Mitral valvuloplasty in pregnancy: a report of 4 cases

Normal gestation is associated with adaptative cardiovascular changes. Pregnant women with mitral stenosis may be unable to tolerate these changes despite optimal medical therapy, and life-threatening complications can occur. Commissurotomy or valve replacement during gestation are very high-risk procedures both for mother and fetus. Percutaneous valvuloplasty is a valid alternative to cardiac surgery. In this study, we describe four pregnant women with mild or severe mitral stenosis who underwent percutaneous valvuloplasty after the first trimester of gestation. Despite tailored medical therapy with diuretics and beta blockers, all patients were symptomatic: NYHA class II in two cases, and class III in the last two. In order to protect the fetus from radiation, the patient's pelvic-abdominal area was shielded and left ventriculography was not performed. Fluoroscopy time was 7 +/- 3 min. No major immediate complications were observed after the procedure. Mitral valve area (sec. Gorlin) increased from 1.05 +/- 0.08 cm2 to 2.52 +/- 0.26 cm2 and mitral gradient decreased from 26.7 +/- 5.7 mmHg to 8.5 +/- 3 mmHg. The four women delivered healthy full-term babies. At a mean follow-up of 22 +/- 8 months, all patients are free of symptoms, two patients with diuretics and two without therapy. Percutaneous valvuloplasty can be considered the treatment of choice for pregnant women with symptomatic mitral stenosis refractory to medical therapy.     

Retroperitoneoscopy--experiences with the first cases

A retroperitoneal access is most commonly applied for open procedures in urology. With introduction of the balloon dissecting technique, this anatomical route could also be used for laparoscopic surgery. MATERIALS AND METHODS: From 12/1992 to 10/1997, a total of 200 retroperitoneoscopic procedures have been performed in 197 patients (age 4-82 years): 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph-node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Thirty-eight patients (19%) had undergone previous abdominal surgery; 22 (11%) had had kidney and ureter operations. Dissection of the retroperitoneal space was done with a balloon catheter in 14 or a balloon trocar system in 93 cases, and in the last 93 patients digital dissection with the index finger proved to be sufficient. RESULTS: We classified 76 as simple (i.e., renal biopsy, renal cyst resections, ureterocutaneostomy) and 102 as difficult (i.e. adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult operations (i.e., pyeloplasty, heminephrectomy, lymphadenectomy). There has been a significant learning curve during the first 50 cases as reflected by increased operating time and complications and the conversion rate to open surgery. After that, the OR times mainly depended on the difficulty of the procedure, averaging 45-100 min for an easy retroperitoneoscopy, 95-185 min for a difficult and 185-240 min for a very difficult operation. In the last 50 cases, the complications, conversion and reintervention rate have become comparable to open surgery (2, 4 and 2%). CONCLUSIONS: After more than 200 cases of retroperitoneoscopy, the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.     

Compression of anomalous circumflex coronary artery by a prosthetic valve ring

Anomalous origin of the circumflex coronary artery from the right aortic sinus, with a retroaortic course, is usually without consequence. We report a patient who underwent aortic valve replacement for bicuspid aortic valve. The prosthesis sewing ring distorted the circumflex, producing myocardial infarcts and sudden death during exercise.     

Measuring first ray mobility with a new device

First ray hypermobility has been linked to many abnormal conditions in the foot. First metatarsal vertical displacement is proportional to the measurement of first ray dorsiflexion. A new device that measures first ray mobility has been built and tested. The device applies a dorsiflexing force to the head of the first metatarsal and measures the amount of vertical displacement that results. The design and instrumentation of the device is described. A safe and reliable testing procedure for measuring maximal first ray displacement is discussed. Clinicians could use this measure when selecting treatment options for patients who suffer foot pathologies resulting from faulty mechanics of the first ray.     

Prognostic factors of prosthetic valve endocarditis. Apropos of 122 cases

We examined relationships among the distance walked in 10 minutes (10 MD), pulmonary function, and pulmonary hemodynamics during exercise on a bicycle ergometer, in patients with chronic pulmonary emphysema who had dyspnea of grade III to IV on the Hugh-Jones scale. The 10 MD did not correlate significantly with desaturation during the 10-minute walk, but it did correlate significantly with the percent of predicted maximum voluntary ventilation, and it correlated negatively with airway resistance. These findings indicate that ventilatory impairment is an important factor limiting 10 MD in these patients. Also 10 MD correlated significantly and positively with %DLco; and it correlated negatively with the index of pulmonary vascular resistance and with the ratio of the change in pulmonary arterial pressure to the change in cardiac index during exercise. (delta Ppa/delta CI). These findings indicate that impairment of pulmonary circulation may also limit the 10 MD and exercise tolerance in patients with chronic pulmonary emphysema.     

Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction

A new, totally flexible ring for atrioventricular annuloplasty is described. The technique for its insertion closely follows the principles of Carpentier's selective annulus reconstruction [4]. Ninety-nine such rings have been inserted (47 in the mitral and 52 in the triscuspid position); 45 valves were simultaneously replaced. There were 6 (4 hospital and 2 late) deaths. The thromboembolic incidence was 4.8%. No instances of dehiscence or late ring deterioration have been detected. Thirty-four patients have been recatheterized, 19 of them with mitral rings. The mitral gradients and angiographic findings show the correct functioning of the implanted ring. It is concluded that use of this flexible ring, which adapts to the continuous changes of the normal mitral annulus, produces a more physiological type of valve operation.     

Finite element modelling of a residual lower-limb in a prosthetic socket: a survey of the development in the first decade

A review is presented of the existing finite element models developed from 1987 to 1996 for the biomechanics of lower-limb prostheses. Finite element analysis can be a useful tool in investigating the mechanical interaction between the residual limb and its prosthetic socket, and in computer-aided design and computer-aided manufacturing of prosthetic sockets. Various assumptions and simplifications are made in these models to simplify the actual problem with complex geometry, material properties, boundary and interfacial conditions, as well as loading situations. The analyses can provide the information on the stress distribution at the stump/socket interface and within the residual limb tissues. More recently, nonlinear models have been developed taking into consideration the process of socket rectifications, the slip/friction conditions and material large deformation. The models so far developed have provided some basic understanding of the biomechanics. Comparison of the predictions of these models with experimental measurements indicated that the predicted stresses were within the ranges measured, although one-to-one correspondence was difficult to achieve. Further research is still required in order to improve these models to obtain higher precision in the results taking into account nonlinear and dynamic effects.     

Unilateral amnesic stroke. Six new cases and a review of the literature

BACKGROUND AND PURPOSE: Although persistent amnesia due to bilateral limbic system infarction is well described, reports of amnesic syndromes due to unilateral stroke have appeared infrequently and unsystematically. We report six new cases and review previously published reports to expand and consolidate knowledge regarding amnesic stroke. CASE DESCRIPTIONS: Six patients developed acute amnesia associated with unilateral stroke. Brain computed tomography or magnetic resonance imaging revealed lesions in limbic structures, which accounted for the memory deficit. Based on these as well as similar cases in the literature, we delineate three distinct syndromes of unilateral amnesic stroke involving the territories of the posterior cerebral, anterior choroidal, and thalamic penetrating arteries. Eighty-five percent of reported cases have involved the left hemisphere. CONCLUSIONS: Persistent as well as transient amnesia may be the sole or primary manifestation of unilateral hemispheric stroke. The vascular mechanisms of amnesic stroke are diverse. Patients presenting with acute amnesia possibly related to cerebral ischemia should be classified by documented or presumed lesion site as well as the involved vascular territory. Left amygdalohippocampal or diencephalic dysfunction may produce a particular vulnerability to global amnesia.     

Partial replacement of an infected arterial graft by a new prosthetic polytetrafluoroethylene segment: a new therapeutic option

PURPOSE: As the title suggests, this is an account of treating infected arterial grafts other than by the accepted methods of complete graft removal and revascularization with autogenous material or extraanatomic bypass. METHODS: Since 1973, 42 patients with infected arterial grafts (n = 35) or autogenous reconstructions (n = 7) were seen with false aneurysm, hemorrhage, or perigraft or perianastomotic pus and were treated by removal of the infected graft and immediate adjacent or in situ revascularization by polytetrafluoroethylene (PTFE) in 39 cases and Dacron in three cases. Management plan included (1) removal of only the obviously infected part of the original graft, (2) obliteration of the infected anastomotic site, and (3) placement of the new PTFE graft in an adjacent clean or debrided route. So treated were 15 aortic Dacron grafts, 20 PTFE grafts (2 iliofemoral, 3 femorofemoral, and 15 femorodistal), and 7 autogenous reconstructions with bleeding. Partial graft salvage was attempted in 10 of 15 Dacron and 19 of 20 PTFE grafts. RESULTS: Four patients required further removal of the original infected graft (three Dacron, one PTFE), giving an ultimate success rate of 7 of 15 Dacron and 18 of 20 PTFE grafts; two patients required further obliteration of the original adjacent infected arterial segment because of rebleeding. An additional PTFE segment was joined successfully to incorporated PTFE in all six repeat operations. Initial failure did not prejudice the outcome; direct arterial flow to at least midthigh level was preserved in 37 of the 42 patients for a mean period of 40 months (range 9 to 130 months). Three of the new PTFE grafts occluded and became infected, which led to amputation and one death at a secondary operation. Visceral complications caused the only two other deaths in the aortic group. Five late amputations (four below the knee and one above the knee) were required because of femorodistal graft occlusion. CONCLUSIONS: Partial removal of infected grafts with adjacent or in situ replacement by PTFE is possible, simplifies management, and permits maintenance of distal circulation with low morbidity and mortality rates.     

