Thin-slice elbow MRI with deep learning reconstruction: Superior diagnostic performance of elbow ligament pathologies.

PURPOSE: With the slice thickness routinely used in elbow MRI, small or subtle lesions may be overlooked or misinterpreted as insignificant. To compare 1 mm slice thickness MRI (1 mm MRI) with deep learning reconstruction (DLR) to 3 mm slice thickness MRI (3 mm MRI) without/with DLR, and 1 mm MRI without DLR regarding image quality and diagnostic performance for elbow tendons and ligaments. METHODS: This retrospective study included 53 patients between February 2021 and January 2022, who underwent 3 T elbow MRI, including T2-weighted fat-saturated coronal 3 mm and 1 mm MRI without/with DLR. Two radiologists independently assessed four MRI scans for image quality and artefacts, and identified the pathologies of the five elbow tendons and ligaments. In 19 patients underwent elbow surgery after elbow MRI, diagnostic performance was evaluated using surgical records as a reference standard. RESULTS: For both readers, 3 mm MRI with DLR had significant higher image quality scores than 3 mm MRI without DLR and 1 mm MRI with DLR (all P < 0.01). For common extensor tendon and elbow ligament pathologies, 1 mm MRI with DLR showed the highest number of pathologies for both readers. The 1 mm MRI with DLR had the highest kappa values for all tendons and ligaments. For reader 1, 1 mm MRI with DLR showed superior diagnostic performance than 3 mm MRI without/with DLR. For reader 2, 1 mm MRI with DLR showed the highest diagnostic performance; however, there was no significant difference. CONCLUSIONS: One mm MRI with DLR showed the highest diagnostic performance for evaluating elbow tendon and ligament pathologies, with similar subjective image qualities and artefacts.

Optimization of a wheat small red bean double cropping system in South Korea.

Wheat (Triticum aestivum L.) and small red bean [Vigna angularis (Willd. Ohwi & Ohashi)] are the main ingredients of walnut-shaped "Hodugwaja". An innovative wheat small red bean double cropping system was evaluated in a rice field in the Cheonan region (Korea) to determine its effect on land use. The effects of different nitrogen levels, sowing dates, and density on growth, yield, and quality of wheat and small red bean were also investigated using selected wheat ('Keumgang', 'Sooan', and 'Goso') and small red bean ('Hongeon', 'Chungju', and 'Arari') varieties. The effect of different fertilizer treatments [N1 (50%, 6.6 kg/10a), N2 (100%, 8.8 kg/10a), and N3 (200%, 13.2 kg/10a)] were investigated for wheat, while the effect of sowing date and density were investigated for the small red beans. Our findings revealed that the best variety, sowing date, and nitrogen level combination for wheat small red bean double cropping system in Cheonan area is 'Goso' sown on October 26, N3 nitrogen application, and 'Chungju' sown on July 10 with high ridge cultivation, at a density of 60 × 15 cm. This system was the most ideal yielding 521.6 kg/10a (1000 m2) and 275 kg/10a of 'Goso' and 'Chungju', respectively. This pioneering research provides a reliable cultivation plan and theoretical basis for implementing the double cropping system of wheat small red beans in central Korea. Undeniably, this study also provides a basis for future field experiments on wheat planting patterns and small red bean fertilization.

Topographical measurement of the attachments of the central band of the interosseous membrane on interosseous crests of the radius and ulna.

BACKGROUND: To suggest a reasonable isometric point based on the anatomical consistency of interosseous membrane (IOM) attachment in association with topographic characteristics of the interosseous crests, the footprints of the central band (CB) of the IOM on the radial and ulnar interosseous crests (RIC and UIC) were measured. METHODS: We measured the distance from the CB footprints from each apex of both interosseous crests in 14 cadavers and the angles between the forearm axis of rotation (AOR) and the distal slopes of the RIC and UIC in 33 volunteers. RESULTS: The CB footprints lay on the downslope of both interosseous crests with its upper margin on average 3-mm proximal from the RIC's apex consistently in the radial length, showing normality (p>0.05), and on average 16-mm distal from the UIC's apex on the ulna without satisfying normality (p<0.05). The average angle between the UIC's distal slope and the AOR was 1.3°, and the RIC's distal slope to the AOR was 14.0°, satisfying the normality tests (p>0.05), and there was no side-to-side difference in both forearms (p<0.05). CONCLUSIONS: The CB attached to the downslope just distal to the RIC's apex constrains the radius to the UIC that coincides with the AOR of the forearm circumduction, maintaining itself both isometrically and isotonically.

