Pacemaker lead infection: report of three cases and review of the literature.

Pacemaker lead infection is a rare condition, most often occurring when intervention is needed after pacemaker implantation. Diagnosis is by blood cultures and confirmation by transoesophageal echocardiography; transthoracic echocardiography is often inadequate. A literature review indicated the microorganism most responsible for late lead infection is Staphylococcus epidermidis (which can grow on plastic material). A retrospective analysis of patient files from the authors' institution (1993-97) yielded three patients with proven pacemaker lead endocarditis. The diagnosis of pacemaker endocarditis was by transoesophageal echocardiography. The endocarditis appeared after a long period and in two of the three patients there was S epidermidis infection. Thoracotomy with removal of the infected system was performed because of the large dimensions of the vegetations. A new pacemaker was implanted: in one patient with endocardial leads, in the other two with epicardial leads. All three patients recovered well and follow up was uneventful for at least one year.

Epicardial crossing of coronary arteries: a variation of coronary arterial anatomy.

Four patients with crossing of two coronary arteries detected by coronary arteriography are presented. This variation of coronary artery anatomy has not yet been reported. The classification of this variation is discussed.

Tako-tsubo cardiomyopathy with left ventricular outflow tract (LVOT) obstruction: case report and review of the literature.

In this report, we describe a case of Tako-Tsubo cardiomyopathy (TTC)--also called 'apical ballooning' syndrome--in which transient left ventricular outflow tract (LVOT) obstruction and mitral regurgitation led to haemodynamic instability. Patients with hypotension should undergo urgent echocardiography to determine if LVOT obstruction is present. This complication has been described in 10-25% of all TTC patients. In patients with hypotension and moderate-to-severe LVOT obstruction, inotropic agents should not be used because they can worsen the degree of obstruction. Instead, it is suggested to use beta-blockers, which can improve haemodynamics by causing resolution of the obstruction. The fact that some patients do not survive their acute TTC event only underscores the importance of prompt recognition and targeted management of dynamic LVOT obstruction.

Validation of new soft tissue software in orthognathic surgery planning.

This study tests computer imaging software (SurgiCase-CMF(®), Materialise) that enables surgeons to perform virtual orthognathic surgical planning using a three dimensional (3D) utility that previews the final shape of hard and soft tissues. It includes a soft tissue simulation module that has created images of soft tissues altered through bimaxillary orthognathic surgery to correct facial deformities. Cephalometric radiographs and CT scans were taken of each patient before and after surgery. The surgical planning system consists of four stages: CT data reconstruction; 3D model generation of facial hard and soft tissue; different virtual surgical planning and simulation modes; and various preoperative previews of the soft tissues. Surgical planning and simulation is based on a 3D CT reconstructed bone model and soft tissue image generation is based on physical algorithms. The software rapidly follows clinical options to generate a series of simulations and soft tissue models; to avoid TMJ functional problems, pre-surgical plans were evaluated by an orthodontist. Comparing simulation results with postoperative CT data, the reliability of the soft tissues preview was >91%. SurgiCase(®) software can provide a realistic, accurate forecast of the patient's facial appearance after surgery.

Prosthetic valve endocarditis due to Listeria monocytogenes. A case report with review of the literature.

We report the case of a 71-year-old man with a prosthetic aortic valve endocarditis caused by Listeria monocytogenes. He was successfully treated with a combination of ampicillin and amikacin, and valve replacement surgery. This case and previously reported cases are discussed.

Balloon angioplasty of coarctation of the aorta: a safe alternative for surgery in adults: immediate and mid-term results.

Patients with coarctation of the aorta can be treated either with surgery or with balloon angioplasty. So far, the last method has proved to be successful in children, but results of this treatment in (young) adults are virtually unknown. The aim of this study was to evaluate the immediate and mid-term follow-up results of balloon angioplasty of native coarctation in (mainly young) adults. Coarctation of the aorta was diagnosed by means of ultrasound or angiography, and defined as a stenosis with a pressure gradient greater than 20 mm Hg. The balloon angioplasty-procedure was carried out under complete anesthesia, and was considered to be successful, if the pressure gradient was reduced to less than 20 mm Hg. Nineteen consecutive adults (12 males, 7 females; aged 14-67 years, median 29) with native coarctation were treated from 1995-99. Mean pressure gradient decreased from 49.3+/- 20.8 to 4.8+/-8.2 mm Hg (P<0.0001). One patient showed a suboptimal result with a residual pressure gradient of 28 mm Hg. In one other patient a stent was placed on request of the referring physician. Follow-up was 100% complete and ranged from 3-47 months (mean 20.2+/- 12.9). At 1-year follow-up mean systolic blood pressure was reduced from 159.4+/-19.5 to 132.5+/-17.6 mm Hg (n = 18; P<0.0001), and mean ankle-arm pressure index improved from 0.73+/-0.09 to 0.96+/-0.05 (n = 18; P<0.0001). Anti-hypertensive medication could either be reduced or stopped in 7 patients (53.8%). With ultrasound or angiography or MRI, no patients had signs of aneurysm formation or worsening restenosis during follow-up. In adult patients with uncomplicated native coarctation of the aorta, balloon angioplasty (without stenting) would seem to be an excellent and safe alternative for surgery. In our hospital it has completely replaced surgical correction in such patients.

