Oxaliplatin-induced acquired long QT syndrome with torsades de pointes and myocardial injury in a patient with dilated cardiomyopathy and rectal cancer.

A 67-year-old woman presented with a history of dilated cardiomyopathy with congestive heart failure since 2003, who subsequently developed lower rectal cancer (adenocarcinoma) with liver, bone, and lymph node metastasis. Abdominoperineal resection and hepatectomy were performed. The patient received two rounds of intravenous chemotherapy, including 12 and six courses of FOLFOX4 (5-fluorouracil, leucovorin, and oxaliplatin; 85 mg/m(2) per cycle). She underwent a third round of intravenous FOLFOX4 because of tumor progression. During the 21(st) course of FOLFOX4 regimen, the patient developed ST segment depression in lead II and prolongation of QT interval with polymorphic ventricular tachycardia, torsades de pointes right after the start of oxaliplatin infusion. Immediate defibrillation and cardiopulmonary resuscitation were administered, and the patient regained spontaneous circulation and consciousness. Twelve-lead electrocardiogram showed ST segment elevation in III, aVF, and ST segment depression in V4-6 after resuscitation. To our knowledge, prolongation of QT interval with torsades de pointes and coronary spasm with myocardial injury that were stabilized in one patient following oxaliplatin infusion has not been reported. We present a patient with these rare complications.

Ruptured aortic dissection presenting with new onset atrial fibrillation.

We report this type A aortic dissection in both ascending and descending thoracic aorta presenting with new onset atrial fibrillation. CT images confirmed the final diagnosis. The mechanism may be due to compression of the left atrium by a large haematoma.

The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.

BACKGROUND: Open surgical treatment for an infected aortic aneurysm has a high rate of surgical morbidity and mortality and does not guarantee eradication of the infected nidus. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. This study assessed the efficacy and outcome of EVAR with an adjunctive antibiotic treatment strategy. METHODS: We focused on the experiences and results of the management of infected aortic aneurysms with positive blood cultures. We drew the blood for culture study, immediately prescribed broad-spectrum antibiotics, performed EVAR procedures, and followed this with sensitive antibiotics and adjunctive procedures. RESULTS: Twelve consecutive patients (mean age, 70 years) were included in this EVAR strategy. Three patients had thoracic, two thoracoabdominal, and the remaining seven had infected abdominal aneurysms. Ten Salmonella, one Staphylococcus, and one Streptococcus spp were identified. There was no hospital death. Three patients underwent computed tomography (CT)-guided drainage, and one underwent open laparotomy debridement. Mean follow-up was 24 months. One late death occurred but was unrelated to reinfection. All patients seemed well, with no evidence of EVAR graft infection at a mean follow-up of 23.6 months. CONCLUSIONS: This small multi-institutional study summarizing the experiences of patients with an infected aortic aneurysm managed by EVAR and an aggressive antibiotic strategy revealed that this EVAR strategy might be a suitable approach to treating this disease. These favorable results may be typical for Salmonella infection, which was present in most of the patients. Further experience is needed to assess whether this therapeutic strategy works equally well in aneurysm infection caused by other organisms.

Increased expression of glucose transporter 3 in gerbil brains following magnesium sulfate treatment and focal cerebral ischemic injury.

Glucose is the primary energy substrate for neurons. Glucose transporter 3 (Glut3) localizes at the neuronal cellular membrane, which transports glucose from the extracelluar space into neurons. Ischemia results in an increased energy demand that is associated with profound changes in brain energy metabolism. Magnesium sulfate (MgSO(4)) ameliorates ischemia-induced neuronal death in the rat and gerbil model. We investigated the effects of MgSO(4) administration on the expression of Glut3 in cortex and hippocampus of gerbils during ischemia. The focal cerebral ischemia was produced by unilateral occlusion of the right common carotid artery and right middle cerebral artery. Following ischemia, Glut3 expression increased significantly versus non-ischemic (contra-lateral) cortex and hippocampus. MgSO(4) treatment significantly increased the level of Glut3 expression in the non-ischemic and ischemic cortex and hippocampus. We found that the MgSO(4)-induced increase in Glut3 expression was not reversed by administration of U0126, a MEK kinase inhibitor. These results suggest that other factors may function to modulate the MgSO(4)-induced Glut3 response. In all, our data showed that MgSO(4) increases the expression of Glut3 in the cortex and hippocampus of gerbil brains both in non-ischemia and ischemia status. However, the MEK signaling pathway might not be involved in MgSO(4)-induced Glut3 expression following focal ischemia.

