Aortic root aneurysm extending into the arch as a rare complication of Kawasaki disease: surgical management.

An aortic aneurysm complicating Kawasaki disease (KD) is extremely rare. We herein report a case of 48-year-old KD patient with severe aortic regurgitation, aneurysm of the aortic root, ascending aorta and aortic arch, and giant heavily calcified coronary aneurysms. The patient underwent successful surgical management. This case raises some unusual technical issues, which are discussed. A review of the literature is also offered.

The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles.

OBJECTIVES: During unilateral selective cerebral perfusion (uSCP), with right axillary artery or brachiocephalic trunk cannulation, the brain receives blood only via the right common carotid artery and right vertebral artery (VA). The left hemisphere is perfused mainly through the circle of Willis (CW). However, at least 50% of individuals have some variation in the CW. The aim of the present work was to study the variations in CW and VA that could have an impact on haemodynamics during uSCP. METHODS: From May 2005 to March 2012, a total number of 250 circles obtained via routine dissection for medico-legal reasons were examined. The external diameters of all CW segments and both VAs were measured. From January 2008 to March 2012, a total number of 250 patients subjected to computed tomographic angiography of the CW were also examined. RESULTS: Nine evident configurations of the CW that could cause hypoperfusion during uSCP were observed. They were subdivided in to seven types, according to location and the number of major vessels at risk of hypoperfusion. Type IA: hypo/aplasia of left posterior communicating artery (PComA), found in 35.6% of cases; Type IB: hypo/aplasia of anterior communicating artery (AComA), found in 2% of cases; Type IIA: hypo/aplasia of both left PComA and AComA, found in 4.8% of cases; Type IIB: hypo/aplasia of precommunicating (P1) segment of left posterior cerebral artery or right VA, found in 9.2% of cases; Type IIIA: hypo/aplasia of precommunicating (A1) segment of right anterior cerebral artery, found in 6% of cases; Type IIIB: hypo/aplasia of both right VA and AComA, found in 0.2% of cases; Type IV: hypo/aplasia of both right A1 and right VA or both right A1 and left P1, found in 0.8% of cases. All types were present in 58.6% of all examined CWs. CONCLUSIONS: Our results show that CW variations are present in a significant number of patients. Our data support the need for extensive preoperative examination and meticulous intraoperative monitoring of cerebral perfusion during uSCP. Finally, our data support the superiority of bilateral SCP over uSCP, because most of the variations reported do not have haemodynamic significance during bilateral SCP.

Light and electron-microscopic study of leucine enkephalin immunoreactivity in the cat claustrum.

The claustrum is a complex telencephalic structure owing to its reciprocal connectivity with most--if not all--cortical areas. However, there is a paucity of data in the literature concerning its histochemical components, including opioid peptide neurotransmitters. The aim of the present study was to examine the morphology, distribution and ultrastructure of leucine-enkephalin-immunoreactive (Leu-enk-ir) neurons and fibers in the dorsal claustrum (DC) of the cat. Seven healthy, adult male and female cats were used in our study. All animals received humane care. They were irreversibly anesthetized and transcardially perfused with fixative. Brains were removed, postfixed, blocked and sectioned. Sections were incubated with polyclonal anti-Leu-enk antibodies using the Avidin-Biotin-Peroxidase Complex method. Leu-enk-ir neurons and fibers were distributed throughout the DC. Some of the neurons were lightly-stained, while others were darkly-stained. Light-microscopically, they varied in shape: oval, fusiform, multipolar and irregular. With regard to size, they were categorized as small (15 µm or less in diameter), medium (16-20 µm in diameter) and large (21 µm or more in diameter). No specific pattern of regional distribution was found. On the electron microscope level, immunoproduct was observed in neurons, dendrites and terminal boutons. Different types of Leu-enk-ir neurons differ in their ultrastructural features, including two types of synaptic boutons. No gender-specific features were observed. In conclusion, it is our hope that our study will serve to contribute to a better understanding of the functional neuroanatomy of the DC in the cat, and that it can be extrapolated and applied to other mammals, including humans.

Neuronal nitric oxide synthase immunopositive neurons in cat claustrum--a light and electron microscopic study.

