Congenital coronary arteriovenous fistula presenting with syncope.

Previous reports of syncope in patients with coronary arteriovenous fistula (CAVF) have theorized that it occurs secondary to a coronary steal phenomenon. We present a case of syncope in a young woman with a CAVF and no anatomic substrate for coronary steal.

Lysis of a left ventricular thrombus with recombinant tissue plasminogen activator.

A 23-year-old woman with peripartum cardiomyopathy presented with a 2.1 x 2.5-cm pedunculated, mobile, left ventricular thrombus and evidence of systemic embolization. Due to the patient's poor left ventricular function, thrombectomy was not a viable option. Treatment with high-dose IV heparin was initially utilized but was unsuccessful as the thrombus appeared to enlarge on echocardiography. An accelerated weight-adjusted dose of recombinant tissue plasminogen activator (rt-PA) successfully lysed the thrombus without evidence of embolization. Although rt-PA has been used for primary lysis of high-risk ventricular thrombi, this is the first documentation of successful lysis of a left ventricular thrombus in a patient with peripartum cardiomyopathy.

Cancer in patients receiving long-term dialysis treatment.

A large excess of non-Hodgkin's lymphoma has been documented in renal transplant patients and may be related to immunosuppressive therapy, persistent antigenic challenge from the graft, or both. To determine whether immuno-suppression resulting from chronic renal failure is associated with an elevated risk of certain tumors such as non-Hodgkin's lymphoma, the authors studied cancer incidence in a national cohort of 28,049 patients in the United States with chronic renal failure who received maintenance dialysis for at least six months (totaling 66,706 person-years of observation). Compared with national incidence rates, the relative risk (RR) of cancer was 0.9 (excluding nonmelanoma skin cancer, multiple myeloma, kidney cancer, and uterine cervix cancer). Moderate excesses of leukemia, non-Hodgkin's lymphoma, Hodgkin's disease, thyroid cancer, and biliary tract cancer were found, but were not statistically significant for both sexes combined. A significantly elevated risk of non-Hodgkin's lymphoma among patients with chronic glomerulonephritis (RR = 2.6) accounted for the excess observed in the total series, raising the possibility of factors specific to this disease.

The recent U.S. experience in the treatment of end-stage renal disease by dialysis and transplantation.

We determined survival rates and rates of graft retention for patients who had begun to receive dialysis or had received transplants between January 1, 1977, and December 31, 1980, using the data collected by the Medical Information System of the Health Care Financing Administration, which covers nearly all persons with end-stage renal disease in the United States. We found that among patients receiving transplants in successive years in the period from 1977 to 1980 the rates of graft retention showed progressive and substantial increases, whereas survival rates for both dialysis and transplant recipients remained stable. In addition, we found that transplant recipients were subject initially to high risks of graft loss and death, but that these risks decreased rapidly in the few months after transplantation. The population receiving dialysis was subject to a nearly constant death rate, which was generally higher than the stable late-mortality rate among transplant recipients. Blacks had higher survival rates than whites on dialysis, black and white patients had similar survival rates after transplantation, and black patients had lower rates of retention of functioning grafts. Finally, our analysis indicates that the best results were obtained in recipients of kidneys from related donors.