Impact of SARS-Cov-2 infection in patients with hypertrophic cardiomyopathy: results of an international multicentre registry.

AIMS: To describe the natural history of SARS-CoV-2 infection in patients with hypertrophic cardiomyopathy (HCM) compared with a control group and to identify predictors of adverse events. METHODS AND RESULTS: Three hundred and five patients [age 56.6 ± 16.9 years old, 191 (62.6%) male patients] with HCM and SARS-Cov-2 infection were enrolled. The control group consisted of 91 131 infected individuals. Endpoints were (i) SARS-CoV-2 related mortality and (ii) severe clinical course [death or intensive care unit (ICU) admission]. New onset of atrial fibrillation, ventricular arrhythmias, shock, stroke, and cardiac arrest were also recorded. Sixty-nine (22.9%) HCM patients were hospitalized for non-ICU level care, and 21 (7.0%) required ICU care. Seventeen (5.6%) died: eight (2.6%) of respiratory failure, four (1.3%) of heart failure, two (0.7%) suddenly, and three (1.0%) due to other SARS-CoV-2-related complications. Covariates associated with mortality in the multivariable were age {odds ratio (OR) per 10 year increase 2.25 [95% confidence interval (CI): 1.12-4.51], P = 0.0229}, baseline New York Heart Association class [OR per one-unit increase 4.01 (95%CI: 1.75-9.20), P = 0.0011], presence of left ventricular outflow tract obstruction [OR 5.59 (95%CI: 1.16-26.92), P = 0.0317], and left ventricular systolic impairment [OR 7.72 (95%CI: 1.20-49.79), P = 0.0316]. Controlling for age and sex and comparing HCM patients with a community-based SARS-CoV-2 cohort, the presence of HCM was associated with a borderline significant increased risk of mortality OR 1.70 (95%CI: 0.98-2.91, P = 0.0600). CONCLUSIONS: Over one-fourth of HCM patients infected with SARS-Cov-2 required hospitalization, including 6% in an ICU setting. Age and cardiac features related to HCM, including baseline functional class, left ventricular outflow tract obstruction, and systolic impairment, conveyed increased risk of mortality.

Validación de la utilidad de los parámetros de deformación miocárdica para excluir el rechazo agudo tras el trasplante cardiaco: un estudio multicéntrico / Validation of the usefulness of 2-dimensional strain parameters to exclude acute rejection after heart transplantation: a multicenter study

Introducción y objetivos Algunos estudios indican que los parámetros de strain por speckle-tracking pueden ser una alternativa no invasiva a la biopsia endomiocárdica para excluir el rechazo celular agudo (RCA) moderado o grave (≥ 2R) tras el trasplante cardiaco (TxC). En una cohorte inicial, unos puntos de corte del 15,5% para el strain longitudinal global del ventrículo izquierdo (SLGVI) y el 17% para el strain de pared libre del ventrículo derecho mostraron un valor predictivo negativo del 100% para excluir RCA ≥ 2R. Nuestro objetivo es analizar la utilidad del strain y validar estos puntos de corte en una cohorte multicéntrica prospectiva externa.MétodosEstudio multicéntrico y prospectivo que incluyó a pacientes con seguimiento el primer año tras el TC. Se compararon los resultados de biopsias electivas con ecocardiogramas realizados el mismo día.ResultadosSe incluyó a 99 pacientes y 501 pares de biopsias-ecocardiogramas. El RCA ≥ 2R en las biopsias fue del 7,4%. El SLGVI y el strain longitudinal de pared libre del ventrículo derecho fueron menores durante los RCA ≥ 2R en el análisis univariante. En el análisis multivariante, el SLGVI se asoció de manera independiente con el RCA ≥ 2R. Los puntos de corte originales mostraron un valor predictivo negativo del 94,3% el RCA ≥ 2R.ConclusionesEste estudio mantiene un alto valor predictivo negativo para excluir RCA ≥ 2R tras el TxC y el SLGVI se asoció de manera independiente con el RCA ≥ 2R. El strain y, principalmente, el SLGVI pueden ser de utilidad en el diagnóstico y el tratamiento no invasivo del RCA. (AU)

Introduction and objectives Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort.MethodsA prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples.ResultsA total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R.ConclusionsThis study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR. (AU)

Validation of the usefulness of 2-dimensional strain parameters to exclude acute rejection after heart transplantation: a multicenter study.

INTRODUCTION AND OBJECTIVES: Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort. METHODS: A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples. RESULTS: A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R. CONCLUSIONS: This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR.

