Soft tissue lipoma with the radiographic appearance of a neoplasm within the mandibular canal.

Lipomas and lipoma variants are common soft tissue tumours but are not commonly found in the oral and maxillofacial region. We report a case of a classic lipoma located on the medial aspect of the mandibular ramus, but not within bone, first seen by an oral and maxillofacial surgeon during treatment planning for routine extractions. Initial panoramic radiography indicated an expansive tumour in the area of the mandibular foramen and proximal end of the mandibular canal, apparently within the body of the mandible. Subsequent imaging with CT revealed a well-circumscribed soft tissue tumour on the medial aspect of the left mandibular ramus, not within the bone itself. Histological analysis of the operative specimen indicated a classic lipoma.

Ventriculocoronary artery bypass results using a mesh-tipped device in a porcine model.

BACKGROUND: In this report we describe the in vivo evaluation of a device and ventriculocoronary artery bypass procedure that creates a permanent transmyocardial channel between the left ventricle and a coronary artery. METHODS: The transmyocardial device, an L-shaped titanium tube with a meshed distal tip and an exterior polyester cuff, was implanted from the base of the left ventricle to the proximal left anterior descending coronary artery in 11 healthy juvenile domestic pigs using a beating-heart approach. Flow rates were measured at implant. Patency was assessed at explant for surviving animals at 2 (n = 3) and 4 weeks (n = 4). RESULTS: Flow through the transmyocardial device after implantation was 74% of base line. Forward flow occurred during systole. Luminal patency was 100% at 2 weeks and 75% at 4 weeks. Histologic analysis showed little to no intimal proliferation at the coronary interface. CONCLUSIONS: This short-duration study shows promise for perfusing ischemic myocardium with systolic flow. The transmyocardial titanium conduit and treated coronary artery patency was good at 2 and 4 weeks and warrants further studies.

OPCAB surgery: a critical review of two different categories of pre-operative ejection fraction.

OBJECTIVE: Literature review found little information on off-pump coronary artery bypass (OPCAB) procedure in patients with poor left ventricular function and there was no information comparing the low EF and normal EF patients undergoing OPCAB procedure. METHODS: Between 1/1/1998 and 6/30/1999, 387patients had surgery performed utilizing the off-pump technique and 45 of these patients had pre-operative left ventricular function of equal to or less than 30% (LVEF < or =30). The two groups (LVEF < or =30 and LVEF>30) were compared using univariate analysis. Patients in LVEF < or =30 were older and more female gender. LVEF< 30 had more NYHA class IV patients (64 vs. 50%) and more symptoms related to depressed left ventricular function. The mean pre-operative left ventricular function was 25% in LVEF < or =30 and 56% in LVEF>30. Pre-operative predicted risk was 6.4+/-5.5% in LVEF < or =30 and 2.7+/-4.5% in LVEF>30 (P< 0.001). Most (> 95%) of the patients in both groups were elective status, and LVEF < or =30 patients had increased incidence of redo (11 vs. 6%, P=0.2). In LVEF>30, 84% of the patients had stable angina while only 69% in LVEF < or =30 (P=0.009). RESULTS: Intra-operatively no significant differences were measured in number of grafts per patient (2.7 vs. 2.8), amount of blood loss, peak CK-MB, skin-to-skin time, or OR time. Patients with LVEF < or =30 have more frequent utilization IABP during pre, intra and post-operative period. The statistical analysis yields no significance in post-operative major neurological deficit between these two groups; and are comparative to the nationally reported incidence of neurological deficit for on-pump patients. The operative mortality in the low EF group was 4.4 and 1.8% in LVEF>30 group (P=0.23). CONCLUSIONS: Given the clinical presentation of the low EF group, higher prediction risk, longer pre-operative stay, and length of ventilation (24 vs. 8 h P=0.12) a longer surgery to discharge stay (8 vs. 6 days, P=0.02) is anticipated. Short-term clinical outcomes for both groups of OPCAB patients encouraged us to continue to offer this approach to this broad base of patient population.

A multicenter, randomized, controlled trial of Celsior for flush and hypothermic storage of cardiac allografts.

