Clinical features and predictors of survival of AIDS-related non-Hodgkin's lymphoma in a population-based case series in Sydney, Australia.

OBJECTIVES: To analyse clinical features and predictors of survival for AIDS-related non-Hodgkin's lymphoma (NHL) in the era of highly active antiretroviral therapy (HAART), compared to earlier in the HIV epidemic. METHODS: All AIDS-NHL cases diagnosed at three inner Sydney hospitals caring for people with AIDS during 1985-2001 were identified through medical record searches. Demographic, clinical, immunological and histopathological information was recorded. Year of NHL diagnosis was grouped into three periods, corresponding to whether monotherapy (1985-1991), dual therapy (1992-1995) or HAART (1996-2001) was the main treatment for HIV infection. Statistical comparisons were made between the pre-HAART and post-HAART eras. RESULTS: Three hundred cases of AIDS-NHL were identified. Divergent trends were identified for systemic and primary central nervous system (CNS) NHL. For systemic NHL, the CD4 count at NHL diagnosis increased markedly to 208 cells/microL in the post-HAART era (P=0.014) and there was a trend towards presentation as the first AIDS-defining illness (69%, P=0.053), and as earlier stage NHL disease (42%, P=0.048). Median survival time increased from 4.2 months in 1985-1991 to 19 months in the post-HAART era (P<0.001). In a multivariate model, predictors of poor survival from systemic NHL included: NHL diagnosis after another AIDS-defining illness (P<0.001), stage 4 NHL (P<0.001), presentation at extra lymphatic sites (P=0.001), and nonreceipt of chemotherapy (P=0.002). After adjusting for the factors, those diagnosed in the era of HAART had a significant 56% reduction in rate of death (P<0.001). In contrast, for CNS NHL, clinical features were little changed and survival did not improve in the era of HAART. CONCLUSIONS: Systemic NHL is presenting earlier in the course of HIV disease, and at a less advanced NHL stage. There has been a marked improvement in survival in the era of HAART even after adjustment for other prognostic variables. In contrast, primary CNS NHL remains a disease which presents late in the course of HIV infection and is associated with a very poor prognosis.

Prevention of unbalanced lung perfusion and atrial arrhythmias after the lateral tunnel operation.

BACKGROUND: The lateral tunnel operation has become increasingly popular with pediatric cardiac surgeons, as it is technically reproducible, is relatively easy to perform, and can be used in a variety of patients with single-ventricle physiology. The main drawbacks of the original operation are uneven blood flow distribution to the lungs and increasing incidence of supraventricular arrhythmias over time. METHODS: In 1988, we modified this technique by avoiding narrowing of the tunnel at the superior vena cava-atrial junction, avoiding incorporation of the crista terminalis in the baffle suture line, and minimizing damage to the sinoatrial node. Between 1988 and 1995, 19 patients underwent this operation at Marie-Lannelongue Hospital in Paris. RESULTS: There was one early death and no late deaths. At a mean follow-up of 5.2 years, all survivors are in New York Heart Association class I. Early atrial flutter, related to atrial scarring secondary to multiple previous surgical procedures, developed in 1 patient, and late atrial flutter developed in 1 patient who had a previous Blalock-Hanlon atrial septectomy. All patients are currently in sinus rhythm. Atrial flutter did not occur in 17 patients who had had no previous atrial wall surgical procedure. CONCLUSIONS: We believe that the good long-term clinical results are directly attributable to our modifications, which ensure optimal hemodynamics and absence of rhythm disturbances. All patients who had not previously undergone operation on the atrial wall were free from supraventricular tachyarrhythmias at a mean follow-up of 5.2 years. This is a consequence of protecting the sinus node, crista terminalis, and Bachmann's bundle.

Unusual forms of tracheobronchial compression in infants with congenital heart disease.

