Bleomycin sclerotherapy for lymphatic malformation after unsuccessful surgical excision: case report.

Lymphatic malformations (LMs) are benign cystic masses resulting from the abnormal development of lymphatic channels. Lymphatic malformations occur primarily in the head and neck region. Surgical excision of lymphatic malformation is followed by high rate of recurrence and a high risk of complications. Bleomycin is an established antineoplastic drug. It can be used as a sclerosing agent in vascular anomalies. We present a child who was unsuccessfully treated with four surgical resections, with peripheral palsy of facial nerve as complication. The lymphatic malformation was successfully treated in our institution with intralesional administration of bleomycin.

Giant Gartner duct cyst and elevated CA-125.

BACKGROUND: Gartner duct cysts represent vestigial remnants of the caudal end of the mesonephric (Wolffian) ducts. They are often associated with ureteral and renal abnormalities. In most cases they are solitary, less than 2 cm in diameter. Giant Gartner duct cysts are extremely rare. CASE: We present a girl with a giant Gartner duct cyst, without notable associated abnormalities or pathology, successfully treated by surgical excision. Preoperative aspiration revealed elevated level of CA-125 in the cyst fluid, with normal serum level of the same marker. CONCLUSION: Analyzing the aspirated fluid for CA-125 may be a useful tool for evaluation of cystic lesions in this region.

Treatment of nasal hemangiomas.

Hemangiomas are the most common soft tissue tumors of infancy. Almost 60% of these tumors develop in the head and neck region. Nasal hemangiomas, distort human physiognomy and leave long lasting psychological sequelae. Conservative approach (intralesional corticosteroids, laser) may accelerate involution. Proponents of an early surgery suggest that aesthetic improvement during a critical period in child development can be achieved. Fourteen patients with nasal hemangioma were treated during 5-year period (2003-2007) with intralesional corticosteroids, lenticular excision, open rhinoplasty excision, and circular excision with "purse string suture". The first line of treatment for large nasal hemangiomas is intralesional corticosteroids. Excision is indicated for small hemangiomas, while subtotal excision is preferable for large nasal hemangiomas. Circular excision and "purse string suture" is appropriate for prominent hemangiomas with predominant deep component. In our opinion surgery with maximal care for nasal architecture is the treatment option for nasal hemangioma.

Preinfarction angina prevents left ventricular remodeling in patients treated with thrombolysis for myocardial infarction.

BACKGROUND: It has been shown that preinfarction angina may have beneficial effects on infarct size and mortality. However, there are no studies that have serially assessed the impact of preinfarction angina on left ventricular (LV) function in a large series of patients. HYPOTHESIS: The study was undertaken to determine whether preinfarction angina (within 7 days before infarction) influences LV remodeling. METHODS: In all, 119 consecutive patients with acute myocardial infarction were serially evaluated by 2-dimensional echocardiography (on Days 1, 2, 3, and 7; at 3 and 6 weeks; and at 3, 6, and 12 months following infarction). Left ventricular volumes were determined using Simpson's biplane formula and normalized for body surface area. Wall motion score index and sphericity index were calculated for each study. Coronary angiography was performed before discharge. RESULTS: Preinfarction angina was detected in 39 of 119 patients. Initial echocardiographic and clinical data as well as the incidence of patent infarct-related artery and collaterals were similar for patients with and without preinfarction angina. In the subset of thrombolysed patients, patients with preinfarction angina showed decrease of LV end-diastolic and end-systolic volumes during the follow-up period (p = 0.033 and p = 0.001, respectively), and improvement of wall motion score index (p < 0.001) and ejection fraction occurred (p = 0.001), without changing of LV shape (p > 0.05); in addition, patients with preinfarction angina had smaller LV volumes and higher ejection fraction than did those without angina, from 3 weeks onward. These favorable effects were not detected in patients not treated with thrombolysis. CONCLUSIONS: These data indicate that preinfarction angina has an inhibiting effect on long-term LV remodeling in patients who underwent thrombolysis for first acute myocardial infarction. It appears that preinfarction angina has no impact on infarct size and early postinfarction LV function.

Short early filling deceleration time on day 1 after acute myocardial infarction is associated with short and long term left ventricular remodelling.

