Management of Late-Presenting Congenital Combined Heart Defect - Bicuspid Aortic Valve and Ventricular Septal Aneurysm.

BACKGROUND Bicuspid aortic valve is the most common congenital heart malformation, encountered in 1-2% of the population, while interventricular septal defect and patent ductus arteriosus are the most common congenital malformations associated with bicuspid aortic valve. Although bicuspid valve can have no clinical manifestation, patients with bicuspid valve are prone to develop vascular abnormalities. Aortic dilatation is the most common of these abnormalities, which in turn can lead to serious complications and often requires surgical treatment. Coexistence of bicuspid aortic valve and interventricular septal aneurysm is very extremely rare. CASE REPORT We present a very rare case of a female patient with combined congenital cardiac pathology. The patient was asymptomatic until age 68 years, and presented with nonspecific persistent cough. The diagnostic work-up for the unexplained cough showed normal function of the bicuspid valve and an ascending aorta aneurysm accompanied with interventricular septal aneurysm. The patient was referred for surgery. The diagnostic work-up and the decision for surgical treatment were thoroughly discussed to determine whether it was a true or a false aneurysm. CONCLUSIONS The presented case is an example of late diagnosis of a congenital cardiac defect. The silent evolution and the scarce clinical presentation led to incidental discovery of the pathology, which was fully assessed only by computed tomography. Although echocardiography is essential for discovering heart defects, non-invasive imaging techniques are required for detailed morphological assessment and for planning optimal surgical treatment.

Antibiotic treatment and resistance in chronic wounds of vascular origin.

BACKGROUND AND AIM: The problem of antibiotic resistance is worldwide and affects many types of pathogens. This phenomenon has been growing for decades and nowadays we are faced with a wide range of worrisome pathogens that are becoming resistant and many pathogens that may soon be untreatable. The aim of this study was to determine the resistance and antibiotic treatment in chronic wounds of vascular origin. METHODS: We performed a cross sectional study on a sample of patients with chronic vascular wounds, hospitalized between October 2014 and August 2015, in the Clinic of Vascular Surgery in Trakia Hospital Stara Zagora. The statistical analysis of data was descriptive, considering the p value of ≤0.05, the threshold of statistical significance. RESULTS: In the group of 110 patients, the significantly most frequent chronic wound (p<0.001) was peripheral arteriopathy (47.3%, CI95%: 38.19-56.54). Among 159 strains, 30% of patients having multiple etiology, the species most frequently isolated were Staphylococcus aureus, E.coli, Enterococcus faecalis, Pseudomonas aeruginosa and Proteus mirabilis with a significant predominance (p<0.05) of the Gram negative (55.1%). The spectrum of strains resistance included the Beta-lactams (36.4%, p<0.001), Macrolides (20%), Tetracyclines (9.1%), Aminoglycosides (8.2%) and Fluoroquinolones (4.5%). CONCLUSIONS: Gram negative microorganisms were the main isolates in patients with vascular chronic wound. Significantly predominant was the resistance to the beta-lactam antibiotics.

The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles.

OBJECTIVES: During unilateral selective cerebral perfusion (uSCP), with right axillary artery or brachiocephalic trunk cannulation, the brain receives blood only via the right common carotid artery and right vertebral artery (VA). The left hemisphere is perfused mainly through the circle of Willis (CW). However, at least 50% of individuals have some variation in the CW. The aim of the present work was to study the variations in CW and VA that could have an impact on haemodynamics during uSCP. METHODS: From May 2005 to March 2012, a total number of 250 circles obtained via routine dissection for medico-legal reasons were examined. The external diameters of all CW segments and both VAs were measured. From January 2008 to March 2012, a total number of 250 patients subjected to computed tomographic angiography of the CW were also examined. RESULTS: Nine evident configurations of the CW that could cause hypoperfusion during uSCP were observed. They were subdivided in to seven types, according to location and the number of major vessels at risk of hypoperfusion. Type IA: hypo/aplasia of left posterior communicating artery (PComA), found in 35.6% of cases; Type IB: hypo/aplasia of anterior communicating artery (AComA), found in 2% of cases; Type IIA: hypo/aplasia of both left PComA and AComA, found in 4.8% of cases; Type IIB: hypo/aplasia of precommunicating (P1) segment of left posterior cerebral artery or right VA, found in 9.2% of cases; Type IIIA: hypo/aplasia of precommunicating (A1) segment of right anterior cerebral artery, found in 6% of cases; Type IIIB: hypo/aplasia of both right VA and AComA, found in 0.2% of cases; Type IV: hypo/aplasia of both right A1 and right VA or both right A1 and left P1, found in 0.8% of cases. All types were present in 58.6% of all examined CWs. CONCLUSIONS: Our results show that CW variations are present in a significant number of patients. Our data support the need for extensive preoperative examination and meticulous intraoperative monitoring of cerebral perfusion during uSCP. Finally, our data support the superiority of bilateral SCP over uSCP, because most of the variations reported do not have haemodynamic significance during bilateral SCP.

Expression of ICAM-1, VCAM-1, E-selectin and TNF-alpha on the endothelium of femoral and iliac arteries in thromboangiitis obliterans.

Immunohistochemical light and electron microscopical analysis of surgical biopsies obtained from femoral and iliac arteries of patients with thromboangiitis obliterans (TAO) were performed to investigate the presence of tumour necrosis factor-alpha (TNF-alpha) and expression of the endothelial cell adhesion molecules intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin. Expression of ICAM-1, VCAM-1 and E-selectin was increased on endothelium and some inflammatory cells in the thickened intima in all TAO patients. Ultrastructural immunohistochemistry revealed contacts between mononuclear blood cells and ICAM-1-, and E-selectin-positive endothelial cells. These endothelial cells showed morphological signs of activation. The present data indicate that endothelial cells are activated in TAO and that vascular lesions are associated with TNF-alpha secretion by tissue-infiltrating inflammatory cells, ICAM-1-, VCAM-1- and E-selectin expression on endothelial cells and leukocyte adhesion via their ligands. The preferential expression of inducible adhesion molecules in microvessels and mononuclear inflammatory cells suggests that angiogenesis contributes to the persistence of the inflammatory process in TAO.