originate from the third pharyngeal pouch. They occur equally in men and women and usually are diagnosed in the second to fourth decade of life. They are more often benign than malignant, although malignant lesions may have a favorable postoperative prognosis and benign lesions may exhibit high morbidity and mortality because of their size and location. These tumors present radiographically as lobulated masses that may contain calcification or peripheral collections of air. They most often occur in the upper lobes. The computed tomographic findings of intrapulmonary teratoma are less well known but have been described in two cases. An additional case is presented with a review of the literature and a tabular summary of the characteristics of this unusual entity.

A giant occipital encephalocele with spontaneous hemorrhage into the sac: A rare case report.

In giant encephalocele, head size is smaller than the encelphalocele. Occipital encephalocele is the commonest of all encephalocele. In our case, there was rare association with giant encephalocele with old hemorrhage in the sac. This was a unique presentation. In world literature, there was rare association with giant encephalocele with hemorrhage.