Pregnancy after uterine artery embolization: a case report in a woman with leiomyomata.

Background. Several pregnancies have been reported after embolization of uterine artery. This procedure is an accepted nonsurgical treatment for symptomatic uterine fibroids but its safety in women desiring future childbearing is not well established. Case Report. We present a 40-year-old woman with leiomyomata who became pregnant after previously undergone uterine artery embolization for three times. The placenta was previa and the fetus was in transverse position. She had a cesarean delivery of an appropriately grown fetus at 37 weeks, which was followed by uterine atony requiring hysterectomy. Conclusion. Although pregnancy-related outcomes remain understudied, the available reports evidence that pregnancies after uterine artery embolization may be at significantly increased risk for postpartum hemorrhage, cesarean delivery, abnormal placentation, and malpresentation. In patients who are undergoing this type of treatment and contemplating pregnancy, the possibility of adverse complications should be taken in consideration and women should be appropriately advised.

Fetal vulvar cysts with spontaneous resolution.

Congenital anomalies of the external genitalia occur in 2-3 per 100 infants. These anomalies might bring variable degrees of morbidity to the infant and often constitute diagnostic challenges for health professionals. We present a case report of a fetus with bilateral vulvar cysts diagnosed during the third trimester ultrasound. The cysts spontaneously regressed before birth and the newborn showed no genital anomalies at birth.

Implications for single phase prospective CT coronary angiography for the diagnosis of significant coronary stenoses in clinical practice.

BACKGROUND: CT coronary angiography (CTA) with 64 slice multi-detector CT (64-MDCT) has assumed an increasing role in clinical practice; however the high radiation dose associated with retrospective ECG-gated CTA has led to suggestions that a low dose prospectively gated strategy may be more appropriate. This study aims to assess the feasibility of this proposed strategy amongst standard referral for CTA in our centre. METHODS: We retrospectively analyzed 200 consecutive clinical CTA studies assessing the number of cardiac phases required to allow full diagnostic visualisation of the coronary tree. We assessed whether the pre-test likelihood of coronary disease, heart rate, heart rate variability and range, current beta-blockers use, coronary calcium score, breathing artefact or study quality affected the number of phases required. RESULTS: 125/200 patients (62.5%) required only a single phase for full diagnostic visualisation of the coronary tree [most commonly 65% of the R-R interval-109/125 (87.2%)]. A successful diagnostic single cardiac phase was most likely in patients with a low heart rate (Heart rate < 70 bpm OR = 2.64; p = 0.003 and heart rate < 60 bpm OR = 4.81; p < 0.001 respectively) and low likelihood of coronary disease [OR = 1.97 95% CI (1.09, 3.58) p = 0.025]. CONCLUSION: High image quality is possible using single phase analysis in those patients with low likelihood of coronary disease, low heart rates and full cooperation with inspiratory breath hold. In patients with HR of <60, prospective ECG-gated acquisitions reduce radiation dose but may be non-diagnostic in as many as one third. Careful patient selection is therefore essential.

Imaging techniques in cardiac resynchronization therapy.

Cardiac resynchronization therapy is a high cost therapeutic option with proven efficacy on improving symptoms of ventricular failure and for reducing both hospitalization and mortality. However, a significant number of patients do not respond to cardiac resynchronization therapy that is due to various reasons. Identification of the optimal pacing site is crucial to obtain the best therapeutic result that necessitates careful patient selection. Currently, using echocardiography for mechanical dyssynchrony assessment performs patient selection. Multi-Detector-Row Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI) are new imaging techniques that may assist the cardiologist in patient selection. These new imaging techniques have the potential to improve the success rate of cardiac resynchronization therapy, due to pre-interventional evaluation of the venous coronary anatomy, to evaluation of the presence of scar tissue, and to improved evaluation of mechanical dyssynchrony. In conclusion, clinical issues associated with heart failure in potential candidates for cardiac resynchronization therapy, and the information regarding this therapy that can be provided by the imaging techniques echocardiography, MDCT, and MRI, are reviewed.

Cardiac involveent in type 1 myotonic dystrophy.

Myotonic dystrophy is a multisystem disorder in which cardiac involvement is common, particularly in conduction tissue. Its severity and symptoms vary, and so careful monitoring is required and a permanent pacemaker may need to be implanted. The aim of the study was to evaluate cardiac alterations and to correlate them with genetic (CTG expansion) and neurological data. Of the 46 patients studied, 80.4% presented asymptomatic cardiac conduction abnormalities but only one had impaired global systolic function, despite 32.6% having changes in left ventricular segmental contractility. Left ventricular noncompaction was found in 8 patients. Patients with greater CTG expansion had more severe neurological involvement and conduction abnormalities, and those with greater neurological disability had also more significant conduction tissue involvement.

Ambulatory electrocardiographic monitoring in type 1 myotonic dystrophy.