BACKGROUND: A multicenter, randomized, controlled, open-label trial was conducted to evaluate the safety and efficacy of Celsior when used for flush and hypothermic storage of donor hearts before transplantation. METHODS: Heart transplant recipients were randomized to one of two treatment groups in which donor hearts were flushed and stored in either Celsior or conventional preservation solution(s) (control). Study subjects were followed for 30 days after transplantation. RESULTS: A total of 131 heart transplant recipients were enrolled (Celsior, n = 64; control, n = 67). The treatment groups were evenly distributed in donor and recipient base line characteristics. Graft loss rate was lower in the Celsior group on day 7 (3% versus 9%) and on day 30 (6% versus 13%), but the difference was not statistically significant based on 95% confidence interval analysis. No significant difference was measured between the Celsior and control groups in 7-day patient survival (97% versus 94%) and the proportion of patients with one or more adverse events (Celsior, 88%; control 87%) or serious adverse events (Celsior, 38%; control, 46%). Significantly fewer patients in the Celsior group developed at least one cardiac-related serious adverse event (13% versus 25%). CONCLUSIONS: Celsior was demonstrated to be as safe and effective as conventional solutions for flush and cold storage of cardiac allografts before transplantation.

A retrospective assessment of safety, efficacy, and pharmacoeconomics of generic azathioprine in heart-transplant recipients.

Although a generic formulation of azathioprine (AZA) has been available since 1996, safety, efficacy and pharmacoeconomic implications following conversion from Imuran (AZA) to generic AZA in heart-transplant patients remains to be determined. A retrospective, safety and efficacy assessment, in addition to a cost comparison, was performed in 30 heart-transplant patients who had been switched from Imuran to generic AZA. In heart-transplant patients converted from Imuran to generic AZA, no compromise in safety and efficacy, as measured by white blood cell (WBC) count, infections, rejections, malignancies, and hospitalizations was observed. Generic substitution of Imuran results in an annual cost savings of $318 per patient.

The initial United States experience with the ATS mechanical cardiac valve prosthesis.

From January 1, 1997 through June 30, 2000, 224 patients underwent valve replacement with the ATS Medical cardiac valve prosthesis under a USFDA-approved investigational device exemption study. Aortic valve replacement (AVR) was conducted in 152 patients (39 with coronary bypass) and mitral replacement (MVR) in 72 patients (18 with coronary bypass). Overall operative mortality was 1.8% (AVR = 2.8%, MVR = 0%), with only one valve-related death. In 372 patient-years of follow-up, there were an additional four patient deaths, two of which were valve related following a stroke. Valve-related complications included: thromboembolism (linearized rate = 3.8% per patient year), of which 3/11 had chronic deficits (0.8% per patient year); thrombosis (1 MVR = 0.8% per patient year); paravalvular leak (1 AVR = 0.4% per patient year); anticoagulant-related hemorrhage (1 AVR and 5 MVR = 1.6% per patient year) with no patient mortality; prosthetic valve endocarditis (1 MVR = 0.8% per patient year); and valve dysfunction (0%). Echocardiographic gradients were proportional to valve size and did not significantly change over the follow-up period. This study documented the ATS Medical prosthesis to be a valuable addition to the surgeon's armamentarium in the treatment of cardiac valvular disease.

Is low ejection fraction safe for off-pump coronary bypass operation?

BACKGROUND: Does the manipulation of the heart during off-pump coronary artery bypass (OPCAB) procedure further compromise the hemodynamic stability of a patient with depressed left ventricular function compared with the conventional coronary artery bypass (CCAB) approach? Does this manipulation induce a more dramatic hypoperfused state that may contribute to an increase in the incidence of related complications or mortality? This retrospective review of data attempted to answer the above concern. METHODS: Between January 1, 1998, and June 30, 1999, 177 patients with ejection fractions of 30% or less underwent full sternotomy coronary artery bypass grafting at our institution. Of these patients, 45 underwent OPCAB procedures and 132 patients underwent CCAB. Pre-, intra-, and postoperative variables as identified by The Society of Thoracic Surgeons National Cardiac Surgery Database were compared using univariate and logistical regression analysis. RESULTS: Despite recognized hemodynamic derangement during cardiac displacement, these groups of OPCAB patients appeared to tolerate the procedure well. Univariate analysis of cardiac enzyme leak and blood loss was statistically significant in the OPCAB patients. Utilizing regression analysis, cardiopulmonary bypass was the only predictor for all postoperative complications. CONCLUSIONS: Multivessel coronary artery bypass utilizing the OPCAB approach in patients with depressed left ventricular function of equal to or less than 30% is appropriate and applicable. Analysis of CCAB and OPCAB variables was nonsignificant except for operative and postoperative blood loss and peak cardiac enzyme leak. Attention to intraoperative detail and hemodynamic management could be credited for the success with OPCAB.

Does multivessel, off-pump coronary artery bypass reduce postoperative morbidity?