Biomechanical Analysis of the Kirschner-Wire Depth of the Modified Tension Band Wiring Technique in Transverse Patellar Fractures: An Experimental Study Using the Finite-Element Method.

BACKGROUD: Modified tension band wiring is one of the most preferred surgical methods for transverse patellar fractures. However, the optimal depth or sagittal position of a Kirschner wire (K-wire) in modified tension band wiring has yet to be determined. The purpose of this study was to evaluate whether the depth of a K-wire affects the biomechanical characteristics of modified tension band wiring using the finite-element method. METHODS: A patella model was designed with a cuboid shape (length, 34.3 mm; width, 44.8 mm; and thickness, 22.4 mm) and divided into the cortical and cancellous bone parts. A transverse fracture line was formed on the midline of the cuboid shape model. The cuboidal model was applied to modified tension band wiring. The depth or sagittal position of the K-wire was divided into superficial, center, and deep. With the Abaqus v2017 program (Dassault System Inc.), the distal part of the model was fixed, and a tensile load of 850 N was applied to the proximal part of the model at an angle of 45°. The maximum pressures of the cortical and cancellous bones at the fracture plane were measured. The largest von Mises values of the K-wire and stainless steel wire were also measured. The fracture gap on the distracted or anterior side was measured. RESULTS: In deep K-wire placement, the highest peak von Mises values of the cortical and cancellous bones were observed. The K-wire and stainless steel wire showed the highest von Mises values in deep K-wire placement. The fracture gap was also largest in deep K-wire placement. CONCLUSIONS: The depth of the K-wire affects the biomechanical characteristics of modified tension band wiring. Deep placement of the K-wire will be more favorable for bone union than the empirically known 5-mm anterior or center placement of the K-wire.

Lateral ulnar collateral ligament (LUCL) reconstruction for the treatment of recalcitrant lateral epicondylitis of the elbow: a comparison with open débridement of the extensor origin.

BACKGROUND: Based on the controversy over whether the extensor tendon is the only lesion of lateral epicondylitis of the elbow and numerous reports of concomitant lateral collateral ligament involvement, potential damage to the lateral collateral ligament complex should be considered for the treatment. METHODS: About 25 elbows in 23 patients (débridement group) and 22 elbows in 20 patients (reconstruction group) who were diagnosed with lateral epicondylitis and had an average of 22 months of symptoms revealing anatomical lesion on MRI were included. The capitellum-sublime tubercle-radial head (CSR) angle was measured on both sides preoperatively, and the visual analog scale (VAS) and Mayo elbow performance score (MEPS) were measured over 12 months, postoperatively. RESULTS: The initial preoperative mean VAS was statistically significant with 4.6 in the débridement group and 6.5 in the reconstruction group (P < .05). Postoperative VAS was continuously decreased in both groups with no significant difference at each assessment period (P < .05) but showed more rapid improvement in the reconstruction group compared with the débridement group. For MEPS, the reconstruction group showed significant improvement during the follow-up periods, and at the final follow-up MEPS, 3 cases in the débridement group and 0 cases in the reconstruction group showed a poor result, which was considered as surgery failure. The CSR angle of the affected side (7.2 ± 1.9) was significantly larger than that of the normal side (3.6 ± 1.5) (P < .05) in the reconstruction group. Increased CSR by more than 5 degrees was identified as a significant predictive indicator for potential concomitant ligament insufficiency (area under curve = 0.875, P < .001) showing 80.9% of the sensitivity, 82.1% of the specificity. CONCLUSIONS: In the surgical treatment of recalcitrant lateral epicondylitis, lateral ulnar collateral ligament reconstruction added to the débridement of extensor origin may provide better results for the patients with suspicious lateral ligament insufficiency or failed previous surgery.

Clinical Assessments and MRI Findings Suggesting Early Surgical Treatment for Patients with Medial Epicondylitis.