Abnormal exercise echocardiography plus abnormal E/e' ratio at exercise portends worse outcome in patients with dyspnea.

BACKGROUND: The role of exercise echocardiography (ExE) for the assessment of patients with dyspnea is promising. We aimed to analyze the clinical characteristics and outcome of patients with this condition referred for ExE. METHODS: A total of 505 patients (66 ± 11 years, 57% women) referred for evaluation of dyspnea were considered. Mitral regurgitation, ratio of early left ventricular inflow wave to early diastolic annulus wave (E/e'), and wall motion abnormalities (WMAs) were measured at rest and at exercise. Considered events were overall mortality, non-fatal myocardial infarction, late revascularization, and admission for heart failure. RESULTS: Ischemia was observed in 102 patients (20%), whereas WMAs were already present at rest in 55 patients (11%). A percent achieved of predicted metabolic equivalents >100% was found for most of the patients (70%). During a median follow-up of 3.50 years, 66 patients had events (annualized event rate 3.5%). An E/e' value of 13 at post-exercise was the best cut-off value to predict events. After adjustment by clinical and ExE variables, the combination of an abnormal ExE and E/e' values at post-exercise ≥13 was an independent predictor of events (hazard ratio = 3.67, 95% confidence interval = 2.11-6.38, p < 0.001). The worse outcome corresponded to patients with abnormal ExE and raised E/e' values at post-exercise (annualized event rate 17.2%). Patients with normal E/e' values at post-exercise had better outcome irrespective of the ExE results (annualized event rate 2.2% with normal ExE and 2.9% with abnormal ExE), whereas patients with high E/e' values at post-exercise but normal ExE results were at intermediate risk (annualized event rate 5.0%). CONCLUSIONS: Despite favorable ExE results, event rate remains high among patients with dyspnea referred for ExE, which may have a role to predict outcome in this setting. Patients with both raised E/e' values at post-exercise and abnormal ExE results are at the highest event risk.

Prognostic Factors of Death in 151 Adults With Hemophagocytic Syndrome: Etiopathogenically Driven Analysis.

OBJECTIVE: To characterize the etiologies and clinical features at diagnosis of patients with hemophagocytic lymphohistiocytosis (HLH) and correlate these baseline features with survival using an etiopathogenically guided multivariable model. PATIENTS AND METHODS: The Spanish Group of Autoimmune Diseases HLH Study Group, formed in 2013, is aimed at collecting adult patients with HLH diagnosed in internal medicine departments between January 3, 2013, and October 28, 2017. RESULTS: The cohort consisted of 151 patients (91 men; mean age, 51.4 years). After a mean follow-up of 17 months (range, 1-142 months), 80 patients died. Time-to-event analyses for death identified a worse survival curve for patients with neoplasia (P<.001), mixed microbiological infections (P=.02), and more than 1 infection (P=.01) and glucocorticoid monotherapy (P=.02). According to univariate analyses, platelets of less than 100,000/mm3 (hazard ratio [HR], 3.39; 95% CI, 1.37-8.40), leukopenia (HR, 1.81; 95% CI, 1.01-3.23), severe hyponatremia (HR, 1.61; 95% CI, 1.02-2.54), disseminated intravascular coagulation (HR, 1.87; 95% CI, 1.05-3.34), bacterial infection (HR, 1.99; 95% CI, 1.09-3.63), mixed microbiological infections (HR, 3.42; 95% CI, 1.38-8.46), and 2 or more infectious triggers (HR, 2.95; 95% CI, 1.43-6.08) were significantly associated with death. In contrast, peripheral adenopathies (HR, 0.63; 95% CI, 0.40-0.98) and the immunosuppressive drug/intravenous immunoglobulin/biological therapies (HR, 0.44; 95% CI, 0.20-0.96) were protective against all-cause mortality. Multivariable Cox proportional hazards regression analysis identified 2 or more infectious triggers (HR, 3.14; 95% CI, 1.28-7.68) as the only variable independently associated with death. CONCLUSION: The mortality rate of adult patients diagnosed with HLH exceeds 50%. Infection with more than 1 microbiological agent was the only independent variable associated with mortality irrespective of the underlying disease, epidemiological profile, clinical presentation, and therapeutic management.

Venous thrombosis and relapses in patients with Behçet's disease. Descriptive analysis from Spanish network of Behçet's disease (REGEB cohort).