OBJECTIVE: To assess the relations between early filling deceleration time, left ventricular remodelling, and cardiac mortality in an unselected group of postinfarction patients. DESIGN AND PATIENTS: Prospective evaluation of 131 consecutive patients with first acute myocardial infarction. Echocardiography was performed on day 1, day 2, day 3, day 7, at three and six weeks, and at three, six, and 12 months after infarction. According to deceleration time on day 1, patients were divided into groups with short (< 150 ms) and normal deceleration time (>/= 150 ms). SETTING: Tertiary care centre. RESULTS: Patients with a short deceleration time had higher end systolic and end diastolic volume indices and a higher wall motion score index, but a lower ejection fraction, in the year after infarction. These patients also showed a significant increase in end diastolic (p < 0.001) and end systolic volume indices (p = 0.007) during the follow up period, while ejection fraction and wall motion score index remained unchanged. In the group with normal deceleration time, end diastolic volume index increased (p < 0.001) but end systolic volume index did not change; in addition, the ejection fraction increased (p = 0.002) and the wall motion score index decreased (p < 0.001). One year and five year survival analysis showed greater cardiac mortality in patients with a short deceleration time (p = 0.04 and p = 0.02, respectively). In a Cox model, which included initial ejection fraction, infarct location, and infarct size, deceleration time on day 1 was the only significant predictor of five year mortality. CONCLUSIONS: A short deceleration time on day 1 after acute myocardial infarction can identify patients who are likely to undergo left ventricular remodelling in the following year. These patients have a higher one year and five year cardiac mortality.

[Percutaneous transluminal ablation of the myocardial septum by embolization of the first branch of the anterior descending coronary artery using a small amount of absolute alcohol]. / Perkutana transluminalna ablacija septuma miokarda embolizacijom prve septalne grane prednje descedentne koronarne arterije malom kolicinom apsolutnog alkohol.

Percutaneous transluminal septal myocardial ablation (PTSMA) is becoming more and more significant in the therapy of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We report on the first successful PTSMA done in Yugoslavia in a 65-year old female patient with HOCM and in NYHA functional class III. The procedure was performed with infection of a relatively small amount of absolute alcohol (3 ml) in the first septal branch of LAD, and short duration of balloon inflation (3 minutes), with reduction of the left ventricular outflow tract gradient at rest from 88 mm Hg to 11 mmHg. The patient's in-hospital course was uneventful and has improved to NYHA functional class I.

[Reversible left ventricular dysfunction in coronary disease (part one): myocardial stunning]. / Reverzibilna disfunkcija leve komore u koronarnoj bolesti (prvi deo): osamucenost miokarda.

INTRODUCTION: The concept of myocardial stunning has been proposed by Braunwald and Kloner in early 1980's and is defined as transient postischemic myocardial dysfunction that persists after reperfusion, despite the absence of irreversible damage and restoration of normal or near normal coronary flow. Thus, the hallmark of stunned myocardium is the mismatch between coronary flow and myocardial function. MYOCARDIAL STUNNING: The two most plausible hypotheses used to explain the pathogenetic mechanisms of myocardial stunning are calcium and oxyradical hypotheses. According to the first one, myocardial stunning is the result of impaired calcium homeostasis caused either by calcium overload or decreased responsiveness of myofilaments to calcium. The oxyradical hypothesis postulates that generation of free oxygen radicals depresses myocardial function after the ischemic episode. The exact mechanism is unknown, but it is probably due to extreme reactivity of oxyradicals that bind to some cellular components, impairing membrane permeability and function of various cell organelle. Stunned myocardium can be seen in numerous clinical situations in which myocardial ischemia has been followed by reperfusion. These include: coronary artery bypass surgery, acute myocardial infarction, stable, unstable and variant angina, percutaneous transluminal coronary angioplasty and cardiac transplantation. DISCUSSION AND CONCLUSION: In majority of these situations, stunned myocardium is usually well tolerated. However, there is a group of high-risk patients in whom prolonged myocardial dysfunction due to stunning can cause serious hemodynamic instability, which requires pharmacological and/or mechanical support. Therefore, in order to avoid these situations, some authors have suggested that stunned myocardium should be prevented, rather than treated. Since stunned myocardium is by definition reperfused, with normal or near normal coronary flow, treatment is reserved only for those patients in whom stunned region is large enough to cause low cardiac output and hypotension. Revascularisation is usually unnecessary; however, there are situations in which episodes of repetitive stunning cause chronic myocardial dysfunction along with hibernated myocardium, when myocardial revascularization would be beneficial.

[Reversible dysfunction of the left ventricle in coronary disease (part two): hibernation and methods for detection of viability]. / Reverzibilna disfunkcija leve komore u koronarnoj bolesti (drugi deo): hibernacija i metode za otkrivanje vitalnosti.

