Enfermedad cardiovascular en la nefropatía lúpica: un riesgo infraestimado / Cardiovascular disease in lupus nephritis: An underestimated risk

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Accuracy of Contrast-Enhanced Ultrasound in the Diagnosis of Bile Duct Obstruction.

PURPOSE: To investigate the ability of contrast-enhanced ultrasound (CEUS) to differentiate benign from malignant lesions causing biliary duct obstruction. MATERIALS AND METHODS: Between November 2006 and December 2013, 59 patients with bile duct obstruction of undetermined cause in baseline ultrasound underwent CEUS study. The enhancement and posterior washout were analyzed in real time all along the study duration (5'). The final diagnosis suggested by CEUS was compared with histologic diagnosis (47.5%) or with radiologic follow-up with TC, RM or ERCP. RESULTS: Final diagnoses included 42 malignant lesions (cholangiocarcinoma n=22, metastases n=6, pancreatic carcinoma n=6, hepatocarcinoma n=4, gallbladder carcinoma n=2, ampullary carcinoma n=1 and lymphoma n=1) and 17 benign lesions (lithiasis or biliary sludge n=15, xanthogranulomatous cholecystitis n=1 and indeterminate n=1). CEUS accuracy compared with final diagnoses based on combined reference standard was 86.4%. CEUS correctly identified 36 of 42 malignant lesions (sensibility 85.7%) and 15 of 17 benign lesions (specificity 88.2%). The positive predictive value of CEUS for malignancy was 94.7%, while the negative predictive value was 71.4%. CONCLUSION: CEUS is useful to differentiate between benign and malignant causes of obstructive jaundice. This technique improves the detection of bile duct invasion in hepatic neoplasms and permits better evaluation of intra- and extraductal extension of hilar hepatobiliary tumors.

Accessory spleen torsion: US, CT and MR findings.

Torsion of an accessory spleen is a very unusual entity that can appear with abdominal pain associated with the presence of an avascular mass. We report the case of a 13-year-old boy with torsion and infarction of an accessory spleen presenting as a painful abdominal mass in which imaging examination with US, CT and MR showed a large avascular mass in the upper left abdomen.

Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: A multicenter experience.

BACKGROUND: Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients with dysfunction of a prior Fontan connection. METHODS: Thirty-one patients (19.9 +/- 8.8 years) underwent revision of a previous Fontan connection to total extracardiac cavopulmonary anastomosis at four institutions. Complications of the previous Fontan connection included atrial tachyarrhythmias (n = 20), progressive heart failure (n = 17), Fontan pathway obstruction (n = 10), effusions (n = 10), pulmonary venous obstruction by an enlarged right atrium (n = 6), protein-losing enteropathy (n = 3), right atrial thrombus (n = 2), subaortic stenosis (n = 1), atrioventricular valve regurgitation (n = 3), and Fontan baffle leak (n = 5). Conversion to an extracardiac cavopulmonary connection was performed with a nonvalved conduit from the inferior vena cava to the right pulmonary artery, with additional procedures as necessary. RESULTS: There have been 3 deaths. Two patients died in the perioperative period of heart failure and massive effusions. The third patient died suddenly 8 months after the operation. All surviving patients were in New York Heart Association class I (n = 20) or II (n = 7), except for 1 patient who underwent heart transplantation. Early postoperative arrhythmias occurred in 10 patients: 4 required pacemakers, and medical therapy was sufficient in 6. In 15 patients, pre-revision arrhythmias were improved. Effusions resolved in all but 1 of the patients in whom they were present before revision. The condition of 2 patients with protein-losing enteropathy improved within 30 days. CONCLUSIONS: Conversion of a failing Fontan connection to extracardiac cavopulmonary connection can be achieved with low morbidity and mortality. Optimally, revision should be undertaken early in symptomatic patients before irreversible ventricular failure ensues.

Amyloid goitre: CT and MR findings.

Two cases of amyloid goitre presented as an enlarged thyroid mass with cystic components. Solid parts of the goitre showed high attenuation on computed tomography (CT) and moderate hypointensity on T1 and T2-weighted images. Fine needle aspiration was negative for amyloid, but pathological studies of surgical specimens demonstrated amyloid infiltration of the thyroid interstitium and regressive colloid cysts. In a patient at risk for systemic amyloidosis, thyroid enlargement with a cystic component suggests amyloid goitre. In this case, needle biopsies should be directed to solid areas of the mass because amyloid material may not be present in the cysts.

The effect of reperfusion pressure on early outcomes after coronary artery bypass grafting. A randomized trial.

Among 60 patients randomly assigned to a reperfusion pressure of 50 mm Hg or one of 75 mm Hg (30 mm Hg during the first 2 minutes in both groups) during initially hyperkalemic, controlled aortic root reperfusion after coronary artery bypass grafting, no in-hospital deaths occurred, no patient received an intraaortic balloon pump, no patient had new Q waves, and creatine kinase MB release was similar in the two groups. Median interval between the beginning of reperfusion and the return of rhythmic cardiac contractions in the 50 mm Hg group was 7 minutes; in the 75 mm Hg group, it was 5 minutes (P = 0.1). The initial reactive hyperemic response was greater in the 75 mm Hg group. There were no believable differences (P < 0.1) between the two groups in postoperative cardiac output, left and right atrial pressure, arterial blood pressure, and prevalence of catecholamine administration.

Superiority of controlled surgical reperfusion versus percutaneous transluminal coronary angioplasty in acute coronary occlusion.

