Cardiac three-dimensional rotational angiography can be performed with low radiation dose while preserving image quality.

AIMS: The effective radiation dose (ED) of three-dimensional rotational angiography (3DRA) is 5-8 mSv, leading to reticence on its use. We evaluated the potential of 3DRA with a reduced number of frames (RNF) and a reduced dose per frame. METHODS AND RESULTS: Three-dimensional rotational angiography was performed in 60 patients (52.5 ± 9.6 years, 16 females) referred for ablation in the right (RA; n = 10) and left atrium (LA; n = 50). In a simulation group (n = 20), the effect of dropping frames from a conventional 248 frames 3DRA LA acquisition was simulated. In a prospective group (n = 40), RNF 3DRA were acquired of LA (n = 30) and RA (n = 10) with 67 frames (0.24 Gy/frame) and 45 frames (0.12 µGy/frame), respectively. Accuracy was evaluated qualitatively and quantitatively. Effective radiation dose was determined by Monte Carlo simulation on every frame. In the simulation group, surface errors increased minimally and non-significantly when reducing frames from 248 to 124, 83, 62, 50, 42, and 31: 0.49 ± 0.51, 0.52 ± 0.46, 0.61 ± 0.49, 0.62 ± 0.47, 0.71 ± 0.48, and 0.81 ± 0.47 mm, respectively (Pearson coefficient 0.20). All 3D LA images were clinically useful, even with only 31 frames. In the prospective group, good or optimal 3D image quality was achieved in 80% of LA and all of RA reconstructions. These accurate models were obtained with ED of 2.6 ± 0.4 mSv for LA and 1.2 ± 0.5 mSv for RA. CONCLUSION: Three-dimensional rotational angiography is possible with a significant reduction in ED (to the level of prospectively gated cardiac computed X-ray tomography) without compromising image quality. Low-dose 3DRA could become the preferred online 3D imaging modality for pulmonary vein isolation and other anatomy-dependent ablations.

Diagnostic criteria of broad QRS complex tachycardia: decades of evolution.

Broad QRS complex tachycardia still presents a diagnostic challenge when confronted with a 12-lead electrocardiogram (ECG). The ECG differential diagnosis includes ventricular tachycardia vs. supraventricular tachycardia with functional aberration, pre-existing bundle branch block, intraventricular conduction disturbances, or pre-excitation. Despite all available criteria, broad complex tachycardias are still misdiagnosed or remain undiagnosed. This paper will briefly review the most recognized criteria.

Combined anterior and inferior ST-segment elevation Electrocardiographic differentiation between right coronary artery occlusion with predominant right ventricular infarction and distal left anterior descending branch occlusion.

Seven cases are reported of acute right coronary artery occlusion and predominantly right ventricular myocardial infarction with typical ST-segment elevation in the precordial leads resembling acute anterior wall myocardial infarction. These electrocardiograms were compared with those of 5 unselected patients who had combined inferior and anterior ST-segment elevation due to a distal occlusion of the left anterior descending artery. In this manuscript, the electrocardiographic features of both conditions are briefly discussed.

Acute anteroseptal myocardial infarction in a patient with dextrocardia.

Dextrocardia with situs inversus is an uncommon congenital condition in which the major visceral organs are reversed. The clinical diagnosis and electrocardiographic localization of myocardial infarctions in these patients remain a great challenge. We report a case of a 64-year-old man known with dextrocardia and situs inversus totalis presenting with acute chest pain irradiating to the right arm. The admission and reversed "normalized" electrocardiogram are presented, allowing for correct diagnosis of an acute anteroseptal myocardial infarction. The present case emphasizes the importance of performing a reversed electrocardiogram in patients with dextrocardia.

Dystocia, consumptive coagulopathy, and cardiac failure as complications of a congenital benign mesenchymoma.

A congenital benign mesenchymoma which arose in the right foot resulted in dystocia. Shortly after birth, high-output cardiac failure developed secondary to abnormal shunting in the extensive irregular vasculature. Consumptive coagulopathy also occurred, believed to be the result of widely dilated abnormal vessels and extensive necrosis secondary to the trauma of the dystocia. These problems disappeared after resection of the tumor; there has been no recurrence after 2 years.

Cone biopsy during pregnancy.

Under a diagnostic schema that used cervical conization liberally for evaluating women with abnormal Papanicolaou smears, 82 pregnant patients underwent conization. Fifteen had significant morbidity related to cervical bleeding. The uncorrected perinatal mortality was 44.1/1000. Sixty-one cone biopsies, performed before colposcopy was introduced into the schema, uncovered 2 cases of previously undiagnosed invasive carcinoma. Among 21 patients who underwent colposcopy before conization, 1 case of microinvasive carcinoma was diagnosed. During the study, 15 patients with frankly invasive carcinoma were identified, 9 by punch biopsy of a gross lesion, 2 by cone biopsy without prior colposcopy, and 4 by colposcopically directed punch biopsy. As a result of the review, the diagnostic schema has been changed so that biopsy is used less often on pregnancy patients.