Purpose: To evaluate the MRI findings and clinical factors that are characteristic of patients who ultimately undergo surgery for medial epicondylitis. Materials and Methods: Fifty-two consecutive patients who were diagnosed with medial epicondylitis and underwent an elbow MRI between March 2010 and December 2018 were included in this retrospective study. The patients' demographic information, clinical data, and MRI findings were evaluated. All variables were compared between the conservative treatment and surgical treatment groups. Logistic regression analyses were conducted to identify which factors were associated with surgical treatment. Results: Common flexor tear (CFT) tear size showed a statistically significant difference in both the transverse and longitudinal planes (p < 0.001, p = 0.013). The CFT abnormality grade significantly differed in both the transverse and longitudinal planes (p = 0.022, p = 0.003). A significant difference was also found in the medial collateral ligament abnormality (p = 0.025). Logistic regression analyses showed that only the transverse diameter of the CFT tear size (odds ratio: 1.864; 95% confidence interval: 1.264-2.750) was correlated with surgical treatment. Conclusion: Of patients diagnosed with medial epicondylitis, patients with a larger transverse CFT tear size tend to undergo surgical treatment ultimately.

Effects of axial forearm instability on force transmission across the elbow.

BACKGROUND: The interosseous membrane (IOM) and distal radioulnar joint (DRUJ) provide axial stability to the forearm. Our hypothesis was that injury to these structures alters force transmission through the elbow. METHODS: A custom-designed apparatus that applies axial loads from the wrist to the elbow was used to test 10 cadaveric upper limbs under the following simulated conditions (1) intact, (2) DRUJ injury, (3) IOM injury, or (4) IOM + DRUJ injury. IOM injury was simulated by osteotomies of the IOM attachment to the radius, and DRUJ injury was simulated by distal ulnar oblique osteotomy. We applied 160 N of axial force during cyclic and functional range of forearm rotation (40o pronation/40o supination), and force, contact pressure, and contact area through the elbow joint were measured simultaneously. RESULTS: The force across the radiocapitellar joint was significantly higher in the IOM + DRUJ injury and the IOM injury groups than in the intact and DRUJ injury groups. The mean force across the radiocapitellar joint was not significantly different between the intact and DRUJ injury groups or between the IOM + DRUJ injury and the IOM injury groups. Forces across the ulnohumeral joint showed an inverse pattern to those in the radiocapitellar joint. CONCLUSIONS: These findings suggest that injury to the IOM contributes more to the disruption of the normal distribution of axial loads across the elbow than injury to the DRUJ.

Articular Contact Area and Pressure in Posteromedial Rotatory Instability of the Elbow.

BACKGROUND: Joint incongruity in posteromedial rotatory instability (PMRI) has been theorized to determine early articular degenerative changes. Our hypothesis was that the articular contact area and contact pressure differ significantly between an intact elbow and an elbow affected by PMRI. METHODS: Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and allow passive elbow flexion (0° to 90°). The mean contact area and contact pressure data were collected and processed using the Tekscan sensor and software. After testing the intact specimen (intact elbow), a PMRI injury was simulated (PMRI elbow) and the specimen was tested again. RESULTS: The PMRI elbows were characterized by initial joint subluxation and significantly elevated articular contact pressure. Both worsened, corresponding with a reduction in contact area, as the elbow was flexed from 0° until the joint subluxation and incongruity spontaneously reduced (at a mean [and standard error] of 60° ± 5° of flexion), at which point the mean contact pressure decreased from 870 ± 50 kPa (pre-reduction) to 440 ± 40 kPa (post-reduction) (p < 0.001) and the mean contact area increased from 80 ± 8 mm to 150 ± 58 mm (p < 0.001). This reduction of the subluxation was also followed by a shift of the contact area from the coronoid fracture edge toward the lower portion of the coronoid. At the flexion angle at which the PMRI elbows reduced, both the contact area and the contact pressure of the intact elbows differed significantly from those of the PMRI elbows, both before and after the elbow reduction (p < 0.001). CONCLUSIONS: The reduction in contact area and increased contact pressures due to joint subluxation and incongruity could explain the progressive arthritis seen in some elbows affected by PMRI. CLINICAL RELEVANCE: This biomechanical study suggests that the early degenerative changes associated with PMRI reported in the literature could be subsequent to joint incongruity and an increase in contact pressure between the coronoid fracture surface and the trochlea.