BACKGROUND: Off-pump coronary artery bypass (OPCAB) is an emerging procedure. It is assumed that elimination of cardiopulmonary bypass for coronary artery bypass grafting has the potential for reducing postoperative morbidity. This review evaluates the safety and impact of multivessel OPCABG as compared to CABG. METHODS: A retrospective review of 744 patients undergoing multivessel coronary artery bypass between January 1, 1997, and March 31, 1999, was done. The total population was divided into two groups: group A (n = 609 cardiopulmonary bypass) and group B (n = 135 OPCAB). This consecutive study cohort was elective status, full sternotomy with three or more distal anastomoses performed at a single institution. RESULTS: The mean risk adjusted predicted mortality was 2.3% in group A and 2.7% in group B (p = NS), with the mean number of distal anastomosis being greater in group A (3.8 vs 3.5/patient, p < 0.001). Major postoperative complications were similar but were not statistically significant between groups. Postoperative blood loss and use of blood transfusions were the only significant variables (p < 0.001). CONCLUSIONS: Multivessel OPCABG can be safely performed in selected patients. Elimination of cardiopulmonary bypass did not significantly reduce postoperative morbidity. Prospective randomized trials and long-term follow-up are needed to better define patient selection and the role of OPCABG.

Safety and efficacy of off-pump coronary artery bypass grafting.

BACKGROUND: We evaluated the application of the off-pump coronary artery bypass (OPCAB) procedure relative to safety and efficiency as measured by operative mortality postoperative complications and longitudinal outcome. METHODS: Three hundred and fifty OPCAB patients were compared to 3,171 on-pump or conventional coronary artery bypass (CCAB) patients between January 1, 1997 and December 31, 1998. The groups were divided into three preoperative predicted risk categories: low-risk (0 to 2.59%), medium-risk (2.6 to 9.9%), and high-risk (> or =10%). Society of Thoracic Surgeons National Cardiac Surgery Database definitions and predicted risk group models were utilized to compare all preoperative, intraoperative, and postoperative variables using univariate analysis. RESULTS: Overall comparison of the immediate outcome of CCAB and OPCAB shows little statistical significance in the variables analyzed. The operative mortality was 3.4% in both groups. When the immediate outcome was compared between groups (CCAB vs OPCAB), as well as individual risk groups (low, medium, and high), similar patterns of operative variables and postoperative complications were observed. The operative mortality in the low-risk group was 1.1% for CCAB and 1.4% for OPCAB; 7% for CCAB and 6% for OPCAB in the medium-risk group; and in the high-risk group 28.5% for CCAB compared to 7.7% for OPCAB group (p = 0.008). Short-term follow-up shows a trend of increased recurring angina and reinterventional procedures in the OPCAB patients. CONCLUSIONS: Safety for OPCAB is assessed through retrospective data review. Longitudinal follow-up for survival, reintervention, and quality of postoperative document efficacy and patency rates, compared to on-pump procedures, is mandatory. This study documented the immediate safety of the OPCAB procedure. Preliminary findings at 1-year follow-up is an important finding in this study, but it is not conclusive at this time. Long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB.

A case for minimally invasive coronary surgery as primary treatment for left anterior descending coronary artery disease.

OBJECTIVE: The introduction of minimally invasive coronary bypass surgery has allowed the application of multiple approaches to coronary artery disease. METHODS: Technologic developments have resolved patency and myocardial ischemic issues and increased surgical experience and training have combined to make more coronary bypass surgeons facile in minimally invasive surgical techniques. RESULTS: These advances, along with the decreased invasiveness, shortened recovery and lower cost, suggest the application of these techniques to the primary treatment of disease of the anterior descending artery. CONCLUSION: In selected circumstances such as these in which patient co-morbid risk factors would suggest high recurrence rates in complex lesions or total occlusion of the anterior descending coronary artery and present in cases of in-stent restenosis, primary application of minimally invasive bypass techniques may create long-term benefits for patients.

Nefazodone and cyclosporine drug-drug interaction.

Depression is a significant post-transplant complication often necessitating drug therapy. Many of the newer selective serotonin reuptake inhibitor (SSRI) antidepressants are metabolized by the same cytochrome P450IIIA isoenzyme system that is responsible for the metabolism of cyclosporine, and these agents pose an interactive risk in transplant patients. We have observed nearly a 10-fold increase in whole blood cyclosporine concentrations in a cardiac transplant patient shortly after the addition of nefazodone antidepressant therapy. We suggest there is a clinically significant drug-drug interaction between nefazodone and cyclosporine due to inhibition of cytochrome P-450 IIIA4 isoenzymes by nefazodone.

Management priorities and treatment strategies for medical emergencies in the dental office.