Benign gastric ulcer in a patient with betazole-fast achlorhydria.

We report a case of benign gastric ulcer that occurred in a 50-year-old man with betazole hydrochloride-fast achlorhydria. The rarity of exceptions to the rule that ulcers in achlorhydric stomachs are malignant (to our knowledge, this is only the sixth reported case) confirms the wisdom of regarding such ulcers as malignant until proved unequivocally to be benign.

Specific red cell adherence test applied to tumors of ureter and renal pelvis.

The specific red cell adherence (SRCA) test used previously as a prognostic indicator of bladder tumors was used in a retrospective review of 14 patients with transitional cell carcinoma of the ureter and renal pelvis. SRCA-positive individuals appear to have better survival and progress less frequently to metastatic disease. Of five patients with positive reactions, none had distant metastases. Conversely, in SRCA-negative individuals metastatic disease developed more frequently (4 of 9). The SRCA test can be as useful a test of the prognosis of ureteral and renal pelvis tumors as it is of urinary bladder tumors.

Bladder reconstruction in rabbits with glutaraldehyde-stabilized amniotic membranes.

Glutaraldehyde-treated human amniotic membranes were used to repair rabbit bladders after supratrigonal cystectomies. The membranes maintained the integrity of the bladders until healing and reepithelialization occurred. There was no significant loss of bladder capacity or decreased renal function postoperatively. Calcification did not occur on the membranes but was noted on chromic sutures retaining the membranes in 7 of 27 bladders. These findings suggest that glutaraldehyde-stabilized amnion is well tolerated by the urothelium and may serve as a suitable material for replacement of genitourinary tissues.

Enterobius vermicularis ova in routine cervicovaginal smears. Light and scanning electron microscopic observations.

From 1971 through 1980, four Papanicolaou smears containing pinworm (Enterobius vermicularis) eggs were found among approximately 220,000 routine smears examined at the University of Texas Medical Branch at Galveston. The highest number of ova counted on one slide was 420. Typical light microscopic features of the eggs included elongated oval shapes with flattening of the ventral sides and double-contoured shells folded at one end. The background in three smears showed massive acute inflammation. A scanning electron microscope study of one case revealed that the ova had a relatively smooth surface with an invaginated area at one end.

Detection of endometrial stromal sarcoma in cervicovaginal smears: reports of three cases.

Although the small neoplastic cells of pure endometrial stomal sarcoma do not usually exfoliate readily, they are sometimes detected in cervicovaginal smears. In three cases, constituting half the patients with histologically confirmed endometrial stromal sarcoma from 1971 through 1979 at the University of Texas Medical Branch at Galveston, cervicovaginal smears also contained malignant or suspicious cells. All three had certain common features: mostly rounded, small malignant cells with occasional tapered "comet" forms, discernible nucleoli and a tumor diathesis.

Bizarre atypia in gastric brushings associated with hepatic arterial infusion chemotherapy.

Hepatic arterial infusion chemotherapy (HAIC) for unresectable hepatic neoplasms has been associated with gastric ulcers and epithelial atypia that may be misinterpreted as carcinoma. Gastric brushings were reviewed from six patients who developed gastric ulcers with histologically proven atypia following HAIC. Marked cytologic atypia, reminiscent of a pronounced radiation effect, was present in gastric epithelial cells in five patients. The atypical cells occurred singly or in small sheets. They were markedly enlarged but a low nuclear-cytoplasmic ratio was preserved. The abundant cytoplasm was vacuolated or foamy. Binucleation and multinucleation were common, and massive nucleoli were characteristic. The brushings also contained the reparative, inflammatory and necrotic changes associated with usual benign gastric ulcers. The bizarre atypia associated with HAIC can be a source of misdiagnosis of cancer in cytologic as well as in histologic specimens.

Scanning electron microscopy of alcohol-fixed cytopathology specimens.

Cells in specimens fixed in alcohol and stained by the Papanicolaou method for routine cytodiagnosis were subsequently studied by scanning electron microscopy (SEM) to determine if they manifested topologic features described in specimens prepared for optimal SEM observation. In normal bronchial washings, ciliated columnar cells were obvious, and microridges were detected in several squamous cells. Microvilli, although sometimes coarse and blunted, were present in cells of adenocarcinoma, squamous carcinoma and malignant mesothelioma in fluid specimens. Benign histiocytes in bronchial washings, neuroblastoma cells in a smear of bone marrow aspirate and lymphocytic lymphoma cells in spinal fluid had ruffled surfaces. Should topologic features prove to be diagnostically significant, SEM may be of value in further studying equivocal specimens even though they were previously prepared for routine light microscopic observation.

Hemorrhagic myocardial infarction after percutaneous coronary intervention: Echographic versus autopsy findings.

We present a case of hemorrhagic myocardial infarction after early percutaneous coronary intervention which was suggested by cardiac echocardiography, and later confirmed by post-mortem examination.