Superior vena cava syndrome due to thrombotic occlusion in a thrombophilic renal transplant recipient: a case report.

The case of a superior vena cava syndrome due to a central venous catheter thrombosis occurring in a second renal transplant patient is described. Imaging revealed thrombosis of the right internal jugular vein with extension along the confluence of the brachiocephalic veins and partial obstruction of the superior vena cava. Anticoagulant therapy with subcutaneous low-molecular-weight heparin was followed by warfarin administration. Despite adequate treatment, the symptomatology worsened because of thrombus organization. A workup revealed a complex prothrombotic underlying condition. Cardiothoracic surgeons were consulted, and an operative reconstruction of the superior vena cava using spiral vein bypass grafting was performed. In this report we describe the clinical presentation, diagnosis, and treatment of this case, with an emphasis on the role of thrombophilia.

Usefulness of transesophageal echocardiography in the assessment of aortic dissection.

The acute dissection of the ascending aorta requires prompt and reliable diagnosis to reduce the high risk of mortality; in addition, prognosis is influenced by long-term complications. The aim of this article is to discuss transesophageal echocardiography (TEE) and (1) its diagnostic accuracy in the presurgical evaluation of patients, (2) its role in reducing time of diagnosis and surgery, and (3) its ability to reduce hospital mortality. TEE has also been tested as a screening method in the postsurgical follow-up of these patients. The retrospective investigation concerns a sample of 80 cases of acute dissection of the aorta, submitted for surgical intervention from April 1986 to February 1999. TEE has allowed a precise estimation of aortic diameters and optimal visualization of intimal flap and tear entry with a fine distinction between true and false lumen. A direct comparison of the results of TEE and of transthoracic echocardiography has demonstrated that some elements (visualization of flap and diameters in descending aorta, sites of entry and reentry, direction of jet trough intimal tears, phasic intimal flap movement, diastolic collapse of flap on the valvular plane, false lumen thrombosis, coronary involvement, intramural hematoma, and aortic fissuration) were identified only by TEE, whereas other additional diagnostic elements (cardiac tamponade, aortic valve insufficiency, left ventricular function) show a similar pattern of significance. Routine employment of this method has confirmed a reduction of hospitalization time (about 1.5 hours of waiting time), and hospital mortality has changed from 42.8% to 17.3%. In the follow-up of patients operated on for aortic dissection, fundamental information may be obtained from TEE (assessment of the progression of thrombosis in the false lumen with its complete obliteration and modifications in aortic diameter with a consequent, possible worsening of aortic valve insufficiency). In conclusion, our study demonstrated that TEE may provide fast and efficient detection of acute aortic dissection. In the postsurgical follow-up, TEE has confirmed detection of major complications that can influence long-term prognosis and may be proposed as a method with easy access-one that is repeatable and inexpensive for the screening of aortic dissection surgical patients.

The role of magnesium on the structure of biological apatites.

X-ray diffraction, infrared absorption spectroscopy, and chemical investigation have been carried out on deproteinated samples of turkey leg tendon at different degrees of calcification. The inorganic phase consists of poorly crystalline B carbonated apatite. On increasing calcification, the apatite crystal size, as well as its thermal stability, increase while the relative magnesium content is reduced. On the other hand, synchrotron X-ray diffraction data clearly indicate that apatite lattice parameters do not change as the crystals get larger. At the last stage of calcification the crystal size, chemical composition, and thermal conversion of the apatite crystallites approximate those of bone samples, which have been examined for comparison. The results provide a quantitative relationship between relative magnesium content and extent of apatite conversion into B-tricalcium phosphate by heat treatment. Furthermore, they suggest that the smaller crystallites laid down inside the gap region of the collagen fibrils are richer in magnesium than the longer ones that fill the space between collagen fibrils.

Left ventricular aneurysm secondary to Behçet's disease.

A 16-year-old boy with Behçet's disease who was seen with thrombophlebitis of the leg was found to have coronary artery occlusion with postinfarction left ventricular aneurysm. Recurrent femoral artery aneurysms and orogenital ulceration developed in him. The diagnostic features together with successful treatment of this patient and a discussion of Behçet's syndrome are presented.

Central shunt and pulmonary valvotomy in the treatment of critical pulmonary stenosis.

Pulmonary valvotomy combined with a central shunt ("U shaped" Gore-tex graft) for palliative treatment of critical pulmonary stenosis is reported. The same graft was employed for right ventricular outflow reconstruction at the time of the definitive repair.

Anomalous origin of right pulmonary artery from the ascending aorta.

Anomalous origin of one pulmonary artery from the ascending aorta without associated intracardiac defects is a rare congenital malformation. About 60 anatomic and surgical descriptions have been reported in the literature. Up to 1974, 22 of the 50 reported cases underwent surgical correction with a 40% mortality rate. The natural history without surgery is poor with a very high mortality during the first year of life. Successful anatomic correction of anomalous origin of right pulmonary artery from the ascending aorta in a 6 months old female is reported.

Giant left atrium and mitral valve replacement: risk factor analysis.

Giant left atrium (GLA) associated with mitral valve disease (MVD) has been reported as a significant risk factor in mitral valve surgery with mortality ranging from 8%-32%. Plication of the left atrium has been suggested to reduce postoperative left ventricular failure, respiratory failure and mortality. The 203 consecutive patients with MVD operated upon between 1980 and 1986 were reviewed and divided in two groups: group A without GLA (165 patients) and group B with GLA (38 patients = 19%). The pertinent preoperative and intraoperative notes and the early and late postoperative course were reviewed and correlated. The hospital mortality was 2.4% in group A and 2.6% in group B. Late mortality, at a mean follow-up of 54 months was 4.3% in group A and 5.4% in group B. In this series, GLA was not a significant risk factor in MVR and did not affect early and late results as compared with cases without GLA. Plication may not be required in absence of extracardiac signs of compression.

Cardiorespiratory effects of protamine sulphate in man: intra-aortic vs intra-right atrial rapid administration after cardiopulmonary bypass.

The effects of protamine sulphate on several cardiorespiratory variables were studied under clinical situations in twenty patients following cardiopulmonary bypass. Because recent reports suggest that there may be advantages of intra-aortic versus intra-venous administration we prospectively evaluated cardiorespiratory features 1 and 10 minutes after rapid administering of protamine sulphate either into the aortic arch (through a catheter percutaneously inserted via the radial artery for monitoring purposes) or into the right atrium. Significant variations in some parameters were found in the patients receiving the drug via the aorta, such as a drop of systemic vascular resistances (p less than 0.05), of coronary perfusion pressure (p less than 0.05), of aortic systolic pressure (p less than 0.01), of diastolic (p less than 0.01) and mean blood pressure (p less than 0.05) and a rise in the respiratory quotient (p less than 0.05). It is concluded that the results do not confirm the superior safety of intra-aortic administration of protamine particularly when replenishment of intravascular volume is not provided.

Intracaval and intracardiac leiomyomatosis of uterine origin.

Intracaval leiomyomatosis of uterine origin is a rare disease. Extension to the right heart is exceptional. Based on the review of 11 cases reported in the literature and the case presented herein, which was treated successfully, the diagnostic and therapeutic problems are discussed. Diagnosis should be suggested when a female patient operated on previously for myofibroma of the uterus by hysterectomy, presents with a picture of cardiac myxoma. Diagnosis can be confirmed by iliocavogram and computerized tomography of the abdomen. Excision calls for a cardiac procedure under extracorporeal circulation and caval exploration which may be performed either simultaneously or as a two stage procedure.