Primary melanoma of the esophagus. 2 new cases

Primary melanoma of the esophagus is rare. Until 1990, eight cases had been reported in Spain. We report two patients, 50 and 61-year-old men. Melanomas were located in the distal esophagus and were polypoid (5-6 cm), pediculated and pigmented. Endoscopic biopsy was diagnostic in both cases. Fontana staining technique and monoclonal HMB-45 and S-100 antibodies were used. A revision of clinical characteristics, treatment and survival of the patients with primary melanoma of the esophagus in our country is made.     

Florid cystic endosalpingiosis with tumor-like manifestations: a report of four cases including the first reported cases of transmural endosalpingiosis of the uterus

Four cases of endosalpingiosis presenting as masses that resembled neoplasms are described in women 20, 41, 43, and 74 years of age. Each case was referred in consultation because of difficulties in pathologic diagnosis. In two patients, multiple cysts that involved the serosal surfaces of the uterus and adnexa in one case, and the colon, rectosigmoid, pelvic sidewalls, and the cul-de-sac in the other, were excised. In the other two cases, hysterectomy was performed for an enlarged cystic cervix in one case and presumed uterine leiomyomas in the other. In both of these cases, the uterine cervix and lower part of the uterine corpus were extensively involved by multiple cysts on gross examination, and in one of them, a frozen section of the cervical lesion was initially interpreted as "suspicious for invasive minimal deviation adenocarcinoma." On microscopic examination, benign endosalpingiotic glands and cysts were found in all four cases, with striking transmural involvement of the uterine cervix and lower uterine segment and contiguous corpus in the two cases with uterine involvement. The latter two cases are the first examples, to our knowledge, of endosalpingiosis involving the wall of the uterus; the differential diagnosis in these cases includes minimal deviation adenocarcinoma and florid tubal metaplasia with cystification. The four cases in this report, and rare previously reported cases, indicate that although usually a microscopic finding, endosalpingiosis can rarely present as a clinically or grossly evident mass that can be confused with a neoplasm.     

Mitral valve replacement with the St. Jude Medical prosthesis: a 15-year follow-up

BACKGROUND: A retrospective study was conducted to analyze the results of St. Jude Medical mitral valve replacement. METHODS: From January 1979 to December 1989, 870 patients (54% women, 46% men; mean age, 55.8 +/- 6.2 years) underwent mitral valve replacement with the St. Jude Medical prosthesis. Of these operations 616 were isolated mitral valve replacements and 254 were double valve replacements. Coronary artery bypass grafting was performed concomitantly in 55 patients (6.3%). RESULTS: Overall, early mortality was 5.05%, with 4.2% for the isolated mitral valve procedure and 7.08% for the double valve replacement. Follow-up at 15 years was complete in 859 patients (98.74%). Mean follow-up time was 93.5 months, for a total of 6,436 years. Actuarial survival at 15 years was 59.5% +/- 5%, 60.5% +/- 6%, and 56.9% +/- 9%, for the entire group, the isolated mitral valve and double valve procedures, respectively. Multivariate analysis identified age, sex, hospital stay, and preoperative mitral regurgitation as independent prognosis factors for overall mortality. Of 606 patients alive at the latest follow-up, the New York Heart Association class improved significantly (from 67% class III/IV before the operation to 88% class I/II after the operation). All patients received warfarin to maintain an international normalized ratio between 3.5 and 4. The linearized rates (% per patient-year) of thrombosis, thromboembolism, and major hemorrhage were, respectively, 0.21, 0.75, and 0.94 for the entire group; 0.18, 0.67, and 0.88 for the isolated mitral valve operation; and 0.15, 0.92, and 1.08 for the double valve replacement. For the entire group the freedom from thrombosis and thromboembolism at 15 years was 98.1% +/- 1% and 88% +/- 4%, respectively. No case of structural dysfunction occurred. The freedom from paravalvular leak and endocarditis at 15 years was 95.3% +/- 2% and 97.3% +/- 2.4%, respectively. The probability of remaining free from reoperation at 15 years was therefore 95.6% +/- 2.5%. CONCLUSIONS: These results confirm that the St. Jude Medical valve is a reliable prosthesis with very low thrombosis and thromboembolism rates, allowing the use of a low dose of anticoagulation with an international normalized ratio of about 3.     

