Translocation of aberrant right subclavian artery to the ascending aorta-a treatment for dysphagia lusoria.

Generally, an aberrantly coursing right subclavian artery (ARSA), also known as 'arteria lusoria', is an incidental diagnosis of no clinical consequence. Where correction is indicated, popular practice is for decompression via staged percutaneous +/- vascular methods. Open/thoracic options for correction are not widely discussed. We report the case of a 41-year-old woman with dysphagia secondary to ARSA. Her vascular anatomy precluded staged percutaneous intervention. The ARSA was translocated to the ascending aorta via thoracotomy, utilizing cardiopulmonary bypass. Our technique is a safe option for low-risk patients with symptomatic ARSA. It obviates the need for staged surgery and removes the risk of carotid-to-subclavian bypass failure.

The reliability of carotid ultrasound in determining the return of pulsatile flow: A pilot study.

Manual palpation of pulses is unreliable in detecting pulsatile flow in human participants, complicating the assessment of return of spontaneous circulation after cardiac arrest. Ultrasound may offer an alternative. This study's objective was to investigate whether return of pulsatile flow in humans can be reliably assessed by common carotid artery ultrasound. We conducted a single-blinded randomised study of common carotid artery ultrasound using 20 cardiopulmonary bypass patients to model the return of pulsatile flow. Synchronised time-stamped videos of radial artery invasive blood pressure and 10 two-dimensional or 10 colour Doppler ultrasounds were recorded. Three independent reviewers recorded the timestamp where they considered pulsatile flow was first visible on ultrasound. Ultrasound times were compared to the onset of arterial line pulsatile flow and reliability assessed by intraclass correlation coefficient. The median difference between radial artery and ultrasound flow time (interquartile range (range)) was 24 seconds (5-40 (0-93)) for two-dimensional and 5 seconds (2-17 (-28 to 188)) for colour Doppler. The intraclass correlation coefficient for two-dimensional ultrasound was 0.86 (95%CI 0.63-0.96) and 0.32 (95%CI -0.01 to 0.71) for colour Doppler. The median (interquartile range (range)) mean arterial pressure where ultrasound flow occurred for two-dimensional ultrasound was 62 mmHg (49-74 (33-82)) and 56 mmHg (52-73 (43-83)) for colour Doppler. In our pilot study, two-dimensional ultrasound was reliable in detecting the return of pulsatile flow. Colour Doppler detected pulsatile flow earlier and at lower mean arterial pressure but was not reliable, although a larger study is needed to determine colour Doppler's utility.

Surgical Removal of an Unusual Massive Mediastinal Tumour Preceded by Interventional Embolisation.

Massive mediastinal tumours are rare in clinical practice and complete surgical resection may be associated with serious complications. Preoperative angiography and embolisation are valuable adjuncts in the management of giant tumours to decrease perioperative blood loss, provide a clear operative field and facilitate complete resection. We report the safe use of preoperative embolisation which facilitated excision via clamshell incision, of a highly vascular massive anterior mediastinal tumour with an unusual final diagnosis.

Treatment of Intravenous Leiomyomatosis with Cardiac Extension following Incomplete Resection.

Aim. Intravenous leiomyomatosis (IVL) with cardiac extension (CE) is a rare variant of benign uterine leiomyoma. Incomplete resection has a recurrence rate of over 30%. Different hormonal treatments have been described following incomplete resection; however no standard therapy currently exists. We review the literature for medical treatments options following incomplete resection of IVL with CE. Methods. Electronic databases were searched for all studies reporting IVL with CE. These studies were then searched for reports of patients with inoperable or incomplete resection and any further medical treatments. Our database was searched for patients with medical therapy following incomplete resection of IVL with CE and their results were included. Results. All studies were either case reports or case series. Five literature reviews confirm that surgery is the only treatment to achieve cure. The uses of progesterone, estrogen modulation, gonadotropin-releasing hormone antagonism, and aromatase inhibition have been described following incomplete resection. Currently no studies have reviewed the outcomes of these treatments. Conclusions. Complete surgical resection is the only means of cure for IVL with CE, while multiple hormonal therapies have been used with varying results following incomplete resection. Aromatase inhibitors are the only reported treatment to prevent tumor progression or recurrence in patients with incompletely resected IVL with CE.