OBJECTIVES: To describe the characteristics of patients with Behçet's disease (BD) who presented with venous thrombosis. In addition, we identified the factors associated with this venous involvement and those related with recurrent venous thrombosis. METHODS: Up to January 2015, 544 BD patients from 20 Spanish hospitals had been included in the REGEB (REGistro de la Enfermedad de Behçet as Spanish nomenclature). We selected those patients who presented venous thrombosis. Descriptive analysis was performed and factors related with venous thrombosis were identified. RESULTS: Overall, 99 (18.2%) BD patients had vascular thrombosis, 91 (16.7%) of them (16.7%) involving venous vessels and 18 (19.7%) suffered from venous thrombotic relapse. Lower limbs were the most common location of deep venous thrombosis present in up to 60% of patients. In 12 (13.2%) patients, venous thrombosis affected two vascular territories simultaneously and in 6 (6.6%) the venous and arterial involvement coincided in time. Overall, at the diagnosis of venous thrombosis, 97.6% of patients presented concomitantly other clinical symptoms attributable to BD. In logistic regression multivariate analysis factors associated to venous thrombosis were male sex (Odds ratio [OR] 4.3, 95% confidence interval [CI] 2.5-7.7), erythema nodosum (OR 2.4, 95%CI 1.4-4.1), fever (OR 2.0, 95%CI 1.1-3.8), and central nervous system (CNS) involvement (OR 2.5, 95%CI 1.3-4.8). Considering relapses, CNS involvement was an independent risk factor according logistic regression. However, Cox multivariate analysis did not confirm this finding. CONCLUSIONS: We identified factors related with venous involvement in patients included in the REGEB cohort.

Acute eosinophilic pneumonia as a complication of influenza A (H1N1) pulmonary infection.

Acute eosinophilic pneumonia (AEP) is a rare disease characterized by its acute onset and a clinical presentation simulating a bacterial pneumonia. Although it can be idiopathic, it has been described related to drugs, toxic agents and infections, mostly parasitic. We describe the case of influenza A (H1N1) severe pneumonia complicated by an acute eosinophilic pneumonia. Patient presented with respiratory failure and diffuse ground-glass opacities at chest-computed tomography. Clinical suspicion for this complication and bronchoalveolar lavage with cellular count analysis is crucial.

Eficacia de nuevos anticomiciales como moduladores del afecto en la Era Bipolar / Efficacy of new anticonvulsants as modulators of affection in the Age Bipolar

Introducción: El trastorno bipolar es una enfermedad mental grave, crónica, curso fásico, recurrente y discapacitante, de ahí la importancia en una terapéutica oportuna con fármacos que independientemente posean diferentes mecanismos de acción, su combinación tengan el menor riesgo posible de interacciones y efectos adversos, en este arsenal farmacológico aparecen con el término de estabilizantes del ánimo. Objetivo: Abordar desde una revisión en la literatura las consideraciones actuales en relación a la eficacia del uso de nuevas moléculas anticomiciales en la enfermedad bipolar. Método: Revisión temática basada en la bibliografía especializada, que posee información vigente y relevante sin importar el año de su publicación. La búsqueda se realizó en las bases de datos: Intramed, Pubmed, Google Scholar, Cochrane, y Medline, seleccionándose descriptores en español, inglés y francés.Desarrollo: La Organización Panamericana de la Salud ha declarado como epidemia a los trastornos afectivos, para el ambiente científico esta evidencia constituye un punto álgido y desafiante, por ende, apremia el diagnóstico precoz y una terapéutica farmacológica adecuada. Como no ha sido posible elaborar un fármaco eutimizante ideal, ha llevado a los investigadores a desarrollar tratamientos alternativos con agentes antiepilépticos, que independientemente su mecanismo de acción no ha sido bien establecido han demostrado potente eficacia en el tratamiento del desorden bipolar. Conclusiones: Los anticomiciales evidencian su eficacia como agentes eutimizantes por su perfil de seguridad e interacciones farmacológicas, buena tolerancia, relativa escasez de efectos adversos relevantes y fácil administración que precisan de menor necesidad de monitorización(AU)

