Multi-Modality Imaging of Coronary Artery Fistula with Giant Aneurysms.

A 50-year-old woman was referred to our hospital with a chief complaint of chest pain. Coronary angiography revealed a fistula between the left anterior descending artery and pulmonary artery with giant aneurysms. Although coronary angiography is considered the standard tool to confirm a coronary artery fistula, the patient in this case underwent successful surgical repair with the aid of multi-modality imaging.

Surgical management of left ventricular outflow tract obstruction after biventricular repair of double outlet right ventricle.

Regardless of the preoperative morphology and the type of operation, left ventricular outflow tract obstruction (LVOTO) after biventricular repair of double outlet right ventricle (DORV) may develop. This report presents our 10-yr experience with surgical management of LVOTO after biventricular repair of DORV. Between 1996 and 2006, 15 patients underwent reoperation for subaortic stenosis after biventricular repair of DORV. The mean age at biventricular repair was 23.3+/-18.3 months (1.1-64.2). Biventricular repairs included tunnel constructions from the left ventricle to the aorta in 14 cases and an arterial switch operation in one. The mean left ventricle-to-aorta peak pressure gradient was 54.0+/-37.7 mmHg (15-140) after a mean follow-up of 9.5+/-6.3 yr. We performed extended septoplasty in nine patients and fibromuscular resection in six. There were no early or late mortality. There was one heart block and one aortic valve injury after an extended septoplasty, and two and one after a fibromuscular resection. No patient required reoperation for recurrent subaortic stenosis. The mean pressure gradient was 11.2+/-11.4 mmHg (0-34) after a mean follow-up of 5.6+/-2.7 yr. Extended septoplasty is a safe and effective method for the treatment of subaortic stenosis, especially in cases with a long-tunnel shaped LVOTO.

Multi-modality imaging of a left atrial myxoma.

OBJECTIVES: Although echocardiography has traditionally been used to diagnose myxoma, invasive or non-invasive coronary angiography can be useful diagnostic tool before surgery. METHODS: We present a case of an angiographically detected left atrial myxoma feeding from the left circumflex coronary artery. RESULTS: The patient underwent open-heart surgery to remove the left atrial myxoma. After ligation of feeding artery, the mass was successfully excised. CONCLUSION: Preoperative coronary angiography can offer additional valuable information moreover detecting coronary artery disease. Because, there is sudden death risk from embolization during invasive coronary angiography, preoperative cardiac computed tomography angiography should be considered to plan the surgery of myxoma.

Bilateral skeletonized internal thoracic artery graftings in off-pump coronary artery bypass: early result of Y versus in situ grafts.

BACKGROUND: Use of bilateral skeletonized internal thoracic arteries (ITAs) in off-pump coronary artery bypass (OPCAB) retains several advantages that may eventually result in better patient outcomes. We compared the early results of OPCAB using bilateral ITAs as Y grafts with results of OPCAB using bilateral ITAs as in situ grafts. METHODS: A total of 223 consecutive patients who underwent OPCAB using bilateral skeletonized ITAs as Y grafts (group I, n = 113) or in situ grafts (group II, n = 110) were studied. RESULTS: Both the number of distal anastomoses per patient and the number of distal anastomoses per bilateral ITA were higher in group I (3.5 +/- 1.0 and 2.9 +/- 0.7) than in group II (3.0 +/- 0.7 and 2.4 +/- 0.5) (p < 0.01). Hospital mortality was 1.8% (2/113) in group I and 0.9% (1/110) in group II (p = ns). There were no differences in postoperative complications including atrial fibrillation (13.3% vs 10.9%), perioperative myocardial infarction (0.9% vs 2.7%), mediastinitis (0.9% vs 1.8%), and hypoperfusion syndrome (0.9% vs 0%) between groups I and II (p = ns). Postoperative coronary angiographies performed in 110 patients in group I and 108 patients in group II showed 99.0% (382/386) overall patency and 99.4% (319/321) patency for distal anastomoses using ITAs in group I, and 98.1% (312/318) overall patency and 98.1% (258/263) patency for distal anastomoses using ITA in group II. There were no significant differences in graft patency rates between the two groups (p = ns). CONCLUSIONS: Our results demonstrate that OPCAB using bilateral skeletonized ITAs is technically feasible, with excellent graft patency. Using bilateral skeletonized ITAs as Y grafts increases the number of distal anastomoses that can be performed and does not cause additional postoperative morbidity.

