[Pacemaker implanted in right inguinal region following removal of infected generator; report of a case].

We treated a 62-year-old male who had previously undergone a mitral valve plasty and aorto-coronary bypass. One year after the operation, he underwent pacemaker implantation for atrial fibrillation. Two months following implantation, the pacemaker generator was exposed due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. We selected a new catheter route from the right saphenous vein, and implanted a generator under the fascia of the external oblique abdominal muscle. Thereafter, the pacemaker is functioning without trouble and there is no evidence of infection.

[Non-compromised grafting policy in off-pump coronary artery bypass].

BACKGROUND: The off-pump coronary artery bypass (OPCAB) has been prevalent around the world. However the most optimal selection of graft conduits has still been controversial. METHODS: Between January 2002 and April 2003, 126 consecutive isolated coronary artery bypass procedures were attempted to performed without cardiopulmonary bypass. A mean age of the patients was 69.3 (47-90). Fifteen patients were operated on emergently and 16 were urgently, including 15 patients requiring preoperative intra-aortic balloon pumping (IABP). Five patients underwent reoperative coronary bypass. RESULTS: All procedures were completed without cardiopulmonary bypass. The mean number of grafts per patient was 3.23 (range, 1 to 6). The skeletonized arterial conduits were aggressively used [117 left internal mammary artery (LIMA) to 155 sites, 70 right internal mammary artery (RIMA) to 79 sites, 57 right gastro-epiploic artery (RGEA) to 82 sites and 49 saphenous vein (SV) to 91 sites]. Cardiac-related hospital mortality was none. Angiographic assessment of grafts demonstrated that patency of LIMA, RIMA, RGEA and SV were 98.6%, 100%, 100%, and 97.6% respectively. CONCLUSION: OPCAB with skeletonized in situ arterial conduits is secure and feasible.

Global experience in cervical carotid artery stent placement.

The purpose of this article is to review and update the current status of carotid artery stent placement in the world. Surveys to major interventional centers in Europe, North and South America, and Asia were initially completed in June 1997. Subsequent information from these 24 centers in addition to 12 new centers has been obtained to update the information. The survey asked the various questions regarding the patients enrolled, procedure techniques, and results of carotid stenting, including complications and restenosis. The total number of endovascular carotid stent procedures that have been performed worldwide to date included 5,210 procedures involving 4,757 patients. There was a technical success of 98.4% with 5,129 carotid arteries treated. Complications that occurred during the carotid stent placement or within a 30-day period following placement were recorded. Overall, there were 134 transient ischemic attacks (TIAs) for a rate of 2.82%. Based on the total patient population, there were 129 minor strokes with a rate of occurrence of 2.72%. The total number of major strokes was 71 for a rate of 1.49%. There were 41 deaths within a 30-day postprocedure period resulting in a mortality rate of 0.86%. The combined minor and major strokes and procedure-related death rate was 5.07%. Restenosis rates of carotid stenting have been 1.99% and 3.46% at 6 and 12 months, respectively. The rate of neurologic events after stent placement has been 1.42% at 6-12-month follow-up. Endovascular stent treatment of carotid artery atherosclerotic disease is growing as an alternative for vascular surgery, especially for patients that are high risk for standard carotid endarterectomy. The periprocedure risks for major and minor strokes and death are generally acceptable at this early stage of development and have not changed significantly since the first survey results. Cathet. Cardiovasc. Intervent. 50:160-167, 2000.

Transcatheter embolization of congenital coronary arterial fistulas in adults.

In this report, we describe our experience with transcatheter occlusion of congenital coronary arterial fistulas in adults. From November 1992 to November 1996, 5 symptomatic patients, aged from 47 to 70 years, underwent transcatheter occlusion of fistulas using a retrograde arterial approach. All had chest pain or dyspnea on exertion. Detachable balloons were used in 4 patients, and Gianturco coils in 1. Detachable balloons were implanted through a Debrun system, while the coils were implanted through a 5 French right coronary Judkins catheter. Both were passed through an 8 French guiding catheter (Amplatz II). Each patient had a single fistula. The fistulas originated from the right coronary artery in 3 patients, and from the circumflex artery in 2. They drained into the pulmonary trunk in 3 patients, into the right atrium in 1, and into a bronchial artery in the other. All fistulas were occluded completely in the catheterization laboratory, and the procedures were uncomplicated. At follow up, 3 patients underwent coronary angiography, and there was no evidence of recanalization. Transcatheter embolization in adults of single congenital coronary fistulas with detachable balloons and coils is safe and effective and can be regarded as an acceptable alternative to surgery.