Introduction: Bipolar disorder is a serious mental illness, chronic, phasic, recurrent and disabling course, hence the importance in a timely therapeutic drug that regardless having different mechanisms of action, combination with the lowest possible risk of interactions and adverse effects in this pharmacological arsenal appear with the term mood stabilizers. Objective: To address from a literature review current considerations regarding the efficacy of new molecules anticonvulsants in bipolar disease. Method: Thematic review based on the literature, which has current and relevant information regardless of the year of publication. The search was conducted in the databases: Intramed, Pubmed, Google Scholar, Cochrane, and Medline, selected descriptors in Spanish, English and French. Development: The Pan American Health Organization has declared epidemic affective disorders, for the scientific environment this evidence is a challenging point height and therefore urges early diagnosis and appropriate drug therapy. As it has not been possible to develop an ideal mood stabilizer drug, it has led researchers to develop alternative treatments with antiepileptic agents, regardless their mechanism of action has not been well established have demonstrated potent efficacy in the treatment of bipolar disorder. Conclusions: The anticonvulsant mood stabilizers demonstrate their effectiveness as agents for their safety profile and drug interactions, good tolerance, relative scarcity of relevant adverse effects and ease of administration that require less need for monitoring(AU)

Un Espectro Bipolar Peculiar. A propósito de un caso / A Peculiar Bipolar Spectrum. Report of a case

Introducción: La depresión cada día cobra mayor importancia en la actualidad y cuando se trata del tipo bipolar representa el problema más acuciante en el contexto del espectro bipolar. Este impacto se basa principalmente en el curso crónico del padecimiento independientemente que existen varias alternativas farmacológicas en el mercado para su tratamiento aun las cifras de remisión son muy bajas. Objetivo: demostrar utilidad de la terapia electroconvulsiva en fase aguda de la depresión bipolar tipo II y eficacia de terapia trimodal en fase de mantenimiento. Métodos: se realizó examen físico y entrevista clínica a un paciente con diagnóstico de trastorno afectivo bipolar tipo II, además de exámenes de laboratorio para cuantificación de litio en sangre. Resultados: en la entrevista clínica se identifica la psicopatología relacionada con un episodio depresivo grave con síntomas psicóticos en un paciente bipolar tipo II tratado posteriormente con terapia electroconvulsiva y tratamiento farmacológico con litio, quetiapina y lamotrigina en fase de mantenimiento, evidenciando una evolución clínica satisfactoria restituyendo su integridad psicológica independientemente de un periodo de recaída durante el abordaje terapéutico. Conclusiones: Inadecuado uso en los episodios depresivos de bipolaridad II de antidepresivos tricíclicos y los de segunda generación en estrategias de monoterapia. Se recomienda el uso de terapia electroconvulsiva en depresiones psicóticas graves y combinación de quetiapina, carbonato de litio y lamotrigina en estrategia de mantenimiento(AU)

Introduction: The depression every day has bigger importance at the present time and when it is the bipolar type it represents the most pressing problem in the context of the bipolar spectrum. This impact is based mainly on the chronic course independently that several pharmacological alternatives exist in the market for the treatment the remission figures they are even very low. Objective: to demonstrate utility of the electroconvulsive therapy in acute phase of the bipolar depression type II and efficacy of trimodal therapy in maintenance phase. Methods: was carried out physical exam and clinic interview to a patient with diagnostic of bipolar disorders type II, also laboratory exams for lithium quantification in blood. Results: in the clinical interview it is identified the psychopathology related with a serious depressive episode with psychotics symptoms in a bipolar patient type II tried later with electroconvulsive therapy and pharmacological treatment with lithium, quetiapine and lamotrigine in maintenance phase, evidencing a satisfactory clinical evolution restoring his psychological integrity independently of a period of relapse during the therapeutic boarding. Conclusions: Inadequate use in the depressive episodes of bipolarity II of tricyclic antidepressants and those of second generation in monoterapia strategies. The use of electroconvulsive therapy is recommended in serious psychotic depressions and combination whit quetiapine, lithium carbonate and lamotrigine in maintenance strategy(AU)

Consideraciones actuales del espectro de enfermedad bipolar / Current Considerations about the Spectrum of the Bipolar Disease

Introducción: La importancia del trastorno bipolar ha ido creciendo a instancias de un concepto clínico más amplio de la enfermedad, conocido con el nombre de Espectro Bipolar, de ahí su prevalencia en la población. Su curso crónico, comienzo precoz y diagnósticos errados, favorecen a un alto grado de discapacidad. Objetivos: Destacar desde una revisión bibliográfica actualizada, las consideraciones actuales en relación a la definición del espectro de enfermedad bipolar, y el valor en su diagnóstico oportuno. Método: Revisión temática basada en la literatura especializada, que posee información vigente y relevante sin importar el año de su publicación. La búsqueda se realizó en las bases de datos: Intramed, Scielo, Pubmed, Google Scholar, Cochrane, y Medline, seleccionándose descriptores tanto en español como en inglés y francés. Desarrollo: La evidencia científica en la psiquiatría contemporánea, ha demostrado que el trastorno afectivo bipolar resulta una patología acuciante que exige sumo interés en el campo de la investigación por su alto grado de discapacidad. La definición sobre el espectro de enfermedad bipolar no está exenta de polémicas por los diferentes autores, es una categoría más amplia que la descrita en diferentes glosarios y clasificaciones internacionales, cuyo conocimiento favorece a un diagnóstico de certeza. Conclusiones: El espectro de enfermedad(AU)