Off-pump coronary artery bypass with complete avoidance of aortic manipulation.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) with complete avoidance of aortic manipulation may further reduce perioperative morbidity in addition to the benefits achieved by avoiding cardiopulmonary bypass and cardioplegic arrest. METHODS: We prospectively analyzed 222 consecutive patients with multivessel disease who underwent OPCAB without aortic manipulation (group I), and compared them with 123 consecutive patients who underwent OPCAB using additional free arterial or saphenous vein grafts that were anastomosed on the ascending aorta (group II) and 76 consecutive patients who underwent on-pump conventional coronary artery bypass grafting (group III). RESULTS: No significant differences were noted in operative mortalities among the three groups (2/222, 3/123, and 2/76 in groups I, II, and III, respectively; p = NS). Fewer distal anastomoses were done in group I compared with groups II and III (3.2 +/- 0.9, 3.5 +/- 0.8, and 3.7 +/- 0.9 in groups I, II, and III, respectively; p < 0.001). No differences were noted in the incidences of postoperative morbidities such as mediastinitis, pulmonary complication, and reoperation for bleeding. The incidences of stroke, atrial fibrillation, and acute renal failure were significantly lower in group I than in group III (p < 0.05), although there were no significant differences between groups II and III. The incidence of perioperative myocardial infarction was significantly lower in group I than in groups II and III (p < 0.05), although there was no significant difference between groups II and III. CONCLUSIONS: Our results demonstrate that OPCAB with complete avoidance of aortic manipulation may further reduce the incidence of perioperative morbidities such as stroke, atrial fibrillation, acute renal failure, and perioperative myocardial infarction.

Surgical repair of retrograde type a aortic dissection after thoracic endovascular aortic repair.

It is expected that the stent graft will become an alternative method for treating aortic diseases or reducing the extent of surgery; therefore, thoracic endovascular aortic repair has widened its indications. However, it can have rare but serious complications such as paraplegia and retrograde type A aortic dissection. Here, we report a surgical repair of retrograde type A aortic dissection that was performed after thoracic endovascular aortic repair.

Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study.

BACKGROUND/AIMS: We investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy. METHODS: This retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis. RESULTS: There was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection. CONCLUSIONS: Our data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Clinicoradiologic characteristics and outcomes of metastatic cancer to the pancreas and double primary pancreatic cancer.

OBJECTIVES: The goal of this study was to identify clinicoradiologic characteristics to distinguish metastatic cancer to the pancreas (MCP) from double primary pancreatic cancer (DPPC). METHODS: From 2000 to 2011, we retrospectively identified MCP and DPPC patients among patients with histories of other primary malignancies. RESULTS: A total of 94 patients with histories of other primary malignancies were histologically confirmed to have pancreatic cancer. Among them, 34 patients had MCP and 60 patients had DPPC, which were ductal adenocarcinomas. The kidney was the most common primary cancer site that metastasized to the pancreas (12, 35.3%). In the DPPC group, the stomach was the most common primary cancer site (11, 18.3%). There were 21 patients (61.8%) with metachronous pancreatic cancer in the MCP group and 29 (48.3%) in the DPPC group (P=0.210). Among the metachronous pancreatic cancer patients, the disease-free interval was 88.3 months in the MCP group, and 49.6 months in the DPPC group (P=0.062). The number of the patients who showed elevated CA 19-9 levels was higher in the DPPC group than in the MCP group (39 (65%) vs. 9 (26.5%); P=0.001). Total bilirubin (P=0.006) and fasting plasma glucose (P=0.050) were also higher in the DPPC group. The numbers of patients who showed pancreatic duct dilatation (P=0.002) and pancreatic atrophy (P=0.008) on radiographs were meaningfully higher in the DPPC group than in the MCP group. On the other hand, the numbers of patients who showed well demarcated tumor margin (P<0.000), tumor necrosis (P=0.002), enhancement (P=0.005) and distant metastasis (P=0.028) were significantly higher in the MCP group than in the DPPC group. We evaluated differences in survival between the two groups. The median survival time in the MCP group (55 months) was significantly longer than that in the DPPC group (20 months). CONCLUSIONS: Other than elevated levels of CA 19-9, total bilirubin and fasting glucose, radiologic findings were the most reliable factors for distinguishing the MCP from the DPPC.

Influence of non-alcoholic fatty liver disease on the prognosis in patients with colorectal cancer.