Postinfarction left ventricular rupture salvaged by resuscitation induced pericardial tear.

A 73-year-old diabetic, hypertensive man sustained acute inferolateral wall myocardial infarction 2 days before a syncopal episode, and he was resuscitated on the way to the hospital and during the preoperative examination. An extensive tear of the left posterolateral pericardium with massive left hemothorax and left ventricular free wall rupture with pulsatile bleeding were found during surgery. Iatrogenic pericardial tear due to vigorous cardiac massage could temporarily relieve the pericardial tamponade due to the postinfarction ventricular rupture and allowed the timely surgery to be conducted.

Effects of Tai Chi rehabilitation on heart rate responses in patients with coronary artery disease.

The objective of the present study was to evaluate the effect of a six-month Tai Chi (TC) exercise cardiac rehabilitation program on two prognostic factors of cardiac events, rate-pressure product and rate-pressure product reserve, in patients with coronary artery disease (CAD). Patients (N = 54) with CAD were recruited from the clinics of cardiology and cardiovascular surgery at a regional hospital in Taiwan. Twenty-two of them enrolled in the TC rehabilitation program which consisted of weekly 90-min sessions of Yang's style TC for six months in addition to receiving usual care. The remaining 32 patients received usual care only. Modified Bruce treadmill exercise test was performed to evaluate their exercise test responses at baseline and at six months. The change over time was significantly different between the TC and control group in peak rate-pressure product (RPP) (interaction between group and time, p = 0.029) and in RPP reserve (interaction between group and time p = 0.009) over the six-month period, there was a decrease in peak RPP of 32.0 mmHg x bpm x 10(-2) and in RPP reserve of 37.4 mmHg x bpm x 10(-2) in the TC group. In conclusion, participating in a six-month TC exercise-based cardiac rehabilitation program was associated with improved peak RPP and RPP reserve during exercise testing in patients with CAD. TC exercise program may lead to a better prognosis for cardiac events in patients with CAD.

The effect of t'ai chi exercise on autonomic nervous function of patients with coronary artery disease.

OBJECTIVE: The objective of this study was to evaluate the effect of t'ai chi (TC) on heart rate variability (HRV) from baseline to 9 months in patients with coronary artery disease (CAD). DESIGN: A comparative trial was undertaken comparing the acute and long-term effect of TC on HRV in patients with CAD. PARTICIPANTS: Sixty-one (61) subjects with CAD undergoing percutaneous intervention or coronary bypass grafting for a period of more than 1 month were recruited from the clinics of cardiology and cardiovascular surgery at Chia-Yi Christian Hospital, Taiwan. INTERVENTIONS: The experimental group (n = 22) practiced weekly 90-minute Yang's style TC for 9 months and the control group (n = 39) continued their normal daily physical activity. MAIN OUTCOME MEASURES: HRV was recorded at baseline, 3 months, 6 months, and 9 months in the control group. Resting HRV was recorded before TC exercise and recovery HRV was recorded 30 minutes post TC at the same four time points in the experimental group. RESULTS: The change in the normalized low-frequency power, normalized high-frequency power, and the low-/high-frequency power ratio between resting and post-TC was significantly different at 9 months when compared with those at baseline, 3, and 6 months. The mean difference in normalized low-frequency power and the low/high-frequency power ratio changed from positive values at baseline, 3, and 6 months to negative values at 9 months. However, there were no significant differences in resting HRV between the patients in TC and control groups in either time domain or frequency domain HRV indices. CONCLUSIONS: The change in heart rate and HRV between resting and post-TC suggested that TC exercise could enhance vagal modulation. The potential beneficial effect of long-term regular TC exercise in patients with CAD merits further investigation.