HIBERNATION: Hibernating myocardium is defined as a state of persistently impaired myocardial function, as a consequence of reduced coronary flow, which can be partially or completely reversed if the myocardial oxygen consumption/demand ratio is favorably altered. Since it indicates concordance between flow and function (flow-function relation), it can be concluded that hibernating myocardium, caused by reduced myocardial perfusion, improves its function after surgical revascularization, giving its detection a great clinical importance. Hibernating myocardium can be found in majority of patients with coronary artery disease and chronic left ventricular dysfunction. These patients, even without typical symptoms of angina, will benefit from myocardial revascularization. This beneficial effect is expressed by ejection fraction enhancement, which is directly proportional to the number of dysfunctional, but viable segments. Also, symptom improvement depends on the mass of revascularized myocardium, which is previously shown to be viable. Having that in mind, the mass of viable myocardium must be large enough, so that the degree of expected improvement of myocardial function after revascularization justifies the operation itself. Opposing this classical concept of hibernating myocardium, recent studies have shown that in patients with coronary artery disease, coronary flow at rest is normal or just slightly reduced, which cannot explain the degree of myocardial dysfunction. According to that, it is proposed that myocardial dysfunction is, like in myocardial stunning, the result of flow-function mismatch, meaning that pathophysiology of hibernating myocardium includes a component of stunning as well. Therefore, hibernating myocardium can be defined as a form of reversible left ventricular dysfunction, caused by chronic coronary artery disease, which is partially due to episodes of repetitive stunning and shows improvement after inotropic stimulation. From practical point of view, it is important to detect hibernating myocardium in all patients with coronary artery disease and left ventricular dysfunction, since their treatment and prognosis directly depend on whether the dysfunction is reversible or not. METHODS FOR IDENTIFICATION OF MYOCARDIAL VIABILITY: Detection of myocardial viability has great clinical importance, since both regional and global left ventricular function can significantly improve, either spontaneously or by myocardial revascularization. Noninvasive imaging procedures used for that purpose include positron emission tomography, thallium-201 imaging, technetium-99 imaging, dobutamine echocardiography and tissue characterization. Using these methods, it is possible to assess the presence of viable tissue through evaluation of metabolic activity, integrity of myocyte membrane and the inotropic reserve of myocardium.

[Evaluation of left ventricular diastolic function using Doppler echocardiography]. / Procena dijastolne funkcije leve komore Dopler-ehokardiografijom.

INTRODUCTION: Clinical studies have shown that approximately 40% of patients with congestive heart failure have predominantly diastolic left ventricular dysfunction. Doppler echocardiography is a simple, noninvasive and safe technique that can be used for measurement of diastolic filling and, therefore for assessment of diastolic function. PHYSIOLOGY OF DIASTOLE: Diastole is divided into four phases: isovolumetric relaxation, rapid filling, slow filling (diastasis) and atrial contraction. Diastolic filling can be defined as the period from the onset of mitral valve opening to mitral valve closure. DETERMINANTS OF DIASTOLIC FILLING: The two major determinants of diastolic filling are ventricular relaxation (characterized by the rate and duration of the decrease of left ventricular pressure after systole) and compliance (defined by volume changes over the change in pressure during diastolic filling). NORMAL TRANSMITRAL FLOW PATTERN: When pulsed Doppler sample volume is placed at the tips of mitral leaflets, recorded transmitral velocity pattern is composed of two principal deflections: the E wave, occurring during the rapid filling phase, and the lower A wave, arising from atrial contraction. These two waves are usually separated with relatively low velocity signal during diastasis. Numerous indices derived from this pattern have been proposed as markers of diastolic function (peak and integrated velocities of the E and A waves, their ratio, and acceleration and deceleration times of the E wave). However, it should be noted that these indices, in fact, measure diastolic filling, rather than function. Even in healthy individuals, numerous factors may have impact on transmitral flow pattern, including age, heart rate, loading conditions and filling pressures. NORMAL PULMONARY VENOUS FLOW PATTERN: Analysis of pulmonary venous flow pattern (obtained by pulsed Doppler sample volume placed in pulmonary vein) gives additional information and may help in the assessment of left ventricular filling. Usually, three distinct velocity waves can be observed: S wave, occurring during ventricular systole; 1) wave, diastolic wave that begins after mitral wave opening: and finally, AR wave, reversal velocity during atrial contraction. When diastolic filling is altered, typically there is an inverse relationship between transmitral E and pulmonary venous S wave, as well as transmitral A and pulmonary venous D wave. PATHOLOGIC FILLING PATTERNS: There are three different pathologic filling patterns: 1) delayed (prolonged, impaired) relaxation pattern, characterized by prolonged isovolumetric relaxation time and deceleration time, low E and high A wave velocities with an E/A wave ratio typically 1; 2) restrictive pattern, associated with shortened isovolumetric relaxation time, increased peak E wave velocity with very short deceleration time, and small (or even absent) A wave, leading to an E/A wave ratio 2; and 3) pseudonormal pattern, usually an intermediate stage between delayed relaxation and restrictive filling, as a consequence of disease progression; it may be unmasked by Valsalva maneuver and is characteristically associated with atrial dilatation and prominent pulmonary venous AR reversal. CLINICAL APPLICATIONS: Impaired diastolic function is frequently the first detectable abnormality in many of cardiac diseases. With serial recordings, changing of filling patterns, from delayed relaxation, through pseudonormalization, and, finally, to restrictive filling pattern can be observed. These changes have been demonstrated to correspond well with progression of cardiac diseases. According to the severity of symptoms and transmitral filling pattern, four-grade model of diastolic dysfunction has been proposed. It has been shown that the E/A ratio 2 and deceleration time 150 ms indicate poor prognosis in patients with dilated cardiomyopathy, cardiac amyloidosis and old myocardial infarction, independently of the severity of systolic dysfunction. (ABS