Pulmonary valve endocarditis: mid-term follow up of pulmonary valvectomies.

Four males aged 20-37 years (three drug addicts and one with a congenital mixed pulmonary valve lesion) were diagnosed in 1989, 1991 and 1993 with pulmonary valve endocarditis without tricuspid infection. Three patients were positive for hepatitis B, C or both, and one patient was HIV-positive. The predominant organism in blood cultures was Staphylococcus aureus. Antibiotic treatment of pulmonary valve endocarditis had failed; thus partial or total valvectomies were performed. Postoperatively, all patients were cured of infection and initial recovery was good. At mid-term follow up (5-10 years) there were no recurrences, and tolerance of the resultant pulmonary insufficiency was good. Slight to severe tricuspid valve insufficiency developed, together with right ventricular dilatation, in all cases. Hepatomegaly was apparent in two cases and peripheral edema in one. Despite treatment, the latter patient remained in moderate right ventricular failure, and may require homograft valve replacement. The other three patients remained in good clinical condition. Eradication of the infection was achieved in all patients. It is concluded that pulmonary valve resection is the treatment of choice for pulmonary valve endocarditis when antibiotic treatment has failed. Complete resection of all affected tissue should be performed in these cases. Analysis of preoperative data did not permit differentiation of those patients likely to develop right heart failure.

Primary lymphomas of the heart in immunocompetent patients. Presentation of two cases with one 12 year survival. Analysis of surgical implications.

Two primary malignant lymphomas originating in the right heart cavities have been diagnosed and treated in our department: one, with additional right atrial and inferior vena cava thrombosis required emergency thrombectomy, incomplete excision and chemotherapy and survived 12 years, the other with extensive right ventricular infiltration and failure, died from mediastinitis and aplastic anaemia following surgery and chemotherapy. Quick diagnosis and treatment are indicated. If possible, surgery should be avoided.

Fine needle aspiration of sclerosing lymphocytic lobulitis of the breast. A report of two cases.

BACKGROUND: Sclerosing lymphocytic lobulitis (SLL) was described in 1948 by Soler and Khardori as fibrotic disease of the breast with histologic features similar to those of Hashimoto's thyroiditis. Associations of this process with thyroiditis, artropathy and diabetes mellitus have been seen. CASES: We report the fine needle aspiration biopsy (FNAB) findings of two cases of SLL seen in our service. Both patients showed a breast nodule suspicious for malignancy. The cytologic changes vary according to the stage of the disease, from abundant lymphocytes and scanty fibrosis (case 1) to the presence of a few lymphocytes, epithelioid fibroblasts and significant sclerosis (case 2). CONCLUSION: The cytologic changes seen in FNAB are sufficient to indicate the diagnosis of SLL. The differential diagnosis has to be made with primary breast lymphoma, periductal or perilobular inflammation and different types of sclerosing breast lesions, depending on the stage of the disease.

Familial ochronosis.

We report the case of a 72-year-old female with alkaptonuric ochronosis and symptomatic aortic stenosis requiring aortic valve replacement. She was the seventh of nine children, and four of the nine siblings were diagnosed as having ochronosis. Only one, however presented with aortic stenosis.

Intimal sarcoma of the left pulmonary artery: diagnosis, treatment and survival.

A rare case of intimal sarcoma of the left pulmonary artery, diagnosed by fine needle aspiration biopsy and treated by pneumonectomy, is presented. Survival was nearly 4 years and the patient died as the result of attempted resection of a local recurrence. The literature is reviewed.

Fine needle aspiration cytology of granulomatous prostatitis.

The fine needle aspiration (FNA) cytologic findings are presented for 18 cases of granulomatous prostatitis (12 nonspecific, 5 tuberculous and 1 eosinophilic cases). These cases represented 19% of all prostatitis cases and 2% of all prostatic aspirates examined from January 1986 to December 1987. The cytomorphologic differences between the three types of granulomatous prostatitis are described, with emphasis on the differentiation between the nonspecific and specific varieties. The differential diagnostic features between reactive changes and well-differentiated adenocarcinomas of the prostate are also presented. The findings in these cases indicate that FNA cytology is a reliable procedure for the morphologic diagnosis of granulomatous prostatitis, which can clinically mimic prostatic carcinoma when it presents as a diffuse or nodular enlargement with increased consistency.

Fine needle aspiration cytology of soft-tissue lesions.