Desmoplastic tumors with multiple differentiation. A new entity. Six cases

Desmoplastic tumours with divergent differentiation are principally located in the abdomen and develop locally or regionally. They occur in adolescents or young adults and are characterized at histology by a proliferation of undifferentiated small cells surrounded by a dense stroma. Only immuno-histo-chemistry provides the diagnosis. Since their chemosensitivity is rare and often partial the outcome is usually lethal. Six new cases of this recently described entity are presented here. The authors are in favour of a multidisciplinary and aggressive management, combining intensive polychemotherapy, extensive surgical exerisis and total abdominal radiotherapy.     

Feasibility study of vascular-endoscopic valvuloplasty. Using a laser and flexible endoscope

Percutaneous balloon valvuloplasty is generally accepted, but post procedural complications limit its efficacy and reduce long-term success. To eliminate these risks, the authors explored the feasibility of cardioscopy guided percutaneous laser valvuloplasty in an experimental setting. The combined working model consisted of a separate balloon tipped thin fiber optic endoscope, laser balloon catheter, and a Nd-YAG laser transmitter. A porcine pulmonary valve was used as our in vivo target of laser ablation in a beating heart. Under general anesthesia, the endoscopic catheter is delivered into the pulmonary valve area through either the internal jugular or femoral vein under fluoroscopy. Positioning the pulmonary apparatus coaxial to the endoscopic visual field by manipulation of the catheter allowed for targeting and ablation of the commissure of the pulmonary valve under endoscopic view through the balloon filled with saline solution. The ablation energy was 15-30 W, 0.5-1.0 sec, and 2,000-3,000 J total. The animal was then killed and histopathologic study of the ablated area was done. The commissure of the pulmonary valve was smoothly ablated in 4 cases, and the entire ablation procedure was successfully witnessed through endoscopy. The authors encountered some difficulty in laser targeting, limitations to the endoscopic field of vision, and difficulty in holding the position of the apparatus in the beating heart. These are the barriers to overcome for future clinical application of this procedure. However, these results indicate the clear possibility of future use of cardioscopy guided percutaneous laser valvuloplasty in a clinical setting.     

Merkel cell tumor of the head and neck. Five new cases with literature review

Merkel cell carcinoma (MCC) of the skin is an uncommon, but highly aggressive neoplasm with a marked propensity for local and distant metastasis. Despite the fact that more than half of the 600 cases of MCC reported in the literature involved primary sites in the head and neck, MCC has rarely been discussed in otolaryngology publications. We present five new cases of MCC of the head and neck and summarize 89 additional cases from the literature in which detailed treatment and survival data were given. Our findings again emphasize the difficulty in making the initial histopathologic diagnosis of MCC and demonstrate the necessity of early diagnosis and multimodality treatment.     

Anticancerous chemotherapy trial with duborimycin. Analysis of 151 cases

Duborimycin is a new antimitotic agent approaching danorubicin and adriamycin in activity which has been tried on 151 patients suffering from cancer of different types, is an advanced local/regional stage and/or metastatic disease. It was administered intravenously every fortnight in a mean unit dose of 400 mg, and the duration of the treatment ranged from 2 to 52 weeks. Objective improvement was registered in 56 patients of the 135 cases in whcih the results were assessed (around 41.4% of cases). In 4 cases the regression of tumour volume was greater than 50% (one of these cases was in melanoma, the other a sarcoma) and in 2 cases regression was complete (a squamous cell carcinoma and an embryonal testicular tumour). The subjective effects were appreciable in 53 of the 115 cases which could be studied (46%) and above all in the refractory pain of bony secondaries from breast cancer (a favourable response in 78% of cases). Manifestations of intolerance/toxicity were of a minor nature on the haematologic side, that cardiologic ones relatively frequent (18% of treated cases) and occasionally serious (2 cases of asystole). Great care is therefore necessary in supervision of the treatment. However, the first results obtained by this line of approach, notably in chemo-resistant forms of tumour such as melanoma and sarcomas, utilizing the very strict criteria in one analysis encourage further study of duborimycin in cases of this sort (preferably in association and in accordance with protocols of comparative trials) so that its place in cancer chemotherapy may be more precisely defined.     

Teratoma of the middle ear. Apropos of 4 new cases

Visual acuity measured using the Snellen method in 29 patients with hypophyseal tumors amounts to normal or nearly normal values (6/9-6/6), with mean value of 0.75. Measuring of visual acuity with the more accurate "log MAR" optotype tables yields acuity values which decline with the severity of the disease from 1.04 to 0.87 with a mean value of 0.97. Not withstanding, in all of these patients markedly lowered contrast sensitivity values were found in all of the frequencies tested (1.15-29.25 c/deg). The use of the visual acuity determinations only is insufficient for early detection of functional visual disturbances in compressions of the visual pathway.