Nitric oxide is a unique neurotransmitter, which participates in many physiological and pathological processes in the organism. Nevertheless there are little data about the neuronal Nitric Oxide Synthase immunoreactive (nNOS-ir) neurons and fibers in the dorsal claustrum (DC) of a cat. In this respect the aims of this study were: (1) to demonstrate nNOS-ir in the neurons and fibers of the DC; (2) to describe their light microscopic morphology and distribution; (3) to investigate and analyze the ultrastructure of the nNOS-ir neurons, fibers and synaptic terminals; (4) to verify whether the nNOS-ir neurons consist a specific subpopulation of claustral neurons; (5) to verify whether the nNOS-ir neurons have a specific pattern of organization throughout the DC. For demonstration of the nNOS-ir the Avidin-Biotin-Peroxidase Complex method was applied. Immunopositive for nNOS neurons and fibers were present in all parts of DC. On the light microscope level nNOS-ir neurons were different in shape and size. According to the latter they were divided into three groups-small (with diameter under 15 microm), medium-sized (with diameter from 16 to 20 microm) and large (with diameter over 21 microm). Some of nNOS-ir neurons were lightly-stained while others were darkly-stained. On the electron microscope level the immunoproduct was observed in neurons, dendrites and terminal boutons. Different types of nNOS-ir neurons differ according to their ultrastructural features. Three types of nNOS-ir synaptic boutons were found. As a conclusion we hope that the present study will contribute to a better understanding of the functioning of the DC in cat and that some of the data presented could be extrapolated to other mammals, including human.

Successful implantation of Berlin Heart INCOR system after Bentall/De Bono operation.

Berlin Heart INCOR system is a novel left ventricle assist device (LVAD), which generates a laminar blood flow. Its cannulas are implanted in the heart apex and the ascending aorta. The present paper reports a case of successful implantation of the Berlin Heart INCOR system after a Bentall/De Bono operation. In this case the outflow cannula of the device was implanted in the Sorin Carbonart 27/30 conduit used in the previous operation. After the implantation no unusual events like thrombosis, anastomosis malfunction, and so forth, were observed. On the 100th day after the implantation the patient was discharged home in good condition.

Successful fibrinolysis after acute left ventricular assist device thrombosis.

The Berlin Heart INCOR system (Berlin Heart AG, Berlin, Germany) is a left ventricular assist device that generates a laminar blood flow. One of our INCOR-implanted patients was admitted to the hospital with clinical data indicating device thrombosis. The flow through the pump was assessed by contrast injection into the inflow canula. Lack of flow through the pump was found. A decision was made to perform fibrinolysis, which was performed by a reteplase injection into the device's inflow canula. After the manipulation, a restoration of the flow through the pump was observed. The patient was discharged 9 days after the procedure with no complications.

Some variations of the circle of Willis, important for cerebral protection in aortic surgery--a study in Eastern Europeans.

BACKGROUND: During unilateral selective cerebral perfusion (SCP), via cannulation of the brachiocephalic trunk, the brain receives blood only through the right common carotid artery and the right vertebral artery. For perfusion of the contralateral (left) hemisphere it is counted on the competence of the circle of Willis (CoW). It is well known that variations of CoW are present in more than 50% of the people. Furthermore, these variations usually affect more than one vessel of the circle. The aim of the present work was to study the variations of CoW, which could have an impact on cerebral blood supply during unilateral SCP. METHODS AND MATERIALS: We study 112 CoWs obtained from cadavers via routine dissection in the Department of Forensic Medicine of Medical University, Sofia. The external diameter of both vertebral arteries and all arteries that form CoW was measured with a caliper-gauge. RESULTS: We identify the variations of CoW such as significant hypoplasy and/or lack of a branch of the circle. Bearing in mind the characteristics of the blood flow during unilateral SCP some of these variations were classified as significant during unilateral SCP. They were subdivided into groups according to most probable stroke site after unilateral SCP. CONCLUSIONS: Because of the high percent of the variations, hemodynamically significant during unilateral SCP, a suggestion for routine preoperative CT-angio of CoW could be made. Furthermore, an intraoperative follow-up with NIRO, transcranial Doppler, EEG, and so forth could also be recommended.

The Berlin Heart EXCOR in an 11-year-old boy: a bridge to recovery after myocardial infarction.

When a donor heart is not available during the end stage of heart failure, the implantation of a ventricular assist device is the only therapeutic alternative. Many such devices are designed to provide circulatory support to adults, but very few are available for children and infants, especially in the United States. In children, implantation of ventricular assist devices that are designed for adults carries a high risk of complications, because the low stroke volumes that must be used can result in inadequate pump washout and excessive thromboembolic risk. Herein, we report the case of an 11-year-old boy with congenital heart defects who experienced acute myocardial infarction. Prolonged support with the Berlin Heart excor Pediatric ventricular assist device served as a bridge to recovery. The period after device implantation was challenging, because of the need for prolonged inotropic support, continuous mechanical ventilation, the number of reoperations, and the occurrence of sepsis. Nevertheless, after 29 days, the patient's heart recovered, and the device was explanted. He was discharged from the hospital, in good condition, 30 days after removal of the excor device.

