Annular and leaflet augmentation in Noonan's syndrome with dysplastic pulmonary valve.

Two patients with dysplastic pulmonary valves associated with Noonan's syndrome successfully underwent leaflet augmentation with pericardial membrane and annular enlargement with preservation of valve competence. Both patients are doing well at 36 and 37 months, respectively, postoperatively. Echocardiography and clinical assessment showed gradients of 12 and 16 mmHg, respectively, and negligible pulmonary valve insufficiency. The surgical technique is simple and provides an attractive alternative in patients with dysplastic pulmonary valve and small pulmonary orifice and annulus.

Facial gunshot wounds: a 4-year experience.

PURPOSE: Facial gunshot wounds can result in devastating functional and aesthetic consequences for patients. In an attempt to evaluate the management and outcome in these patients, a 4-year retrospective review was undertaken of all patients presenting with facial gunshot wounds at a level I trauma center. PATIENTS AND METHODS: A total of 121 patients were identified. Medical documentation could be obtained on 84 of those patients. The patients' maxillofacial injuries were treated by the 3 participating services: plastic surgery, oral and maxillofacial surgery, and otorhinolaryngology. The patients ranged in age from 6 to 64 years, with a mean age of 27 years. RESULTS: The gunshot wounds were single in 64% of the cases and multiple in 36% of the cases. Overall mortality in the series was 11%. Sixty-seven percent (56/84) of the patients suffered an injury to the underlying craniofacial skeleton. Seventy-five percent of these patients required surgical intervention. Twenty-one percent of the patients (16/75) required tracheostomy emergently for management of the airway. Eighteen percent (15/84) of these patients had an intracranial injury, with 50% of these patients requiring surgery. Fourteen percent of the patients in the series (12/84) had great vessel injuries diagnosed at the time of angiography, with 50% of these patients requiring surgery for treatment. CONCLUSION: Contrary to much of the published literature, most patients in this series required surgical intervention for treatment of their facial gunshot wounds. Reconstructive procedures were performed early in the patient's course and, when possible, addressed both the soft tissue and underlying bony injury in a minimum number of stages.

Local gene delivery: arterial thrombosis model for endothelial cell-targeted thrombolytic gene therapy research.

The authors describe a rabbit arterial thrombosis model that employs vessel division followed by microsurgical anastomosis and transluminal sutures, to reliably induce thrombus formation in the common femoral artery (CFA). Using two objective measures, "evacuation/refill" evaluation of patency and computer-aided histomorphometric analysis of the thrombus area, thrombus formation was confirmed and characterized in the model at both short- and long-term observation time-points. In addition, a gene delivery method was developed in the CFA that employs an adenoviral vector solution injected through the inferior epigastric artery (IEA). Using this method, a marker transgene (beta-galactosidase) was delivered to endothelial cells locally and without trauma. By subsequently performing beta-galactosidase staining, effective endothelial transfection was demonstrated simultaneously with endothelial viability, with preserved endothelial synthetic function in the immediate environment of the occluding thrombus. The results suggest that these two techniques can be used together in one model, to effectively introduce a foreign therapeutic transgene into endothelial cells and to evaluate the effect of the expressed protein product in a consistent in vivo thrombosis system. This combined model may be used as one of several assays of efficacy in future endothelial cell-targeted thrombolytic/antithrombotic vascular gene therapy research.

Gene therapy to promote thromboresistance: local overexpression of tissue plasminogen activator to prevent arterial thrombosis in an in vivo rabbit model.

