The fantastic journey of a bullet: out with a snare.

Bullet embolus is a rare complication of penetrating missile trauma. Removal of the bullet previously required surgery. We report the case of a 14-year-old with an hepatic vein bullet embolus following a gunshot wound to the left buttock. A transjugular approach was used to extract the bullet percutaneously with an Amplatzer gooseneck snare.

Use of rituximab to decrease panel-reactive antibodies.

Patients with pre-formed antibodies may be at increased risk of rejection after organ transplantation. In this report, we describe the use of rituximab to decrease the percentage of pre-formed antibodies in a pediatric heart transplant recipient.

Aberrant coronary arteries: a reliable echocardiographic screening method.

BACKGROUND: Aberrant origin (ABO) of a coronary artery (CA) from the contralateral aortic sinus with a subsequent interarterial course is a life-threatening condition. It carries a 28% to 55% risk for a sudden coronary event or death, but there are no reliable screening methods. OBJECTIVE: We sought to determine whether imaging a cross section of a coronary segment in the anterior aortic wall on the long-axis view may be used as an echocardiographic screening sign for ABO CA. METHODS: The echocardiograms of all patients with ABO CA were evaluated for the screening sign and compared with those of age-matched control patients. RESULTS: Between January 1989 and October 2002, we identified 8 patients with ABO CA (median age: 15 years). Of these patients, 4 were symptomatic and 4 were discovered incidentally. The electrocardiogram produced normal findings in 5 of 8 patients, maximal stress test produced normal findings in 5 of 6 patients, and thallium perfusion test produced negative results in 2 of 3 patients. There were 4 patients with ABO in the main left CA, 3 with ABO in the right CA, and 1 with ABO in the circumflex CA branch. The screening sign was readily visible in 7 of the 8 patients (88%), and all 7 of these patients had ABO in a main CA. Only in the ABO in the circumflex CA branch was the screening sign not detected. The 1743 control patients (median age: 14 years) showed normal anterior aortic wall, which was void of any CA segment. In 5 control patients (0.3%, P <.001) the normal right CA was visible on the long-axis view, but was not confused for a false-positive screening sign. CONCLUSION: We concluded that the proposed screening sign for ABO CA is reliable and easily recognizable, and should prompt a comprehensive assessment of the CA.

Severe aortic coarctation in infants less than 3 months: successful palliation by balloon angioplasty.

The optimal management strategy of the neonate and young infant with native aortic coarctation (AC) is controversial. We reviewed our experience with balloon angioplasty (BA) in neonates and infants 3 months to test our thesis that BA provides successful palliation, defined as avoidance of surgery for 4 weeks along with control of presenting symptoms. We also compared the results of the transumbilical arterial (UA), transfemoral arterial (FA) and transfemoral venous anterograde (FVA) approaches we have used to accomplish BA. During a 6.5-year period ending June 2001, fifty-one neonates and infants 3 months presenting with heart failure, hypertension or both underwent UA (n = 16), FA (n = 26) and FVA (n = 9) balloon coarctation angioplasty. Immediate and follow-up results were evaluated. Acute reduction of peak-to-peak gradients across the coarctation (40 17 mmHg vs. 5 6 mmHg; p < 0.001), increase in diameter of the coarcted segment (2.2 0.5 mm vs. 5.6 0.8 mm; p < 0.001) and improvement in symptomatology occurred following BA. Surgical relief of aortic obstruction was required in 4 infants at 5, 21, 24 and 28 days after the procedure. Effective palliation was thus achieved in the remaining 47 infants (92%). During intermediate-term follow-up, twenty-two infants (50%) developed recoarctation requiring repeat balloon (n = 14) or surgical (n = 8) intervention 2 10 months (median, 3 months) after initial BA. The indication for reintervention was hypertension in all patients. At a median follow-up of 3 years (range, 0.5 5.5 years), blood pressures remained low (98 11 mmHg) with an arm/leg blood pressure gradient of 4 6 mmHg. Comparison of the groups revealed similar effectiveness both immediately and at follow-up. However, femoral artery complications were seen in only the FA group. Based on these data, we conclude that effective palliation is achieved with BA in all 3 groups, femoral artery complications are seen only in the FA group and BA is an excellent alternative to surgical intervention in the management of native AC in neonates and young infants.

Early renal benefit of rapamycin combined with reduced calcineurin inhibitor dose in pediatric heart transplantation patients.

BACKGROUND: Calcineurin inhibitors such as cyclosporine are effective in preventing rejection in recipients of solid organ transplants. Unfortunately, the prolonged use of calcineurin inhibitors may result in progressive renal injury. METHODS: We studied the renal function of 15 pediatric heart transplant recipients who were taking calcineurin inhibitors. Their renal function was studied before and after rapamycin was introduced to their immunosuppression regimen. With the introduction of rapamycin, the patients were given a lower dose of calcineurin inhibitors, and the calcineurin inhibitor was discontinued in 5 patients. RESULTS: Renal function improved significantly in the patients by 30 days after these changes in the calcineurin inhibitor dose were instituted. Mean levels of blood urea nitrogen and mean serum creatinine decreased, and mean creatinine clearance increased. Pre-rapamycin, the patients' mean level of blood urea nitrogen was 27.1 +/- 12.4 mg/dl and post-rapamycin they decreased to 18.6 +/- 11.1 mg/dl (p = 0.014). Similarly, creatinine decreased from 1.0 +/- 0.5 mg/dl to 0.8 +/- 0.3 mg/dl (p = 0.019). Their creatinine clearance increased from 88 +/- 28 ml/min/1.73 mol/liter2 to 105 +/- 27 ml/min/1.73 mol/liter2 (p = 0.008). The patients' lipid levels did not change after they were prescribed rapamycin. Biopsy-negative rejection developed in 2 patients. CONCLUSIONS: The introduction of rapamycin to the immunosuppressive regimen of patients taking calcineurin inhibitors, with a concomitant reduction of the calcineurin inhibitor dose, may improve renal function within 30 days, without a significant increase in rejection.