A randomized trial of recombinant staphylokinase versus alteplase for coronary artery patency in acute myocardial infarction. The STAR Trial Group.

BACKGROUND: Recombinant staphylokinase (STAR) was shown recently to offer promise for coronary arterial thrombolysis in patients with evolving myocardial infarction. The present multicenter randomized open trial was designed to assess the thrombolytic efficacy, safety, and fibrin specificity of STAR relative to accelerated alteplase (recombinant tissue-type plasminogen activator [RTPA]). METHODS AND RESULTS: One hundred patients with evolving myocardial infarction of < 6 hours' duration and with ST-segment elevation were allocated to accelerated and weight-adjusted RTPA over 90 minutes (52 patients) or to STAR (the first 25 patients to 10 mg and the next 23 patients to 20 mg given intravenously over 30 minutes). All patients received aspirin and intravenous heparin. The main end points were coronary artery patency and plasma fibrinogen levels at 90 minutes. Thrombolysis in Myocardial Infarction (TIMI) perfusion grade 3 at 90 minutes was achieved in 62% of STAR patients versus 58% of RTPA patients (risk ratio, 1.1; 95% CI, 0.76 to 1.5). With 10 mg STAR, TIMI grade 3 patency was 50% (risk ratio, 0.86; 95% CI, 0.54 to 1.4 versus RTPA); with 20 mg STAR, it was 74% (risk ratio, 1.3; 95% CI, 0.90 to 1.8 versus RTPA). Residual fibrinogen levels at 90 minutes were 118 +/- 47% (mean +/- SD) of baseline with STAR and 68 +/- 42% with RTPA (P < .0005). STAR therapy was not associated with an excess mortality or electric, hemorrhagic, mechanical, or allergic complications. However, patients developed antibody-mediated STAR-neutralizing activity from the second week after STAR treatment. As an addendum to the randomized study, 5 patients were given 40 mg STAR over 30 minutes, resulting in TIMI perfusion grade 3 at 90 minutes in 4 patients without fibrinogen breakdown (residual levels at 90 minutes of 105 +/- 8% of baseline). CONCLUSIONS: STAR appears to be at least as effective for early coronary recanalization as and significantly more fibrin-specific than accelerated RTPA in patients with evolving myocardial infarction.

Plasma lipoprotein(a) values and severity of coronary artery disease in a large population of patients undergoing coronary angiography.

To determine possible associations between lipoprotein(a) [Lp(a)] and the severity of coronary artery lesions, we measured lipid, apolipoprotein, and Lp(a) in a large population of Belgian patients (n = 1054) undergoing coronary angiography. In both women and men, univariate analysis demonstrated significant differences in the Lp(a) concentrations according to the severity of the coronary stenosis. However, after adjustment for possible confounding factors, many of these differences were attenuated, indicating that other variables that differentiate patients from control subjects also influence Lp(a) distribution. Differences in lipid, apolipoprotein, and Lp(a) concentrations between male and female patients are discussed.

Brachial, radial, or femoral approach for elective Palmaz-Schatz stent implantation: a randomized comparison.

UNLABELLED: From October 1994 to November 1995, 150 male eligible patients were randomly assigned to Palmaz-Schatz stent implantation through 6 French catheters using the femoral (puncture) (n = 56), radial (puncture) (n = 56), or brachial (cutdown) (n = 38) approach at 6 participating Belgian centers. Acenocoumarol was given for 1 month after stenting. END POINTS: Primary-entry site complications (bleeding, haematoma, transfusion, occlusion, surgery) poststent implantation. Secondary-success rate, stent thrombosis, Q or non Q wave MI, repeat PTCA, CABG, CVA, haemorrage, death. There were no statistically significant differences between the three groups for base line and angiographic patient characteristics, procedural characteristics, in hospital outcome, average hospitalisation time after stenting, events during the month after stenting, or local complications at 1 month follow-up. The only statistically significant difference was the arterial time of the procedure: mean +/- SD (minutes) brachial 31.0 +/- 10.02 *P < 0.001, femoral 42.2 +/- 21.8, radial 55.8 +/- 31.3 **P < 0.0001 (*brachial vs. femoral, **brachial vs. radial). There was a clear trend toward more technical difficulties and more problems with the radial approach. In each group: vascular surgery at entry site: 0%, blood transfusion: 0%. In our study, local complications and length of hospital stay were similar with the three possible approaches, and brachial approach was associated with a shorter arterial time.