[Acquired Left Ventricular-right Atrial Communication due to Infective Endocarditis;Report of a Case].

A 77-year-old woman presented with a 3-week history of low grade fever, appetite loss and dizziness. An electrocardiogram showed complete heart block. Echocardiography demonstrated severe aortic valve stenosis and a mass of probable vegetation 2 cm in diameter on the atrioventricular septum in the right atrium (RA), but no obvious intra-cardiac fistula. There was no growth of organism in blood cul tures. In the 4th week after admission, a harsh and continuous cardiac murmur was detected for the 1st time. Portable echocardiography revealed disappearance of the mass in the RA, and showed an intra-cardiac shunt from the left ventricle( LV) to RA. The shunt was closed by autologous pericardial patch form LV side and directly with mattress suture form RA side during the emergency operation. The aortic valve was replaced with bio-prosthetic valve (SJM Trifecta 19 mm). No organism was detected in the excised tissue, but antibiotics were continued for 2 months until a permanent pacemaker was inserted.

Diagnostic accuracy of a modified subtraction coronary CT angiography method with short breath-holding time: a feasibility study.

OBJECTIVE: To explore the feasibility and diagnostic accuracy of modified subtraction coronary CT angiography (CCTA) with short breath-holding time in patients who have limited breath-hold capability and severe coronary artery calcification. METHODS: 11 patients with a coronary calcium score >400 underwent CCTA using a modified subtraction protocol. All patients were unable to hold their breath for more than 20 s. Subjective image quality using a four-point scale and the presence of significant (>50%) luminal stenosis were assessed for each calcified or stented segment on both conventional CCTA and modified subtraction CCTA images and compared with invasive coronary angiography (ICA) as the gold standard. RESULTS: The mean breath-holding time was 13.0 ± 0.9 s. A total of 35 calcified or stented coronary segments were evaluated. The average image quality was increased from 2.1 ± 0.9 with conventional CCTA to 3.1 ± 0.7 with subtraction CCTA (p < 0.001). The segment-based diagnostic accuracy for detecting significant stenosis according to ICA revealed an area under the receiver-operating characteristic curve of 0.722 for conventional CCTA and 0.892 for subtraction CCTA (p = 0.036). CONCLUSION: Modified subtraction CCTA allows the breath-holding time to be shortened to <15 s. As compared with conventional CCTA, modified subtraction CCTA showed improvement in image quality and diagnostic accuracy in patients with limited breath-hold capability and severe calcification. ADVANCES IN KNOWLEDGE: Modified subtraction CCTA can improve the diagnostic accuracy in patients with a high calcium score and patients who are unable to perform long breath-holds.

Modified Subtraction Coronary CT Angiography Method for Patients Unable to Perform Long Breath-Holds: A Preliminary Study.

RATIONALE AND OBJECTIVES: Severe calcifications of the coronary arteries are still a major challenge in coronary computed tomography (CT) angiography (CCTA). Subtraction CCTA using a 320-detector row CT scanner has recently been introduced for patients with severe calcifications. However, the conventional subtraction CCTA method requires a long breath-holding time of approximately 20-40 seconds. This is a major problem in clinical practice because many patients may not be able to perform such a long breath-hold. We explored a modified subtraction CCTA method with a short breath-holding time to overcome this problem. MATERIALS AND METHODS: This study was approved by our institutional review board, and all patients gave written informed consent. A total of 12 patients with a coronary calcium score of >400 were enrolled in this study. All patients were unable to hold their breath for more than 20 seconds. Modified subtraction CCTA was performed using the bolus-tracking method. The acquisition protocol was adjusted so that the mask scan was acquired 10 seconds after the postcontrast scan during a single breath-hold. The subtraction image was obtained by subtracting the mask image data from the postcontrast image data. The breath-holding times were recorded. Enhancement of the coronary arteries in the subtraction images was assessed. Subjective image quality was evaluated in a total of 32 segments using a 4-point scale. RESULTS: The mean breath-holding time was 12.8 ± 0.8 seconds (range, 12-14 seconds). The average CT number in the coronary arteries was 288.6 ± 80.5 Hounsfield units (HU) in the subtraction images. Average image quality was significantly increased from 2.1 ± 0.9 with conventional CCTA to 3.1 ± 0.7 with subtraction CCTA (P < 0.001). With subtraction CCTA, the number of non-diagnostic segments was significantly reduced from 53% to 19% (P = 0.001). CONCLUSIONS: This preliminary study has shown that our modified subtraction CCTA method allows the breath-holding time to be shortened to <15 seconds. This may substantially improve the success rate of subtraction CCTA by reducing artifacts and allowing this technique to be applied to patients who are unable to perform a long breath-hold.

Abdominal aortic disease caused by penetrating atherosclerotic ulcers.

OBJECTIVE: Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induced aortic dissection, aortic rupture, and secular aortic aneurysm and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta. METHOD: Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture, and isolated abdominal aortic dissection over the past 15 years, giving a total of 65 cases. RESULTS: The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, and the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic, including pain (40%, n = 26), shock (4.6%, n = 3), and lower limb embolism (9.2%, n = 6). The remaining 40% of cases were asymptomatic (n = 26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths. CONCLUSION: We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection, or rupture. (English translation of Jpn J Vasc Surg 2010; 19: 723-730.).

Surgical treatment for papillary fibroelastoma of the aortic valve.

Although cardiac papillary fibroelastomas are benign tumors, they have the potential to cause life-threatening complications such as stroke and myocardial infarction and may even lead to sudden cardiac death. We report a case of surgical treatment for a papillary fibroelastoma of the aortic valve. The patient was a 62-year-old woman who was asymptomatic for cardiac papillary fibroelastoma. Echocardiography demonstrated a mobile, rounded mass on the left coronary cusp of the aortic valve. The patient underwent surgical excision, had an uneventful recovery, and was discharged 10 days after the operation. Pathology examination confirmed papillary fibroelastoma. Surgical excision of the tumor is recommended for patients with symptoms, but the treatment of asymptomatic patients is controversial. We believe that surgical treatment should be performed if the tumor is mobile.

Severely calcified intravenous leiomyomatosis with cardiac extension.

Intravenous leiomyomatosis is a rare benign tumor. In this report we described a case of 72-year-old female who presented with a tumor of this type. Thirty years earlier she had received hysterectomy for uterine myoma. Echocardiography, computed tomography, and inferior vena cavography revealed an intracardiac tumor with calcification arising from the left internal iliac vein. A simultaneous operation was performed successfully with a median sternotomy and left retroperitoneal approach under cardiopulmonary bypass support. Histopathological examination revealed that the resected tumor was a calcified intravenous leiomyoma with cardiac extension. This case showed the three interesting features compared with other reports. Among all reported cases of intravenous leiomyomatosis, this patient and another were the oldest at 72 years old, severe calcification of intravenous leiomyomatosis was infrequent, and the delay (30 years) from hysterectomy to removal of the intracardiac tumor was the longest.

Chylopericardium following mitral valve replacement.

A 49-year-old man with mitral regurgitation developed chylopericardium after mitral valve replacement. On postoperative day (POD) 1, the patient was started on a regular diet. On POD 2, drainage from retrosternal and intrapericardial tubes increased, becoming turbid and milky. Because the triglyceride concentration was high at 197 mg/dl, we diagnosed the condition as chylopericardium. The patient was given nothing by mouth for 2 days and, from POD 4, received a low-fat diet, after which drainage cleared and volume decreased. The 2 drainage tubes were removed on POD 6, and he was discharged without complications on POD 18.