Axial load transmission through the elbow during forearm rotation.

BACKGROUND: Forearm rotation is closely associated with the axiorotational force transmission through the elbow joint. A technique has been developed to study the transmission of force across the radiocapitellar and ulnotrochlear joints during forearm rotation. METHODS: Ten human cadaveric upper limbs were prepared on a custom-designed apparatus that permits the application of extrinsic axial loads across an intact cadaveric elbow joint. A force-sensitive transducer was inserted into the elbow joint of each cadaver. A 160 N axial force was applied to the specimen during cyclic forearm rotation while the force, contact pressure, and contact area through the elbow joint were measured. RESULTS: The mean force across the radiocapitellar joint showed no significant difference between pronation and supination (P = .3547). The radiocapitellar joint showed significantly higher contact area (P = .0001) and lower contact pressure (P = .0001) in pronation than in supination. The mean values for contact pressure, area, and force across the ulnotrochlear joint were not significantly different between supination and pronation. CONCLUSION: The contact pressure and contact area of the radiocapitellar joint in the cadaveric model changed according to forearm rotation while the force remained constant. The mean contact pressure of the radiocapitellar joint in pronation was significantly lower than that in supination because the force across it did not change significantly and its contact area decreased significantly. These findings may suggest that the pronated elbow can play an important role in protecting the radiocapitellar joint in high-impact activities like delivering punch in martial arts or falling on an outstretched arm.

Anterior Dislocation of the Radial Head Combined with Plastic Deformity of the Ulnar Shaft in an Adult: A Case Report.

A 25-year-old woman presented to the emergency room with a painful and swollen right forearm. She had just sustained an injury from an accident during which her arm was tightly wound by a rope as she was lowering a net from a fishing boat. Before being released, her arm was rigidly trapped in the rope for approximately ten minutes. Radiographs revealed anterior dislocation of the radial head that was accompanied by plastic deformation of the proximal ulna, manifested as a reversal of the proximal dorsal angulation of the ulna (PUDA); suggested a Monteggia equivalent fracture. With the patient under general anesthesia, we reduced the radial head by posterior compression at 90° of elbow flexion and at neutral rotation of the forearm. However, the reduction was easily lost and the elbow re-dislocated with even slight supination or extension of the arm. After the osteotomy of the ulnar deformity to restore the PUDA to normal, the reduction remained stable even with manipulation of the arm. We found that the patient could exercise a full range of motion without pain at the 3-month follow-up, and neither residual instability nor degenerative changes were observed at the final 3-year follow-up.

Role of the lateral collateral ligament in posteromedial rotatory instability of the elbow.

BACKGROUND: Posteromedial rotatory instability (PMRI) of the elbow consists of an anteromedial coronoid fracture with lateral collateral ligament (LCL) and posterior bundle of the medial collateral ligament (PMCL) tears. We hypothesized that the LCL tear is required for elbow subluxation/joint incongruity and that an elbow affected by an anteromedial subtype 2 coronoid fracture and a PMCL tear exhibits contact pressures different from both an intact elbow and an elbow affected by PMRI. MATERIALS AND METHODS: Six cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and to passively flex the elbow from 0° to 90° and measure joint contact pressures. After testing of the intact specimen (INTACT-elbow), an anteromedial subtype 2 coronoid fracture with a PMCL tear (COR+PMCL-elbow) and a PMRI injury (PMRI-elbow), after adding an LCL tear, were tested. The highest values of mean contact pressure were used for the comparison among the 3 groups. RESULTS: Neither subluxation nor joint incongruity was observed in the COR+PMCL-elbow. The addition of an LCL detachment consistently caused subluxation and joint incongruity. Mean contact pressures were higher in the COR+PMCL-elbow compared with the INTACT-elbow (P < .03) but lower than in the PMRI-elbow (P < .001). CONCLUSIONS: The LCL lesion in PMRI is necessary for elbow subluxation and causes marked elevations in contact pressures. Even without subluxation, the COR+PMCL-elbow showed higher contact pressures compared with the INTACT-elbow. Treatment of PMRI should be directed toward prevention of joint incongruity, whether by surgical or nonsurgical means, to prevent high articular contact pressures.