Isolated right ventricular intracavitary metastasis of hepatocellular carcinoma in a 74-year-old woman.

A 74-year-old woman with a history of chronic hepatitis C and transcatheter arterial chemoembolization for an unresectable hepatocellular carcinoma (HCC) 2 years previously presented with progressive exertional dyspnea of 1 month's duration. Two-dimensional echocardiography revealed a huge right ventricular mass with right atrial and right ventricular outflow tract extension. Palliative resection of the tumor and adjunctive chemotherapy was performed. However, the right ventricular mass recurred 1 month later and the patient died 4 months after the operation. To our knowledge, this is the oldest patient reported with isolated right ventricular intracavitary metastasis of HCC, and this report reemphasizes the lower surgical indication in patients with metastatic cardiac tumors.

Optimal initial treatment and clinical outcome of type A aortic intramural hematoma: a clinical review.

Intramural hematoma (IMH) of the aorta is a well-known variant of aortic dissection; however, the optimal initial treatment strategy for type A IMH remains controversial. An English language search of Medline for manuscripts on the treatments and outcomes of IMH with the keywords 'intramural hematoma', 'ascending aorta or type A', 'aortic disease' with cross-references was performed for articles dating from January 1986 to September 2006. Primary outcomes of interest were initial treatment strategies as well as the early and overall mortality rates. Earlier publications studying overlapping patient groups from the same institutions were excluded. Case reports and small series of less than 10 patients were not enrolled. Data from 328 reported cases in 12 studies were extracted. Initial surgery and medical treatment were performed for 168 (51.2%) and 160 (48.8%) patients, respectively. Nine out of 12 studies (75%) came from Asia. The early mortality rate was 10.1% (17/168) and 14.4% (23/160) in patients who received initial surgery and medical treatment, respectively (p=0.37). The optimal initial treatment strategy for type A IMH may still be individualized. Initial medical treatment and timed surgical therapy seems to be associated with higher early mortality rates in patients with type A IMH, even in a primarily Asian cohort. The impact of either initial treatment strategy on long-term survival must be evaluated in further study.

Lessons learned from the endovascular treatment of abdominal aortic aneurysm and a preliminary experience of our center.

BACKGROUND: The development of technical approaches for endovascular abdominal aortic aneurysm (AAA) repair during the last decade was briefly reviewed. The role of endovascular AAA repair as a new reliable method of treatment in high-risk patients was evaluated in both the major studies reported and a preliminary result of our center. METHODS: General criteria for the selection and exclusion of high-risk patients were summarized. Six patients (mean age: 72 years) with complex infrarenal AAA underwent endovascular aneurysm repair using the bifurcated stent graft system. Routine follow-up examination included computed tomography performed periodically from the post-operative month up to one year. Patients suspected of endoleak underwent angiography and further endovascular treatment. RESULTS: Successful deployment of the endograft and exclusion of the aneurysm was achieved in all six patients (100%) in our preliminary series. None of our patients required conversion to open aneurysmal repair. Comorbidity was an important factor in the outcome of aneurysm repair in high-risk patients, with cardiovascular disease and chronic obstructive pulmonary disease being the major comorbid conditions. Cardiac events were the most common complications, followed by transient renal failure, wound infection and endoleaks, which were corrected with endovascular treatment. CONCLUSIONS: The long-term results and efficacy of endovascular repair of infrarenal AAA remain to be demonstrated, but the procedure is believed to provide a safe and effective alternative treatment for high-risk patients suffering from AAA.

Is off-pump coronary artery bypass grafting in multivessel feasible.