Parvalbumin in the cat claustrum: ultrastructure, distribution and functional implications.

The presence of the calcium-binding protein (CaBP) parvalbumin (PV) in the neuronal elements of the cat's dorsal claustrum was studied by immunohistochemistry at the light- and electron-microscopic level. PV-immunoreactive neurons and fibers were detected in all parts of the claustrum. The PV-immunoreactive neurons were divided into several subtypes according to their size and shape. Approximately 7% of all PV-immunoreactive neurons were classified as large, while approximately half of the labeled neurons were medium-sized. The small PV-immunoreactive neurons were 45% of the total PV-immunoreactive neuronal population. Ultrastructurally, many spiny and aspiny dendrites were heavily immunolabeled, and the reaction product was present in dendritic spines as well. Several types of synaptic boutons containing reaction product were also found. These boutons terminated on both labeled and unlabeled postsynaptic targets (soma, dendrites, etc.), forming asymmetric or symmetric synapses. Approximately 70% of all PV-immunoreactive terminals contained round synaptic vesicles and formed asymmetric synapses. The majority of these boutons were of the ''large round'' type. A lesser percentage were of the ''small round'' type. This paper represents the first study demonstrating the existence of PV, a CaBP, in the cat claustrum, and its distribution at the light and electron microscope level. Beyond the relevance of this research from the standpoint of adding to the paucity of literature on PV immunoreactivity in the claustrum of various other mammals (e.g. monkey, rabbit, rat, mouse), it is of particular significance that the cat claustrum is more similar to the rabbit claustrum than to any other mammalian species studied thus far, noted by the existence of four distinct morphologic subtypes. We also demonstrate a lack of intrinsic, and possibly functional, heterogeneity as evidenced by the uniform distribution of PV throughout the cat claustrum, across the four cell subtypes (i.e. inhibitory interneurons as well as projection neurons). Indeed, the association with, and influence of, the cat claustrum on diverse multisensory mechanisms may have more to do with its afferent than efferent relationships, which speaks strongly for its importance in the sensory hierarchy. Exactly what role PV plays in the claustrum is subject to discussion, but it can be postulated that, since CaBP is associated with GABAergic interneurons, synaptogenesis and neuronal maturation, it may also serve as a neuroprotectant, particularly with regard to pathologies associated with the aging process, such as in Alzheimer's disease.

New technique for implantation of the inflow canula of Berlin Heart INCOR system.

Berlin Heart INCOR system is a left ventricle assist device (LVAD), which generates a laminar blood flow. Its inflow canula is implanted in the heart apex, while its outflow canula-in the ascending aorta. In the present work a new alternative technique for implantation of the device's inflow canula is reported. The suggested technique is quicker and easier than the conventional one. It saves time and gives excellent results. After the implantation no unusual events like thrombosis, anastomosis malfunction, etc., are observed.

Light microscopical study of nitric oxide synthase I-positive neurons, including fibres in the vestibular nuclear complex of the cat.

Nitric oxide is a gaseous neurotransmitter that is synthesized by the enzyme nitric oxide synthase I (NOS I). At present, little is known of NOS I-positive neurons in the vestibular nuclear complex of the cat (VNCc). The aim of the present study was to examine the morphology, distribution patterns and interconnections of NOS I-positive neurons, including fibres in the VNCc. Five adult cats were used as experimental animals. All cats were anaesthetized and perfused transcardially. Brains were removed, postfixed, cut on a freezing microtome and stained in three different ways. Every third section was treated with the Nissl method, other sections were stained either histochemically for NADPH diaphorase or immunohistochemically for NOS I. The atlas of Berman (1928) was used for orientation in the morphometric study. NOS I-positive neurons and fibres were found in all parts of VNCc: medial vestibular nucleus (MVN); lateral vestibular nucleus (LVN); superior vestibular nucleus (SVN); inferior vestibular nucleus (IVN); X, Y, Z groups and Cajal's nucleus. The NOS I-positive neurons were classified according to their size (small, medium-sized, large neurons type I and type II) and their shape (oval, fusiform, triangular, pear-shaped, multipolar and irregular). In every nucleus, a specific neuronal population was observed. In SVN, a large number of interconnections between NOS I-positive neurons were identified. In MVN, chain-like rolls of small neurons were found. Tiny interconnections between MVN and mesencephalic reticular formation were present. Our data provide information on the morphology, distribution patterns and interconnections of NOS I-positive neurons in the VNCc and can be extrapolated to other mammals.