BACKGROUND/AIM: Non-alcoholic fatty liver disease (NAFLD) is associated with multiple adenomatous polyps and advanced neoplasm. This study aims to investigate the influence of NAFLD on the tumor characteristics and prognosis in patients with colorectal cancer (CRC). METHODS: We analyzed 227 patients who were first diagnosed with CRC and underwent abdominal ultrasonography within six months prior to diagnosis at Samsung Medical Center between 2000 and 2005. RESULTS: Of the study population, 26.0% were diagnosed with NAFLD. Upon baseline comparison, CRC patients with NAFLD had higher BMI and ALT values than CRC patients without NAFLD (25.3 ± 2.7 vs. 22.6 ± 3.0, P=0.000 and 26.6 ± 17.4 vs. 21.2 ± 14.0, P=0.018, respectively). Additionally, CRC patients with NAFLD were diagnosed earlier than CRC patients without NAFLD (P=0.004). However, there were no significant differences between two groups with regard to location and differentiation of tumors, CEA or numbers of synchronous adenoma and advanced adenoma. The cumulative 1-, 3-, and 5-year survival rates in CRC patients with NAFLD were 98.3%, 89.8%, and 86.4%, respectively, which were higher but statistically not significant than 90.4%, 79.6%, and 74.8%, respectively, in CRC patients without NAFLD (P=0.079). During follow-up, freedom from recurrence was similarly observed in CRC patients with and without NAFLD (89.8% and 87.3%, respectively, P=0.614). CONCLUSIONS: The results of this study suggest that the presence of NAFLD does not influence on the prognosis in CRC patients, especially with respect to disease recurrence during follow-up.

Tricuspid valvular myxoma: unusual case of tricuspid valve myxoma mimicking thrombus after pulmonary artery embolectomy and tricuspid annuloplasty in pulmonary thromboembolism patient.

A 55-year-old man with massive pulmonary thromboembolism underwent thrombolysis, pulmonary artery embolectomy and tricuspid annuloplasty. Nine months later, a mobile echogenic intra-cardiac mass was found in the tricuspid valve. Because the patient had undergone annuloplasty, thrombosis was suspected as the most likely diagnosis and thrombolytic therapy was instituted. However, the size of the cardiac mass did not change and after surgical excision the mass was found to be a myxoma. Cardiac valvular tumors are uncommon and when they occur they are usually slow growing fibroelastomas. In this case, the rapid growing cardiac myxoma on the tricuspid valve was found after the occurrence of pulmonary thromboembolism. To our knowledge, this is first reported case of tricuspid valve myxoma in Korea.

Cardiac metastasis from colorectal cancer: a case report.

The heart is an unusual site of metastasis from any malignancy. We report a case of cardiac metastasis from colorectal cancer. A 70-year-old woman was referred with a presumptive diagnosis of sigmoid colon cancer with cardiac myxoma. Two-dimensional echocardiography showed a 4 cm x 4.5 cm mobile mass on the lateral right atrial wall, and computed tomography revealed a low attenuated lobulating mass in the right atrium. The patient underwent anterior resection for sigmoid colon cancer (T4N2). Thereafter, she experienced progressive shortness of breath. Therefore, a cardiac operation was performed 2 wk after the colorectal operation. Histological examination revealed adenocarcinoma, which was identical to the primary lesion. Although two-dimensional echocardiography has become the diagnostic test of choice for detecting cardiac tumors, in patients with colorectal cancer showing a cardiac mass, further diagnostic evaluation such as a magnetic resonance imaging might be necessary.

A case of very late stent thrombosis facilitated by drug eluting stent fracture: comparative images before and after stent fracture detected by 64-multidetector computed tomography.

A stent fracture (SF) is one of the responsible factors for in-stent restenosis after a percutaneous coronary intervention. Factors that have an important role for a SF are vessel tortuosity, the presence of a right coronary artery lesion, overlapping stents, and the use of a drugeluting stent (DES) such as a sirolimus-eluting stent. Unlike with the use of bare metal stents, most SFs have occurred with the use of DES, and a DES may be a possible factor for a SF. A SF can cause clinical problems that range from stable angina to acute coronary syndrome. We experienced a case of acute myocardial infarction that was combined with a SF. We describe here the coronary angiography findings and the 64-multidetector computed tomography images before and after the SF.

The clinical and radiological characteristics of focal mass-forming autoimmune pancreatitis: comparison with chronic pancreatitis and pancreatic cancer.