The use of fine needle aspiration (FNA) cytology was reviewed in 117 cases of soft-tissue lesions: 23 non-neoplastic lesions, 34 benign mesenchymal tumors and 60 histologically proven soft-tissue sarcomas. The soft-tissue sarcoma aspirates were classified according to their cytomorphology into five groups of possible histologic diagnoses. Difficulties were experienced in the correct diagnoses. Difficulties were experienced in the correct assessment of aspirates from low-grade malignancies. On the other hand, in high-grade malignant sarcomas and in recurrent or metastatic soft-tissue sarcoma, FNA cytology was useful in both the initial diagnosis of a new lesion (22 patients) and in the confirmation or exclusion of a suspected treatment failure (38 patients with recurrence or metastases). In the latter, FNA cytology supported the clinical data and reduced the number of repeat open biopsies. However, the final diagnosis of soft-tissue sarcomas should be based upon the histologic study of tissue sections.

Isolated mitral valve replacement and ventricular rupture: presentation of 6 patients.

The cases of 6 patients who had ventricular wall rupture after isolated mitral valve replacement and were seen in our service are reviewed. In the first 2, the main lesion was mitral stenosis and calcification was severe. Injury to the ventricular myocardium during removal of the valve was the causative factor in 1 and the most likely explanation in the other. In the other 4 patients, the dominant lesion was insufficiency. Calcium was absent, and fibrosis of the valves was minimal. Defects of technique were not obvious. All perforations were beneath the annulus. The first of these 4 latter patients underwent operation just after cardioplegic solutions were introduced for myocardial protection in our service. During that period, the incidence of ventricular wall rupture was 7.3% for mitral valve replacement (55 patients). Causing 3 deaths, it became the most important mortality factor. After reviewing the problem, we decided to change our technique by leaving practically all the posterior leaflet and most of the chords intact and placing sutures through fibrous tissue only, never into muscle, as had already been suggested. Since then, we have not seen another rupture in 23 valve replacements.

Removal of infected epicardial electrodes by traction.

Five patients who had infected cardiac pacemakers with epicardial electrodes have been managed by exteriorization of the pulse generator and placement of an endocardial unit. In each case the remaining electrode leads where detached from the myocardium and removed by simple traction, avoiding a surgical procedure. In 4 patients, sets of cables had been sutured to the myocardium through an anterior thoracotomy, in some instances using Teflon pledgets as buttresses. In one of these procedures a pericostal suture had been used to secure the leads from the thoracic cavity against the ribs. The remaining patient had received a subxiphoid pacemaker also implanted with sutures. This is a consecutive series, and we have had no failures so far. All pulse generator units were bipolar and located beneath either the pectoral or the rectus muscle. All of them were functioning properly when infection was diagnosed. This procedure constitutes an alternative method of management when more conservative techniques, such as closed irrigation and debridement, cannot be utilized.

Retroclavicular route for electrode placement in endocardial pacemakers.

In order to avoid skin erosion and electrode infection in endocardial pacemakers placed through the external jugular vein, we direct the wires from their point of entry into the vessel to the pacing unit placed in the pectoral region by dissecting a retroclavicular tunnel. This can be done under general or local anesthesia, and so far we have not seen any injuries to the subclavian vein. In this way the entire pathway of the cables is deep enough so that they cannot be palpated through the skin, and the dangers of exposure through erosion are minimized.

Intraoperative placement of central venous pressure monitoring cannulas.

A method for placement of central venous pressure monitoring and fluid administration catheters is described which we have found quite useful in our practice for the past three years in patients undergoing sternotomy incisions, most commonly for cardiac procedures.

[Experience in the use of porcine heterologous grafts of the Hancock type for replacement of the mitral valve. 4 years of continuous use]. / Experiencia en el uso de injertos heterólogos porcinos tipo Hancock para el reemplazo de la valvula mitral Cuatro años de uso continuo

We present a statistical analysis on the use of the Hancock porcine heterograft for mitral valve replacement in 151 consecutive cases. A 14% early, and 3.9% late mortality rate is found. An evaluation of the factors contributing to this figure shows that the most important is the degree of myocardial derangement prior to surgery, with 3.5% mortality for stage III and 32% for stage IV (New York Heart Association classification). Our rate for thromboembolism is 9%. Study of other conditions favoring this complication indicates that factors other than valve replacement are present in all cases, making the evaluation of the thrombogenic qualities of these prosteses difficult. In a period of study of 4 832 patient-months (21 average) or 5 526 valve-months (19 average) which nicludes all our Hancock prosteses. There have been no failures that can be traced to mechanical derangement nor biological deterioration. This fact together with their favorable hemodinamic characteristics, make us recommend this model for clinical use.