Hemodynamic compromise (tricuspid stenosis and insufficiency) caused by an unruptured aneurysm of the sinus of Valsalva.

A patient is described with an unruptured aneurysm of the noncoronary sinus of Valsalva that occupied the right ventricular inflow tract and caused dynamic tricuspid stenosis and insufficiency. Results of two-dimensional echocardiography delineated the anatomy of the aneurysm and pulsed Doppler examination provided evidence that the aneurysm was unruptured. The unruptured aneurysm was resected successfully.

Carcinoid heart disease: a clinical pathologic, and therapeutic update.

The carcinoid syndrome is a rare clinical entity, the unique manifestations of which continue to excite the interest of physicians. Despite a common origin from neural crest tissue, the tumors are partially differentiated, as evidence by the different secretory products of foregut, midgut, and hindgut carcinoids. They also differ in their ability to metastasize, thus presenting an even more varied clinical picture. The prognosis of patients with carcinoid syndrome varies with the origin of the tumor and extent of metastases. The management of patients with carcinoid syndrome is difficult. Despite an understanding of the neurohormones that carcinoid tumors secrete, their various antagonists and inhibitors have been only partially successful in providing symptomatic relief. Carcinoid heart disease represents the most intriguing aspect of this syndrome. Although valvular dysfunction most often coexists with flushing and diarrhea, the findings of tricuspid regurgitation or stenosis occasionally provide the first clue to the presence of the disease. Despite intensive research, the definite etiology of these valvular lesions has not been established. A small group of patients has been managed by valve replacement. While surgical treatment has been successful in improving hemodynamics in most of these patients, it is expected to prolong life only in those without extensive liver metastases. In patients with extensive metastatic disease, one must carefully consider whether the risks and trauma of cardiac surgery for palliation are justified.

An unusual complication of left ventricular pseudoaneurysm: hemoptysis.

Left ventricular aneurysm is a common sequela of anterior myocardial infarction. At the time of coronary artery bypass grafting, resection of this aneurysm is frequently undertaken to alleviate symptoms of heart failure and/or refractory ventricular tachycardia. Complications related to aneurysmectomy are uncommon. We describe an unusual patient who presented with hemoptysis related to the formation of a pseudoaneurysm which communicated with the lung parenchyma. The etiology of the pseudoaneurysm formation was an indolent, slow-growing infection.

Chloroquine-induced cardiomyopathy.

Biventricular hypertrophy and failure developed in two patients during treatment of systemic lupus erythematosus with chloroquine phosphate. In both patients, morphologic analysis of the myocardium, obtained by a right ventricular endomyocardial biopsy in one patient and at autopsy in the other, revealed accumulations of electron-dense concentric and parallel lamellae and curvilinear bodies within cardiac myocytes. These deposits were similar to those reported in chloroquine-induced skeletal myopathy and were considered to represent evidence of chloroquine-induced cardiotoxicity rather than a cardiovascular manifestation of the underlying disease. Clinical awareness and an endomyocardial biopsy specimen are necessary for the appropriate diagnosis of chloroquine-induced cardiomyopathy.

The pathogenesis and prognosis of end-stage heart disease.

The final outcome of many forms of heart disease is congestive heart failure (CHF), a condition in which the heart can no longer pump enough blood to fulfill the body's metabolic requirements. Systolic heart failure is characterized by an impairment of myocardial contractility, whereas diastolic heart failure results from the left ventricle's inability to distend normally. The general features of CHF include pressure or volume overload, muscle loss, decreased myocardial contractility, or restrictive filling. Treatment is palliative, and 50% of the patients with CHF can be expected to die within 5 years; the mortality is much higher in those with coronary disease or limiting symptoms. The following signs are associated with a particularly poor prognosis: age > 55 years, cardiomegaly, a cardiac index of < 3, a left-ventricular end-diastolic pressure of > 20 mmHg, an ejection fraction of < 30%, a thin ventricular wall, dyspnea, and evidence of atrial fibrillation or ventricular tachycardia. Because of their high mortality, many of these patients eventually become candidates for cardiac transplantation.

Left stellate ganglionectomy for the long Q-T interval syndrome: nine-year follow-up of a patient.

Ventricular arrhythmias in patients with the long Q-T interval syndrome remain difficult to treat. In 1972, the first left stellate ganglionectomy was performed successfully to alter the pattern of ventricular recovery with control of ventricular arrhythmias. To date, no long-term evaluation has been carried out in any patients who have undergone left stellate ganglion removal for control of life-threatening arrhythmias. We report the case of a 52-year-old woman previously afflicted with idiopathic prolongation of the Q-T and syncope 9 years after successful partial ablation of the left stellate ganglion for the control of ventricular tachyarrhythmia.