OBJECTIVES: We investigated the clinical and radiological features of focal mass-forming autoimmune pancreatitis (FMF AIP) to help physicians avoid performing unnecessary surgery because of an improper diagnosis. METHODS: We evaluated 23 patients with chronic inflammatory pancreatic masses and who underwent pancreatectomy for presumed pancreatic cancer from April 1995 to December 2005. These patients were distinguished into 8 FMF AIP patients and 15 ordinary chronic pancreatitis patients through a histological review, along with considering the immunoglobulin G4 staining. Twenty-six randomly selected pancreatic cancer patients were also evaluated as a control group. RESULTS: On the portal venous phase of computed tomography, 6 (85.7%) of 7 FMF AIP patients showed homogeneous enhancement, whereas only 3 chronic pancreatitis patients (25%) and none of the pancreatic cancer patients showed homogeneous enhancement (P < 0.001). None of the FMF AIP patients showed upstream main pancreatic duct dilatation greater than 5 mm or proximal pancreatic atrophy. CONCLUSIONS: For patients with a pancreatic mass, if their radiological images show homogeneous enhancement on the portal venous phase, the absence of significant upstream main pancreatic duct dilatation greater than 5 mm, and the absence of proximal pancreatic atrophy, then conducting further evaluations should be considered to avoid performing unnecessary surgery.

Catecholamine cardiomyopathy associated with paraganglioma rescued by percutaneous cardiopulmonary support: inverted Takotsubo contractile pattern.

A case of catecholamine cardiomyopathy associated with paraganglioma, which was rescued by percutaneous cardiopulmonary support system (PCPS), is presented. Unlike typical apical ballooning, transthoracic echocardiography and left ventriculography revealed severe left ventricular (LV) dysfunction and an abnormal contractile pattern, consisting of akinesis of the basal and midventricular segments and hyperkinesis of the apical segments. Because of the intractable cardiogenic shock, despite conventional treatment, PCPS was performed. The underlying disease was paraganglioma. Catecholamine excess may induce not only transient LV apical ballooning but also atypical LV ballooning without involvement of the LV apex. Early use of PCPS is important for the patient with a catecholamine crisis who is not stabilized by intra-aortic balloon pump as well as infusion of fluid and inotropic agents.

Hemodynamic changes during posterior vessel off-pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device.

BACKGROUND: Displacement of the heart to expose posterior vessels during off-pump coronary artery bypass may cause hemodynamic derangement. The aims of this study were (1) to elucidate the hemodynamic changes during off-pump coronary artery bypass for the obtuse marginal branch (OM) of the left circumflex artery; and (2) to compare the hemodynamic changes caused by a deep pericardial suture technique with those caused by a vacuum-assisted apical suction device for displacement of the heart. METHODS: Hemodynamic changes during posterior vessel off-pump coronary artery bypass were studied in a prospective randomized manner. A deep pericardial suture technique (group 1, n = 10) or a vacuum-assisted apical suction device (group 2, n = 10) was used to facilitate the exposure of the OM. Hemodynamic variables such as cardiac index, stroke volume index (SVI), mean arterial pressure, mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, heart rate, systemic vascular resistance, pulmonary vascular resistance, left ventricular stroke work index, and right ventricular stroke work index were monitored during off-pump coronary artery bypass. Hemodynamic data were obtained before revascularization of the left anterior descending coronary artery at a baseline (T0), 3 minutes after heart displacement for revascularization of OM (T1), 3 minutes after the beginning of OM grafting (T2), and 3 minutes after the completion of OM grafting and heart repositioning (T3). RESULTS: There were no significant differences in the baseline hemodynamic variables (T0) between the two groups. In group 1, SVI, cardiac index, left ventricular stroke work index, and right ventricular stroke work index decreased significantly, and central venous pressure and pulmonary capillary wedge pressure increased significantly, during displacement of the heart (T1, p < 0.05). In group 2, SVI decreased significantly, and central venous pressure, pulmonary capillary wedge pressure, and mean pulmonary artery pressure increased significantly during displacement of the heart (T1, p < 0.05). The percent changes of cardiac index, SVI, and right ventricular stroke work index during OM grafting (T2) in comparison with baseline values (T0) were significantly larger in group 1 than in group 2 (cardiac index, 73% +/- 12% versus 90% +/- 11%; SVI, 69% +/- 12% versus 86% +/- 8%; right ventricular stroke work index, 30% +/- 17% versus 71% +/- 25%, in groups 1 versus 2, respectively; p < 0.05). CONCLUSIONS: Displacement of the heart using either a deep pericardial suture technique or a vacuum-assisted apical suction device caused a significant decrease in SVI. The hemodynamic changes during OM grafting were smaller when using a vacuum-assisted apical suction device.