The importance of prioritization in the management of the emergency dental patient cannot be overemphasized. Each dentists' ability to recognize and deal with emergencies depends on the dentists' education, the training of the staff, and the available equipment. This article helps the dentist prioritize the management of medical emergencies by examining preventive protocol and treatment options, as well as preparation and training strategies.

Evaluation of two new heart valve surgery techniques: partial sternotomy and port-access approaches.

OBJECTIVES: This review attempts to compare the port-access and partial sternotomy approaches of minimally invasive valve surgery. METHODS: Our brief experiences of the two techniques are summarized with an attempt to compare safety, cost-effectiveness of the procedure and post discharge follow-up. One hundred and two patients undergoing the procedures between May 1996 and October 1998 were analyzed. There were 65 patients in the partial sternotomy (MIV) group and 37 patients in the port-access (PAV) group. With the exception of a higher incidence of COPD in the MIV patients, there was no significant difference in pre-operative variables between these two groups. RESULTS: Total operating room time, surgery time and cross-clamp time were significantly increased in the PAV group. The operative mortality of patients with MIV was 3% (n = 2) while the PAV group was 8% (n = 3) (P = ns). More new atrial fibrillation was found in the MIV (26% versus 5%, P = 0.009). Otherwise, there was no significant complications observed in either group. During the 4-6 week follow-up, of those who were employed, 76% of MIV and 69% of PAV patients had returned to work. Of the retired patients more than 95% of the patients in both groups had resumed their daily routine activity. Importantly, the study showed PAV patients returned to work about 4 weeks sooner than MIV patients. CONCLUSIONS: MIV approach is more 'surgeon friendly' and can be carried out without increased intra-operative resource utilization. The PAV approach requires formal training and capital outlay for unique equipment, disposable and ancillary procedures. From a financial perspective, if the PAV technique is to become widely accepted intra-operative efficiencies must be maximized, post-operative fast-tract protocol must be utilized, financial expenditures for disposable equipment must decrease and requirement of ancillary procedures must be reduced.

Comparison between port-access and less invasive valve surgery.

BACKGROUND: Valvular operations have followed coronary artery bypass grafting as procedures that are amenable to a minimally invasive approach. This study is a review of our brief experiences of less invasive valve surgery (LIVS) through a partial sternotomy approach and port-access valve surgery (PAVS) with an attempt to compare safety and cost-effectiveness of the surgical procedure and post-discharge follow-up. METHODS: Forty PAVS and 66 LIVS procedures performed between May 1996 and December 1998 were reviewed. The PAVS patients were younger, included more men, and had greater left ventricular function. Aside from these particular data points, there was no significant difference in preoperative variables between groups. RESULTS: Operating room time, surgery time, and cross-clamp time were significantly longer in the PAVS group. The operative mortality was 3% (LIVS) and 5% (PAVS). There was more new atrial fibrillation in LIVS (26% versus 5%, p = 0.009). Postoperative follow-up revealed 77% of LIVS and 76% of PAVS patients had returned to work and more than 95% of the retired patients in both groups had resumed their daily activities. Importantly, PAVS patients returned to work about 4 weeks sooner than LIVS patients did. CONCLUSIONS: Early clinical outcomes are comparable between the two approaches, which indicates safety and importance of appropriate patient selection. More follow-up is required to assess postoperative pain and cosmetic satisfaction. At the present time, LIVS appears to be more cost-effective. Early return to work in the PAVS group may be the most important finding to further support the port-access approach. However, with practice pattern changes and increased intraoperative efficiencies, each of these two surgical techniques may continue to have an important role in the minimally invasive valve surgery arena.

Cost-effectiveness of minimally invasive coronary artery bypass surgery.

BACKGROUND: Coronary artery bypass grafting without cardiopulmonary bypass is gaining popularity as an alternative to conventional on-pump technique for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off-pump (OPCAB) methods. These two approaches should be evaluated for financial and clinical appropriateness. METHODS: Records of patients who had single or double bypass (internal mammary artery and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed. These included 44 MIDCAB, 62 OPCAB, and 243 conventional coronary artery bypass (CCAB) patients. Univariate analysis was applied to pre, intra, and postoperative variables, comparing MIDCAB and OPCAB to the CCAB group. Procedural cost information was obtained from participating institutions. RESULTS: MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4+/-11 versus 2.3+/-2.8, p = 0.012) and OPCAB patients had a predicted risk of 5.3+/-7.8. MIDCAB and OPCAB procedures required less operating room time and blood utilization. Observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6%, and CCAB 2.8% (not significant). Mean hospital costs were CCAB at $19,000, OPCAB at $15,000, and $17,000 for MIDCAB. CONCLUSIONS: Off pump procedures currently reflect acute episode-of-care cost savings over CCAB.