Thoracic cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy for pseudomyxoma peritonei.

BACKGROUND: Pleural dissemination of pseudomyxoma peritonei (PMP) is considered an advanced/terminal disease. We review our experience with thoracic cytoreductive surgery (CRS) and intraoperative hyperthermic intrathoracic chemotherapy (HITHOC) for the treatment of pleural recurrence of PMP following previous intraabdominal surgery. PATIENTS AND METHODS: An observational study of five patients with pleural dissemination from PMP treated with thoracic CRS and intraoperative HITHOC with mitomycin C for 90 min at 41.5 degrees C. RESULTS: There were three men. The mean age was 46.5 (10.5) years. Postoperatively, one patient developed Grade I, one patient developed Grade III and one patient developed Grade IV postoperative complication. Two patients had an unremarkable postoperative recovery. Only one patient has died 38 months since treatment from abdominal complication of this disease with no evidence of thoracic disease. The four surviving patients are still alive 4.6-47.4 months after treatment. Two patients have evidence of an intraabdominal recurrence. CONCLUSIONS: Thoracic CRS and intraoperative HITHOC is a safe and effective procedure to treat pleural dissemination from PMP. Long-term disease-free survival can be achieved from this treatment for which no other potentially curative therapy has been described.

Reoperation for a patient with Starr-Edwards aortic valve malfunction due to pannus formation twenty-nine years after implantation.

We report a re-do case of severe aortic valve stenosis due to pannus formation 29 years after an aortic Starr-Edwards caged-ball valve implantation. A huge shelf of calcified and thick pannus tissue below the valve had reduced the already small orifice by at least a third in surface area. The explanted Starr-Edwards valve revealed no mechanical or structural failure. Early detection and treatment of pannus outgrowth is essential in order to prevent life-threatening prosthetic valve malfunctions.

Effect of treatment on ventricular function and troponin I proteolysis in reperfused myocardium.

Effects of ischemia time and treatment interventions upon troponin I (TnI) proteolysis and function of reperfused myocardium were examined in isolated, perfused rabbit hearts. Hearts were randomized to 90 min aerobic perfusion, 15 min low-flow (1 ml/min) ischemia (I) and 60 min reperfusion (R) or 60 min low-flow I and 60 min R. Hearts subject to 60 min I and 60 min R received either no treatment, l -arginine treatment, or treatment with oxygen free radical (OFR) scavengers (mercapto-proponyl-glycine, catalase and superoxide dismutase). Hearts from cholesterol-fed rabbits were also studied after 60 min I and R. Isovolumic LV pressure and heart rate were recorded throughout and Western analysis of ventricular myocardium, using 3 specific antibodies, detected intact TnI (29 kDa) and TnI fragment (25 kDa). Hearts subject to 15 min I had minimal irreversible injury (TTC negative region=0.6+/-0.4% LV) but hearts subject to 60 min I had more extensive injury (TTC negative=40.7+/-5.8% LV). Recovery of rate-pressure product after 15 min I and 60 min R (56+/-9% of baseline) was better than after 60 min I and 60 min R (23+/-9%, P<0.01). Both l -arginine and OFR scavengers were associated with better recovery of function after 60 min I, (66+/-7% and 72+/-3% of baseline respectively, P<0.01 v no treatment) but cholesterol hearts had poor recovery after 60 min I (37+/-8%). The 25 kDa TnI (% total TnI immunoreactivity) was 8.7+/-0.9% in controls, 10.0+/-1.6% after 15 min I and 60 min R, and 17.4+/-2.4% after 60 min I and 60 min R (P<0.01 v controls and 15 min I). The proportion of 25 kDa TnI was increased in all hearts after 60 min I and did not change with treatment (l -arginine 16.8+/-1.8%, OFR scavengers 16.0+/-3.2%, cholesterol 14.0+/-1.9%). There was no relation between proportion of 25 kDa TnI and recovery of function. Samples from freshly excised rabbit hearts and human right atria also had 25 kDa TnI (relative intensities 8.5+/-2.3% and 5.1+/-2.6% respectively). Although TnI fragmentation increases after prolonged ischemia and reperfusion, the functional recovery of stunned myocardium is independent of degree of TnI fragmentation.