[Assessment of internal thoracic artery grafts using duplex scanning].

In an effort to develop a noninvasive method to evaluate flow characteristics of the internal thoracic artery grafts (ITAG) after coronary artery bypass grafting, we performed duplex scanning of ITAGs of 51 patients who underwent bypass grafting. The ITAG was visualized with a duplex scanner of 7.5 MHz through the first or second left intercostal space. The visualization of the ITAG was adequate to make reliable measurements in 47 patients (92.2%). The diameter of the vessel, systolic peak velocity, and diastolic peak velocity were recorded, and systolic flow volume, diastolic flow volume, velocity ratio, flow volume ratio, and diastolic flow volume fraction were calculated. The velocity ratio, flow volume ratio, and diastolic flow volume fraction were markedly higher in the unstenotic subjects than in the stenotic subjects. In the group in which severe LAD stenosis were recognized preoperatively, both systolic and diastolic flow volumes were increased compared with moderately stenotic group. No differences in flow characteristics could be demonstrated between the subjects with old anterior myocardial infarction and without it. In 10 patients in whom flow pattern was abnormal or not identified, angiography revealed graft stenosis or predominant native coronary arterial flow. Duplex scanning is thought to be a reliable, sensitive, and noninvasive technique for the assessment of the ITAG.

[Prosthetic valve replacement in children].

Between 1975 and 1998, 27 patients aged 3 months to 14 years underwent replacement of the aortic, mitral, tricuspid, and pulmonary valves. Five different types of prosthetic valves were used; three were mechanical valves and two were bioprosthetic valves. There were 3 hospital deaths. Among the 24 survivors there were 4 late deaths. Arrhythmia requiring pacemaker implantation occurred in 2 cases after AVR and TVR. Thromboembolic events occurred in 3 patients, all with mechanical valves in pulmonary position. Infective endocarditis occurred in 1 patient after PVR with a mechanical valve. No bleeding complication occurred among the patients on a regimen of Coumadin and Dipyridamole. Two patients, both with Hancock bioprosthesis, required a second valve replacement on account of severely calcified changes. Mechanical valves in left side heart had a satisfactory long-term performance. One patient who had undergone MVR for congenital parachute mitral valve received reoperation for growth. A larger sized prosthetic valve should be used at the first replacement, and special procedures including supra-annular positioning or annular augmentation are recommended for MVR or AVR respectively.

VIPergic innervation of diabetic pancreas in rats.

Morphological, ultrastructural, and immunocytochemical studies of nerves containing vasoactive intestinal peptide (VIP) are described in diabetic pancreas of rats after streptozotocin treatment. The observations covered 48 hours and 6 months following streptozotocin treatment. At the ultrastructural level, degenerative changes were already observed in axons of nerve ganglia in the pancreas 48 hours (early stage) after streptozotocin treatment. These changes were hardly detected at the light microscopic level and VIP-like immunoreactivities were seen in nerves and fibers in such pancreas. The nerve ganglia were almost absent in the diabetic pancreas 6 months after streptozotocin treatment (late stage). Associated with the absence of nerve ganglia, nerves and fibers containing VIP-like immunoreactivities were also absent at this late stage. The findings indicated that the changes in the diabetic pancreas were neuropathic caused by metabolic disturbance after long standing diabetes and resulting absence of VIP-like immunoreactive nerves occurred. It was suggested from the present study that the changes in nerve ganglia began as damage at the ultrastructural level due to acute toxicity of the chemical at an early stage and then developed destruction and absence at a late stage.