BACKGROUND: "Off-pump" coronary artery bypass grafting (OPCABG) became more popular in recent years for its potential advantages of reducing perioperative morbidity related to cardiopulmonary bypass (CPB). We retrospectively analyzed the early results of multivessel OPCABG to compare them with conventional CABG under CPB. METHODS: From April 2000 to Oct 2000, 15 patients received multivessel OPCABG (group A). CTS or Octopus II stabilizer was used with coronary anastomosis. "Auto-perfusion system" was used at late stage of our series for myocardial protection in the procedure. At the same time, patients who received primary isolated CABG under CPB were compared as control (group B). RESULTS: There was no operative mortality or major morbidity in the group of multivessel OPCABG. Two patients who failed multivessel OPCABG due to hemodynamics compromise were converted to conventional CABG under CPB uneventfully. The amount of operative blood loss and donor blood transfusion, the duration of postoperative mechanical ventilation support, the mean intensive care unit stay and postoperative hospital stay were less in group A. CONCLUSIONS: Multivessel OPCABG is feasible in surgical techniques in selected patient. It is associated with minimal operative mortality and morbidity partly because of obviating the adverse effect of CPB. Prospective study with long-term follow-up is needed to better define the role of OPCABG.

Perioperative result of carotid endarterectomies with venous patch angioplasty.

BACKGROUND: Carotid endarterectomy (CEA) is an effective treatment of carotid stenosis to reduce the risk of stroke. The purpose of the current study is to investigate the result of surgical treatment of carotid stenosis in Taipei Veterans General Hospital. METHODS: The medical records of 103 patients receiving 113 CEA with or without patch angioplasty in our service between January 1993 and July 1999 were reviewed retrospectively. The clinical and operative variables were collected for analysis. According to the method of carotid arteriotomy closure, all operations were categorized into 3 groups: 76 CEA with venous patch angioplasty, 27 CEA with synthetic angioplasty and 10 primary closure without patch angioplasty. The outcomes of CEA among 3 groups were compared. RESULTS: There was no significant difference of patient characteristics between 3 groups. Four patients died in the same admission. The incidence of hospital mortality was 0% for venous patch group (p = 0.01), 11.1% for synthetic patch group and 10% for primary closure group. There were 5 perioperative complications including 3 with ipsilateral stroke and 2 with wound hematoma. The incidence of perioperative complication rate was 2.6% for venous patch group, 7.4% for synthetic patch group and 10% for primary closure group (p = 0.87). The incidence of perioperative CVA was 1.3% for venous patch group, 3.7% for synthetic patch group, 10% for primary closure group (p = 0.43). CONCLUSIONS: Our study showed that CEA could be performed with low risk and that venous angioplasty carried lower hospital mortality than other methods of carotid arteriotomy closure.

Is combined abdominal aortic aneurysm repair and coronary artery bypass grafting feasible?

BACKGROUND: Significant coronary artery disease requiring coronary artery bypass grafting (CABG) may co-exist with large abdominal aortic aneurysm (AAA) in some patients. We reviewed our experience in either staged or simultaneous operation. METHODS: The records of all patients receiving both CABG and AAA repairs in recent 7 years were retrospectively reviewed. The patient demographics, severity of coronary disease, AAA size, duration of staged procedures, perioperative morbidity and mortality rates as well as the hospital cost were analyzed. RESULTS: From June 1993 to Sept 2000, totally 14 patients received both CABG and AAA repair, including 6 patients for simultaneous operation (group A, 42.8%) and 8 for staged operation (group B, 57.2%) with CABG first. Patients in the group A were younger and with larger AAA. There was neither operative mortality in both group nor interprocedure AAA rupture in group B. Total postoperative hospital stay and hospital cost were significantly decreased in group A than in group B rehospitalized patients. CONCLUSIONS: Simultaneous CABG and AAA repair is feasible in surgical technique. In those younger patients with larger AAA, combined surgery could be performed as safely as staged procedures.