Tandem stenting of crossed renal arteries with ostial stenosis.

Ostial stenosis of renal arteries has been shown to respond favorably to stenting. Heterogeneity of renal artery anatomy is very common and often increases the technical difficulty of percutaneous treatment of stenotic lesions. We present the case of a 69-year-old man with severe hypertension who had 2 right renal arteries, both of which had ostial stenosis. We treated these stenoses with simultaneous stenting of both renal ostia. Since the procedure, the patient has had significantly improved control of his hypertension.

Congestive cardiomyopathy presumably secondary to oxacillin.

A patient developed congestive cardiomyopathy after a long-term course of oxacillin. When the drug was discontinued, cardiac function returned to normal. The summary of clinical findings strongly suggested a cause-and-effect relationship between the intake of oxacillin and the deterioration in myocardial contractility.

Unusual electrocardiographic presentation of right ventricular myocardial infarction.

Isolated right ventricular infarction is uncommon, but when it occurs its prompt recognition may alter therapy substantially. Electrocardiographic changes accompanying acute right ventricular infarction are variable and may be difficult to recognize. The case of a 40-year-old man who had right ventricular infarction with unusual electrocardiographic findings is presented. The clinical, hemodynamic, and electrocardiographic findings of right ventricular infarction are discussed.

Endovascular exclusion of abdominal aortic aneurysms: initial experience with stent-grafts in cardiology practice.

The use of an endovascular stent-graft prosthesis for the treatment of infrarenal abdominal aortic aneurysms is receiving increasing attention as an option that may avoid the significant morbidity and mortality associated with open surgical treatment. We studied the clinical effectiveness of stent-grafts in patients with infrarenal abdominal aortic aneurysms. Between October 1995 and May 1998, 33 patients underwent infrarenal abdominal aortic aneurysm exclusion with a homemade polytetrafluoroethylene-covered stent, and between November 1998 and September 1999, 56 patients underwent abdominal aortic aneurysm exclusion with the Medtronic AneuRx stent-graft. Overall, these patients represented a high-risk surgical group. The technical success rate was 100% in both groups. No patient required immediate conversion to open repair. With the polytetrafluoroethylene-covered stent, the primary success rate was 33%, and the secondary success rate was 76%. In the AneuRx group, the primary success rate was 82.8%, and the secondary success rate was 85.3% at 6 months. There was no procedural or 1-month mortality or major morbidity in either group. By showing that infrarenal abdominal aortic aneurysms can be treated safely and successfully with an endoluminal stent-graft, our early results provide additional support for the endovascular treatment of abdominal aortic aneurysms. Further follow-up studies will determine the long-term ability of such treatment to prevent aneurysmal rupture and death.

Carotid stenting for post-endarterectomy restenosis and radiation-induced occlusive disease.

Surgical treatment of carotid restenosis and radiation-induced occlusive disease is challenging because of the high morbidity and mortality associated with this procedure. Carotid stenting has been proposed as an alternative approach. We report a series of 8 patients who were treated via the percutaneous approach for either carotid restenosis (n = 4) or radiation-induced occlusive disease (n = 4). Technical success was achieved in all of the cases. There have been no deaths or strokes during the periprocedural or follow-up period. After dilation of the extracranial vessel, 1 patient experienced severe intracranial internal carotid arterial spasm that required stent placement. Wallstents were used in 6 patients and S.M.A.R.T. stents were used in the remaining 2. Restenosis occurred in 2 patients and was treated successfully with redilation or restenting. Carotid stenting appears to be a feasible and safe alternative to surgery for restenosis after carotid endarterectomy and for radiation-induced occlusive disease.

Successful thrombolysis for prosthetic pulmonary valve obstruction.

Thrombosis is a serious complication of prosthetic heart valve operations. In recent years, systemic thrombolysis has emerged as a suitable alternative to surgery. Experience with thrombosis of pulmonary prosthetic valves is very limited. We report a case of successful administration of intravenous streptokinase for thrombosis of a St. Jude Medical prosthetic valve 3 weeks after pulmonary valve replacement.

Cardiac Kaposi's sarcoma following heart transplantation.

Kaposi's sarcoma (KS) is a tumor seen with increased frequency in organ transplant recipients. We present a case of disseminated KS in a heart transplant recipient of Mediterranean origin in whom myocardial involvement was suspected on the basis of coronary angiographic and magnetic resonance imaging (MRI) findings. KS in the transplant population and cardiac KS are reviewed. Cathet. Cardiovasc. Intervent. 49:208-212, 2000.