Coronoid reconstruction using osteochondral grafts: a biomechanical study.

HYPOTHESIS: The purposes of this study were to test the hypothesis that coronoid deficiency in the setting of posteromedial rotatory instability (PMRI) must be reconstructed to restore articular contact pressures to normal and to compare 3 different osteochondral grafts for this purpose. METHODS: After creation of a anteromedial fracture, six cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and to passively flex the elbow. Mean articular surface contact pressure data were collected and processed using TekScan sensors and software. After testing of the intact specimen (intact condition), a PMRI injury was created (PMRI condition). Testing was repeated after reconstruction of the lateral collateral ligament (LCL) (LCL-only condition), followed by reconstruction of the coronoid with 3 different osteochondral graft techniques (reconstructed conditions). RESULTS: Contact pressure was consistently significantly higher in the PMRI elbow compared with the intact, LCL-only, and reconstructed conditions (P < .006). The LCL-only elbow contact pressure was significantly higher than that of the intact and reconstructed conditions from 5° to 55° of flexion (P = .018). The contact pressure of the intact elbow was never significantly different from that of the reconstructed elbow, except at 5° of flexion (P ≤ .008). No significant difference was detected between each of the reconstructed techniques (P ≥ .15). However, the annular surface of the radial head was the only graft that yielded contact pressures not significantly different from normal at any flexion angle. CONCLUSION: Isolated reconstruction of the LCL did not restore native articular surface contact pressure, and reconstruction of the coronoid using osteochondral graft was necessary. There was no difference in contact pressures among the 3 coronoid reconstruction techniques.

Stress radiography for clinical evaluation of anterior shoulder instability.

BACKGROUND: The purpose of this study was to examine the validity of stress radiography using the Telos GA-IIE as a clinical methodology to evaluate shoulder instability. METHODS: On 36 anterior shoulder dislocators and 23 uninjured volunteers, 4 types of stress radiographs were captured while applying 15 daN of force anteriorly (AER0 and AER60) and posteriorly (PER0 and PER60) at 2 different positions: (1) 90° of abduction combined with 0° external rotation and (2) 90° of abduction combined with 60° external rotation. The results of the anterior drawer test and of the same test under anesthesia were correlated. RESULTS: AER0 and AER60 from the affected shoulder revealed significantly larger displacement than on the normal side (P < .05), and all 4 radiographs from the affected joints demonstrated significantly larger displacement (P < .05) than in the volunteers. Among the 4 types of radiographs, AER0 and AER60 showed significantly higher displacement in the patients (P < .001), whereas there were no differences in the volunteers (P = .167). The results of the anterior drawer test positively correlated to AER60 (Pearson correlation coefficient [PCC] = 0.453; P = .005) and AER0 (PCC = 0.529; P = .001), and those of examination under anesthesia weakly correlated to AER60 (PCC = 0.287; P = .264) but highly correlated to AER0 (PCC = 0.695; P = .002). CONCLUSION: Stress radiographs on the affected shoulder frequently correlated with physical examinations, and the displacement of >3 mm on AER0 suggests anterior instability.

Tumor cells loaded with α-galactosylceramide promote therapeutic NKT-dependent anti-tumor immunity in multiple myeloma.

Tumor cells have been used as the tumor antigen sources for developing cancer vaccines. Due to their low immunogenicity, tumor antigens are combined with various adjuvants to enhance immunogenicity of cancer vaccines. Among them, a natural killer T cell (NKT)-ligand, α-galactosylceramide (αGC) has been reported as a powerful adjuvant showing therapeutic effects in solid tumors as well as hematological malignancies including lymphoma. In this study, we applied αGC-based tumor cell vaccine in mouse multiple myeloma model. The αGC-loaded MOPC315BM myeloma cell vaccine efficiently retarded tumor growth, induced regression of established tumors, and protected surviving mice from tumor rechallenge. Therapeutic responses were associated with induction of strong humoral immune responses, including myeloma-specific antibodies, and cellular immune responses, including myeloma-specific CD8(+) cytotoxic T lymphocytes and memory T cells. In addition, regulatory T cells were significantly decreased in mice that received the αGC-loaded myeloma cell vaccine. Thus, our results demonstrated that αGC-loaded myeloma vaccine efficiently promoted NKT-dependent anti-tumor immunity in a mouse model. These findings are informative for improving the efficacy of tumor-cell-based immunotherapy for patients with MM and other CD1d-expressing tumors.