Introduction: The importance of the bipolar disorder has been increasing due to a wider clinical concept of the disease known as Bipolar Spectrum. A high degree of disability occurred because of its chronic course, the precocious beginning and wrong diagnosis. Objective: To emphasize since a current bibliographic review, the recent considerations related to the definition of the spectrum of the bipolar disease and the value of its early diagnose. Methods: A review based on the specialized literature with current and relevant information without taking into consideration the year of publication. The search was done in searchers such as Intramed, Scielo, PubMed, Scholar Google, Cochrane and Medline with a selection of descriptors on Spanish, English and French. Development: The scientific evidence on modern psychiatry has shown that the bipolar disorder is a burning pathology that demands a high interest on the investigation field due to its high degree of disability. The definition about the bipolar spectrum is theme of discussion by several authors. The definition is a category wider than the one describes in different glossaries and international classifications and which knowledge helps a secure treatment. Conclusion: The spectrum of the bipolar disease is characterized by the chronic evolution, and an early start, it is a critical, prevailing and disabling disease that a mistaken diagnose delays the beginning of an adequate treatment(AU)

Registry of the Spanish network of Behçet's disease: a descriptive analysis of 496 patients.

OBJECTIVES: To describe the clinical features of a large cohort of 496 Spanish patients with Behçet's disease (BD) and to analyse if patient's sex influenced the initial and cumulated prevalence of disease manifestations. METHODS: Retrospective and descriptive study of 496 patients recruited in sixteen centres on the frame of the Spanish Registry of Behçet Disease Project Group. Demographic and clinical data are presented in addition to treatments and their related adverse effects. Clinical features at disease onset and during follow-up were compared according to the sex of the patients. RESULTS: On the whole series, female to male ratio was 1.2:1.0. Mean age at disease onset was 28.7±12.6 years (range 17-73). Oral ulcers were the most frequent initial manifestation presented in 52.0% of patients. During follow-up, eye inflammatory disease was recorded in 45.1% of patients; thrombosis in 19.7% and central nervous system involvement in 13.5%. Men had higher prevalence of ocular involvement and venous thrombosis (52.5% vs. 39.2%, p=0.004 and 26.3% vs. 9.6%, p<0.001, respectively). CONCLUSIONS: Spanish patients with BD presented similar clinical characteristics as their counterpart in the same geographical area and other world regions. In addition, we confirmed that ocular and vascular involvements are more frequent in men than in women.

Paramuscular perforators in DIEAP flap for breast reconstruction.

UNLABELLED: One of the main steps in perforator flap surgery is to identify the dominant perforator. Using multidetector row computed tomography (MDCT) for the preoperative planning of deep inferior epigastric artery perforator (DIEAP) flap surgery, we identified a perforator with a large caliber, an excellent location in the middle abdominal region, and a totally extramuscular trajectory in a significant number of patients. We describe the frequency of this perforator and determine its characteristics. PATIENTS AND METHODS: We conducted a retrospective study of 482 patients who underwent 526 DIEAP flaps for breast reconstruction from October 2003 to October 2011. Mean age at surgery was 51.3 years old. A preoperative MDCT of abdominal vascularization was performed in all patients. RESULTS: MDCT identified a dominant perforator with a paramuscular course in 12.4% of abdominal walls. In all cases, it was located in the midline and emerged directly from the deep inferior epigastric system. Its mean caliber was 1.9 mm. The flap was harvested based on this perforator in all these patients, and mean harvest time was 51 minutes. The characteristics of this perforator made dissection easier and reduced morbidity at the donor site. There were no flap losses and the only complications were minor. CONCLUSION: We located a paramuscular perforator in 12.4% of patients undergoing breast reconstruction with abdominal perforator flaps. Its morphological features and extramuscular course make it the perforator of choice in DIEAP flap surgery.

Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction.