Myotonic dystrophy is a multisystemic disease, in which cardiac involvement is the second most common cause of death. Cardiac conduction tissue involvement is the most frequent, characteristically in a variably progressive and asymptomatic form. Careful surveillance through ambulatory monitoring is therefore needed, but with unknown periodicity. Our aim was to evaluate de novo changes on Holter monitoring performed at eight-month follow-up of a previously studied group of 36 patients with the genetic diagnosis of type 1 myotonic dystrophy, and to correlate them with genetic, neurological, and electrocardiographic data and risk factors for cardiac events. We found a high prevalence and variety of changes between baseline and follow-up Holter that justified permanent pacemaker implantation in 11 patients. In eight these were not documented in previous Holter readings. On the basis of our findings, we suggest that Holter monitoring in type 1 myotonic dystrophy patients should be performed on a regular basis, at intervals not greater than six months. Predictive parameters for the occurrence of these changes were not found.

Myxoma in the right ventricular outlow tract.

We present a patient with dyspnea, cyanosis and presyncope during exercise related to intermittent obstruction of the right outflow tract by a myxoma of the right ventricle attached to the membranous interventricular septum by its pedicle. We also review the specific medical and surgical features of such tumors. Right ventricular myxomas are rare benign tumors and clinical manifestations depend mainly on size and site of attachment. They can cause obstructive events, and embolism is also possible. Both forms of clinical presentation are potentially fatal and surgical removal should be urgently scheduled. This is usually curative, although recurrences have been reported, generally when these tumors are part of the Carney complex. The best surgical approach is individualized, and transesophageal echocardiography is an important tool in the decision. In our case right atriotomy was considered the best option.

Isolated pulmonary valve endocarditis due to Pseudomonas aeruginosa.

Isolated endocarditis of the native pulmonary valve is a rare clinical condition. It usually appears in association with certain predisposing factors, particularly intravenous drug abuse, alcohol abuse, sepsis, endovascular infections or congenital heart disease. The authors describe the case of isolated pulmonary valve endocarditis due to Pseudomonas aeruginosa of possible nosocomial origin in the absence of the predisposing factors mentioned above. Native pulmonary valve infection due to Pseudomnzonas aeruginosa in the absence of predisposing factors has not been described in the literature. The authors stress the importance of diagnosing this entity as early as possible as it is associated with high mortality and is on the increase due to the growing number of invasive procedures applied to patients in the hospital environment.

Noncompaction of ventricular myocardium.

Noncompaction of ventricular myocardium is a rare cardiomyopathy thought to be caused by arrest of normal embryogenesis of the endocardium and myocardium; its true prevalence is still uncertain. A strong association between noncompaction and neuromuscular disorders has been described. Its major clinical manifestations are heart failure, arrhythmias and systemic embolic events. Diagnosis of noncompaction of ventricular myocardium can be made by conventional two-dimensional and color Doppler echocardiography. Recently contrast echocardiography has been used to provide a definitive diagnosis in most cases in which conventional echocardiography could not do so. We describe the case of a patient with clinical suspicion of noncompaction of ventricular myocardium established by conventional two-dimensional and color Doppler echocardiography and definitive diagnosis, as well as additional information, obtained by cardiac magnetic resonance imaging. We also discuss the difficulties in defining the therapeutic approach.

Papillary fibroelastoma located deep in the left ventricle: case study and literature review.

The authors report a case of a 68-year-old male, with no known cardiac disease until he suffered a cerebral embolic event related to the presence of a papillary fibroelastoma located in the mid third of the inferior left ventricular wall. They also perform a literature review, particularly of the specific characteristics of the tumor and the surgical approach. They point out that the location of the fibroelastoma described is very unusual; its clinical and echocardiographic characteristics are similar to those described for fibroelastomas with this location and the surgical approach should be decided for each individual patient. Thus transaortotomy, which provided better visualization and enabled complete removal of the tumor (which is essential for good clinical evolution and to avoid recurrence), was the option for surgical removal of this tumor.

Familial apical hypertrophic cardiomyopathy with aneurysmal evolution--an unusual form.

The authors present the case of a 76-year-old patient with multiple vascular risk factors, admitted with acute coronary syndrome. The initial electrocardiogram was compatible with evolving anterior wall myocardial infarction and the echocardiogram showed an image interpreted in this context as left apical pseudoaneurysm. Complementary echocardiographic findings of atypical apical hypertrophy and echocardiographic screening performed on close relatives suggested apical hypertrophic cardiomyopathy as the most likely diagnosis, later confirmed by genetic study. This unusual presentation with evolution to ventricular aneurysm is probably due to progressive left ventricular apical remodeling and an echocardiographic image similar to that described points to the diagnosis of this entity. We emphasize the rarity of this phenotypic expression of apical hypertrophic cardiomyopathy, in particular with familial association.