A wide dynamics and fast scan interrogating method for a fiber Bragg grating sensor network implemented using code division multiple access.

We propose and demonstrate a fiber Bragg grating (FBG) sensor network employing the code division multiple access (CDMA) technique to identify information from individual sensors. To detect information without considering time delays between sensors, a sliding correlation method is applied, in which two different signals with the same pseudo-random binary sequence (PRBS) pattern, but slightly different frequencies, are applied to the source and detector sides. Moreover, for time domain detection, a wavelength-to-time conversion technique using a wavelength dispersive medium is introduced. The experimental results show that the proposed sensor network has a wide strain dynamic range of 2,400 µÎµ and a low crosstalk of 950:1.

Parathyroid hormone 1-34(teriparatide) treatment in pelvic insufficiency fractures - a report of two cases -.

As a result of aging population, the incidence of pelvic insufficiency fracture has been increasing. Pain-related immobility caused by pelvic insufficiency fractures may result in a serious dependency and high mortality with preexisting comorbidities. We present two cases of pelvic insufficiency fracture in elderly patients which had good clinical outcome by parathyroid hormone 1-34(teriparatide) treatment as well as a literature review.

Delayed diagnosed stage 1, 2 distractive flexion injury of the cervical spine.

STUDY DESIGN: Retrospective study. PURPOSE: To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments. OVERVIEW OF LITERATURE: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs. METHODS: The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined. RESULTS: The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%). CONCLUSIONS: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.

Successful percutaneous coronary intervention for acute coronary syndrome in a patient with severe hemophilia a.

Patients with hemophilia generally have a reduced frequency of coronary artery disease compared to the general population. As advances in the management of hemophilia have increased their life expectancy, the prevalence of coronary artery disease also has increased. However, there are no standard treatment guidelines for coronary artery disease in patients with hemophilia, especially in the field of coronary intervention. We report the case of a patient with severe hemophilia A who presented with acute coronary syndrome and was successfully treated with percutaneous coronary intervention.

Multiple sequential complications after sirolimus-eluting stent implantation: very late stent thrombosis, stent fracture, in-stent restenosis, and peri-stent aneurysm.

A 55-year-old male patient presented with an acute myocardial infarction. A sirolimus-eluting stent (SES) was implanted in the proximal left anterior descending artery (LAD). Eight months later, there was a newly developed distal LAD lesion. An additional SES was implanted. Twenty-eight months after the index procedure of primary coronary intervention, the electrocardiogram showed ST elevation in the precordial leads and an emergency coronary angiogram showed diffuse stent thrombosis (ST) in the proximal LAD. Thirty-four months after the index procedure, coronary angiography showed a large peri-stent coronary aneurysm in the proximal LAD and focal in-stent restenosis (ISR) at the proximal edge of the distal LAD stent. On fluoroscopy, a fracture was noted in the middle part of the distal SES. A zotarolimus- eluting stent (ZES) was deployed and overlapped the restenosis and fracture sites. Forty months after the index procedure, there were no changes in the size of the aneurysm or in the other stent complications including the fracture and restenosis. At present, the patient has remained asymptomatic for eight months.

Nonsurgical management of a tricuspid valvular pedunculated papillary fibroelastoma.

A 25-year-old woman with a history of kidney transplantation for lupus nephritis was referred for the evaluation and management of a mass incidentally found on echocardiography. An oval and pedunculated mass attached to the tricuspid valve was managed with nonsurgical treatment. No symptoms and complications attributable to the mass developed. Three years later, the size of the mass decreased. Here we report the case of a probable cardiac papillary fibroelastoma (PFE), a mobile mass, with a stalk on the septal leaflet of the tricuspid valve that was managed for three years without surgical treatment.