Precision in preoperative evaluation of the abdominal wall vascular anatomy is of utmost importance in successful planning and execution of perforator flap surgery for breast reconstruction after mastectomy. We performed a study in 357 patients scheduled for deep inferior epigastric artery perforator (DIEAP) flap breast reconstruction to review our 5-year experience with the technique we developed based on our previous research confirming accuracy of a computed tomographic (CT) angiogram (multidetector row computed tomography [MDCT]) in preoperative planning of abdominal perforator flap surgery. Images obtained from the radiological study were used to create an accurate map of dominant abdominal perforators of the deep inferior epigastric artery, showing their location, size, and anatomic considerations of relevance for the preoperative flap design. Anatomic dissection of all perforators was performed in the first 36 cases to compare the data with preoperative MDCT findings. In the following 321 patients, the dominant perforator was chosen solely on the basis of MDCT and dissected directly. Exact correlation between surgical and radiological results was found in the first 36 cases. A significant reduction in average operating time and postoperative complications was noted in the following 321 patients. CT angiogram provides important preoperative information on inferior abdominal wall vascular anatomy, facilitating DIEAP flap harvest, saving operative time, and reducing complications and costs. It proved to be an invaluable tool in the preoperative algorithm for DIEAP flap breast reconstruction.

MDCT in the preoperative planning of abdominal perforator surgery for postmastectomy breast reconstruction.

OBJECTIVE: This study aimed to evaluate the utility of MDCT in planning abdominal perforator surgery for breast reconstruction in patients who have undergone mastectomy. SUBJECTS AND METHODS: One hundred twenty-six consecutive patients scheduled for postmastectomy breast reconstruction using deep inferior epigastric perforator flaps underwent MDCT. The images were evaluated to identify, characterize, and map the dominant musculocutaneous perforator vessels of the deep inferior epigastric artery. In the first 36 patients, we compared the intraoperative findings with the preoperative MDCT findings. In the latter 90 patients, the dominant perforator vessels were directly selected on the basis of MDCT findings. RESULTS: We found an exact correlation between the intraoperative and radiologic findings in the first 36 cases. In the following 90 cases, the average operating time saved per patient was 1 hour 40 minutes and there was a significant reduction in postsurgical complications. The preoperative evaluation by MDCT confirmed the wide range of variability in the vascular anatomy of the abdominal wall previously described in anatomic studies. CONCLUSION: MDCT provides valuable information before surgery about the arterial anatomy of the inferior abdominal wall. It enables accurate identification of the most suitable dominant perforator vessel and makes surgical perforator flap procedures for breast reconstruction faster and safer.

The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases.

A preoperative abdominal wall study was conducted using a multidetector scanner in 162 women who had undergone breast reconstruction with abdominal perforator flaps. A map of the abdominal perforator vessels dependent on the deep inferior epigastric artery was created. In the first 36 cases, anatomic dissection of all perforators was performed during surgery. The outcome was then compared with the radiologic findings. In the following 126 cases, the perforator vessel chosen preoperatively by the multidetector scanner was located and dissected directly. In the first 36 cases, an absolute correlation was observed between the radiologic information and intraoperative findings. In the following 126 cases, surgery time and the rate of postoperative complications decreased significantly. The multidetector scanner provides valuable preoperative information enabling identification of the most suitable perforator in view of its caliber, location, course, and anatomic relationships. Once located, we can proceed directly to its dissection during surgery, making it a faster and safer technique.

The 'propeller' distal anteromedial thigh perforator flap. Anatomic study and clinical applications.

BACKGROUND: The leg and peripatellar region have always been known as a poor source of available flaps. One flap donor site that has proven to be adequate is the distal anteromedial half of the thigh. Due to the potential and plentiful vascular sources of this anatomic region we decided to study the distal anteromedial thigh and its clinical applications. ANATOMIC STUDY: Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators of the distal anteromedial thigh and their source vessels were studied. CLINICAL STUDY: In a period between December 2000 and June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients were transferred, as local perforator flaps, to reconstruct the peripatellar region and upper leg soft tissue defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, as a 'propeller', through 180 degrees and the flap was named 'the propeller distal anteromedial thigh perforator flap'. RESULTS: In the distal anteromedial thigh the anatomic variability includes not only perforator vessels but also their source vessels. Skin perforators can come from each of the deep vessels. Our clinical results, with a follow up of 1-4 years, show no total flap losses. Partial necrosis > 20% happened in one diabetic patient. CONCLUSION: The propeller distal anteromedial thigh perforator flap can be reliably transferred based on only one adequate perforator vessel. It reduces the morbidity and improves the availability of the distal anteromedial thigh as a flap donor site and represents an additional reconstructive option for knee and upper leg defects.