Although percutaneous transluminal coronary angioplasty is successful in more than 90% of patients after acute coronary occlusion, overall mortality remains approximately 10% with higher subgroup mortality (i.e., occlusion of the left anterior descending coronary artery, multivessel disease, age older than 70 years, cardiogenic shock) and early recovery of regional wall motion is marginal. This multicenter report shows that controlled surgical reperfusion in patients with acute coronary occlusion reduces overall and subgroup mortality and restores substantial early contractility. In a survey from six institutions, 156 consecutive patients with acute coronary occlusion documented by angiography underwent surgical revascularization with controlled reperfusion using amino acid-enriched blood cardioplegic solution on total vented bypass. Ventricular wall motion was studied by echocardiography or multiple gated acquisition scan on postoperative days 5 to 7 and scored independently (0 = normal, 1 = mild hypokinesia, 2 = severe hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared with results in 1203 patients with acute coronary occlusion treated by angioplasty in five reported medical series. Surgically treated patients were revascularized at longer ischemic intervals (6.3 versus 3.9 hours, p < 0.05) and had a greater incidence of left anterior descending occlusion (61% versus 43%, p < 0.05), multivessel disease (42% versus 22%, p < 0.05), and cardiogenic shock (41% versus 10%, p < 0.05), with 12 patients undergoing cardiopulmonary resuscitation en route to the operating room. Surgical results were superior in all categories, with overall mortality reduced from 8.7% after angioplasty to 3.9% after coronary bypass (p < 0.05). All surgical deaths occurred in patients with preoperative cardiogenic shock. Regional wall motion recovered significantly (score < 2) in 131 of 150 (87%) surgically treated patients with an average score of 0.9 +/- 0.8 (normal to mild hypokinesia) despite longer ischemic times.

Riedel thyroiditis: US, CT, and MR evaluation.

We report the ultrasound, CT, and MR findings in a patient with Riedel thyroiditis. The hypointensity of the lesion observed on T1- and T2-weighted sequences, especially when associated with infiltration of adjacent structures of the neck, can be suggestive of Riedel thyroiditis.

Chylous ascites associated with acute pancreatitis in a patient undergoing continuous ambulatory peritoneal dialysis.

We report on a case of chylous ascites associated with acute pancreatitis secondary to gallbladder stone disease, in a patient undergoing continuous ambulatory peritoneal dialysis. The initial clinical presentation was one of bacterial peritonitis, with later appearance of chylous peritoneal drainage. Diagnosis was suggested by abdominal computed tomography and confirmed by surgical exploration. We discuss the main diagnostic keys of peritoneal dialysis-associated pancreatitis and the possible etiologic role of this entity in chylous ascites of these patients.

Hemorrhagic cyst mimicking renal malignancy in a child.

Hemorrhage is a very rare complication of renal cyst in childhood. We report a six year-old-male with spontaneous macroscopic hematuria in which ultrasound and CT studies demonstrated a solid renal mass. Pathological examination of the resected lesion revealed a hemorrhagic cyst.

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.

Mechanical cardiac valve thrombosis. Is fibrinolysis justified?

BACKGROUND: Thrombosis is a serious complication of heart valve replacement, and management is often difficult. In recent years, thrombolytic therapy has been used as the primary technique by some investigators. METHODS AND RESULTS: Sixty-four consecutive patients presenting with 75 instances of prosthetic heart valve thrombosis (41 mitral, 33 aortic, one tricuspid) were treated with fibrinolytic agents. Obstructed prosthetic valves comprised 39 tilting disc and 36 bileaflet valves. The time interval between valve replacement and obstruction ranged from 15 days to 192 months (mean, 38 months). Fibrinolytic agents used were streptokinase (42 patients), urokinase (27 patients), or recombinant tissue-type plasminogen activator (six patients). Immediate results of fibrinolytic treatment were 1) full success after one or several consecutive fibrinolytic regimens in 55 cases (73%), 2) incomplete improvement in two cases, and 3) failure in 18 cases, leading to an emergency surgery in nine cases. Nine patients died (four strokes, four cardiac arrests, one hemorrhage). Only one severe hemorrhagic complication was observed, but 11 cases of embolism occurred during fibrinolytic treatment (14.6%) (four major cerebral embolisms with death). The immediate efficacy was better for thrombosed aortic prosthesis than with the mitral prosthesis (85% versus 63%). CONCLUSIONS: Fibrinolytic treatment appears to be an attractive nonsurgical alternative for prosthetic heart valve thrombosis, but because of the risk of cerebral embolism, its use should be reserved for tricuspid valve thrombosis or critically ill patients with mitral or aortic valve thrombosis. The use of a fibrinolytic agent in cases of small, nonobstructive paravalvular thrombosis demonstrated with transesophageal echocardiography needs further studies.

A new biodegradable elastin-fibrin material; its use in urological, digestive and cardiovascular surgery.

A new original artificial connective matrix mainly made of elastin and fibrin-like product is used to reinforce damaged tissues and to close and restore a loss of substance in several domains of surgery: all sites in the digestive system and urinary tract; besides, it can substitute for the pericardium in iterative heart operations. In all cases, the original tissue is restored ad integrum while the biodegradable material disappears completely, without any complications.

[Cardiac compression by a large thymic cyst. Apropos of a case, review of the literature]. / Compression cardiaque par un volumineux kyste thymique en bissac. A propos d'un cas, revue de la littérature.

Thymic cysts are rare and almost always asymptomatic. The authors report the case of a 45 year old woman with a thymic cyst diagnosed after recurrent right sided heart failure resulting in signs suggestive of adiastole, regressing after "pleural" (mainly cystic) aspiration and diuretic therapy without any morphological or functional changes on Doppler echocardiography. This report concerns a rare tumour, with an exceptional volume (2 litres) extending down the cardiac borders and causing cardiac compression. It illustrates the diagnostic difficulty of a pathology with an unusual clinical presentation, despite complementary investigations including CT scan and MRI, very sensitive in this type of problem. A complete cure was obtained by total surgical ablation.