Tissue-type plasminogen activator (tPA) catalyzes the rate-limiting initial step in the fibrinolytic cascade. Systemic infusion of tPA has become the standard of care for acute myocardial infarction. However, even the relatively short-duration protocols currently employed have encountered significant hemorrhagic complications, as well as complications from rebound thrombosis. Gene therapy offers a method of local high-level tPA expression over a prolonged time period to avoid both systemic hemorrhage and local rebound thrombosis. To examine the impact of local tPA overexpression, an adenoviral vector expressing tPA was created. The construct was characterized functionally in vitro, and the function of the vector was confirmed in vivo by delivery to the rabbit common femoral artery. Systemic coagulation parameters were not perturbed at any of the doses examined. The impact of local overexpression of tPA on in vivo thrombus formation was examined subsequently in a stasis/injury model of arterial thrombosis. The construct effectively prevented arterial thrombosis in treated animals, whereas viral and nonviral controls typically developed occluding thrombi. This construct thus offers a viable technique for promoting a locally thromboresistant small-caliber artery.

Local overexpression of thrombomodulin for in vivo prevention of arterial thrombosis in a rabbit model.

-Endothelial thrombomodulin plays a critical role in hemostasis by binding thrombin and subsequently converting protein C to its active form, a powerful anticoagulant. Thrombomodulin thus represents a central mechanism by which patency is maintained in normal vessels. However, thrombomodulin expression decreases in perturbed endothelial cells, predisposing to thrombotic occlusion. An adenoviral construct expressing thrombomodulin (Adv/RSV-THM) was created and functionally characterized in vitro and in vivo. The impact of local overexpression of thrombomodulin on in vivo thrombus formation was subsequently examined in a stasis/injury model of arterial thrombosis. The construct prevented arterial thrombosis formation in all animals, while viral and nonviral controls typically developed occluding thrombi. By histological analysis, nonviral controls exhibited intravascular thrombus occluding a mean of 70.52+/-3.72% of available lumen, while viral controls reached 86. 85+/-2.82% thrombotic occlusion; in contrast, Adv/RSV-THM reduced thrombosis to 28.61+/-3.31% of lumen in cross section. No significant intima-to-media ratio was observed in the thrombomodulin group relative to controls. Local infiltration of granulocytes and macrophages significantly decreased in the Adv/RSV-THM group relative to controls, while neutrophilic infiltration increased in viral controls relative to nonviral controls. This construct thus offers a viable technique for promoting a locally thromboresistant small-caliber artery, without the inflammatory damage that has limited many other adenoviral applications.

Leech therapy in the management of acute venous congestion of an infant's lower limb.

We report the successful use of leech therapy in the postsurgical management of an infant with acute venous congestion of an entire lower limb. Two days of constant leech therapy, followed by 5 days of intermittent application, decongested the affected tissues. There were no complications related to the leech therapy, and mild cutaneous hyperpigmentation was the only long-term complication of the acute venous congestion. The volume of the affected tissue may limit the success of leech therapy in cases of acute venous congestion in the limbs of adults. Nevertheless, the use of leeches to manage acute venous congestion of large portions of infants' bodies should be considered when surgical therapies are not feasible.

The intradermal anatomy of the inframammary fold.

The anatomy of the inframammary fold has been a subject of controversy. This report describes the anatomic location and the histologic structure of the inframammary fold on the basis of caderveric dissections and microscopic examination. Ten breast cadaver dissections were performed on female cadavers (ages 35 to 72). Twenty specimens after en bloc resections of the inframammary fold and subcutaneous tissue, including the pectoralis muscle, were harvested. Specimens were examined for gross collagen stricture by using India ink to highlight the collagenous aspects of the subcutaneous soft-tissue networks. The inframammary fold skin and dermis from the contralateral breast and control samples of skin and dermis from the upper chest and the abdomen were collected for microscopic studies. These samples were stained with Sirius red and examined microscopically by polarized light. On histologic examination, regular arrays of collagen were found running parallel with the inframammary fold, and the control sections showed random patterns of collagen deposition. On gross examination, a condensation of the superficial fascial system was observed. This formed a zone of adherence between the skin and the underlying pectoralis fascia. The conclusion of this study is that the inframammary fold is an intrinsic dermal structure consisting of regular arrays of collagen held in place by a zone of adherence that is a specialized area of the superficial fascial system. The clinical significance of this study is that the intradermal structure of the inframammary fold should be preserved in any breast procedure for natural aesthetic results.