Three groups of unusual forms of tracheobronchial compression caused by vascular anomalies are presented. Three patients had an encircling right aortic arch with a left-sided descending aorta and ligamentum arteriosum (group 1), two patients had airway compression caused by a pincer effect between a malposed and enlarged ascending aorta and the descending aorta (group 2), and three patients had airway compression after an arterial switch operation for transposition of the great arteries (group 3). Symptoms developed in all patients before the age of 4 months, and six of them had multiple failed attempts at extubation before the surgical intervention directed at relieving the airway compression. Fiberoptic endoscopy was used in all patients as a first-line diagnostic tool and was 100% accurate in establishing the diagnosis. The operations performed were aortic uncrossing in group 1, dissection and aortopexy of the right or left main bronchus in group 2, and dissection of the left main bronchus and lysis of adhesions in group 3. In group 1 there was one early death, resulting from aspiration, and one late death 4 years later, resulting from an unrelated cause. In this group, bronchomalacia was noted after the operation and resolved gradually in the year after the intervention. In group 2, one patient died of an aortobronchial fistula after placement of a bronchial stent. Group 3 patients had good postoperative results. Two of them are completely symptom-free and one has residual bronchomalacia and may need placement of a bronchial stent.

Heart transplantation for chyloptysis after Fontan operation.

Chyloptysis is a rare clinical problem, fewer than 10 patients having been reported in the literature. We report a patient with intractable chyloptysis associated with a Fontan procedure, who was palliated by heart transplantation.

High resolution mapping of Koch's triangle using sixty electrodes in humans with atrioventricular junctional (AV nodal) reentrant tachycardia.

BACKGROUND: Recent evidence suggests that atrioventricular junctional reentrant tachycardia (AVJRT) uses a reentrant circuit that involves the atrioventricular (AV) node, the atrionodal connections, and perinodal atrial tissue. Electrogram morphology has been used to target the delivery of radiofrequency energy to the site of the "slow pathway," a component of this reentrant circuit. The aim of this study was to localize precisely the sites of atrionodal connections involved in AVJRT and to examine atrial electrogram morphologies and their spatial distribution over Koch's triangle. METHODS AND RESULTS: Electrical activation of Koch's triangle and the proximal coronary sinus was examined in 13 patients using a 60-point plaque electrode and computerized mapping system. Recordings were made during sinus rhythm (n = 12), left atrial pacing (n = 8), ventricular pacing (n = 12), and AVJRT (n = 12). During sinus rhythm electrical activation approached Koch's triangle and the AV node from the direction of the anterior limbus, activating the anterior part of the triangle before the posterior part. A zone of slow conduction during sinus rhythm was found within Koch's triangle in 64% of patients. The pattern of atrial activation in Koch's triangle during anterograde fast pathway conduction was similar to that seen during anterograde slow pathway conduction. Retrograde fast pathway conduction during ventricular pacing and during anterior (typical) AVJRT caused earliest atrial activation at the apex of Koch's triangle near the AV node-His bundle junction. In individual patients the site of earliest atrial activation was similar for both anterior AVJRT and retrograde fast pathway conduction during ventricular pacing. Retrograde slow pathway conduction during ventricular pacing and during posterior (uncommon or atypical) AVJRT caused earliest atrial activation posterior to the AV node near the orifice of the coronary sinus. This posterior or "slow pathway" exit site was 15 +/- 4 mm from the His bundle. In individual patients the site of earliest atrial activation was similar for both posterior AVJRT and retrograde slow pathway conduction during ventricular pacing. In one patient anterograde and retrograde conduction occurred via separate slow pathways during AVJRT: Complex atrial electrograms with two or more components were observed near the coronary sinus orifice and in the posterior part of Koch's triangle in all cases. These were categorized as either low or high frequency potentials according to the rapidity of the second component of the electrogram. Low frequency potentials were present at the site of earliest atrial excitation during retrograde slow pathway conduction in 5 of 5 cases (100%) and high frequency potentials in 4 of 5 cases (80%). However, both slow and high frequency potentials could be found at sites up to 16 mm from the site of earliest atrial excitation. CONCLUSIONS: At least two distinct groups of atrionodal connections exist. The site of earliest atrial activation during anterior AVJRT is similar to that of fast pathway conduction during ventricular pacing. This site is close to the His bundle-AV node junction. The site of earliest atrial activation during posterior AVJRT is similar to that of slow pathway conduction during ventricular pacing. This site is near the coronary sinus orifice, approximately 15 mm from the His bundle. The anterograde slow pathway appears to be different from the retrograde slow pathway in some patients. Double atrial electrograms are an imprecise guide to the site of earliest atrial excitation during retrograde slow pathway conduction.

Ascending aortic aneurysms associated with aortic valve regurgitation: St Vincent's Hospital's experience.

This report represents a retrospective analysis of the St Vincent's Hospital experience with combined replacement of the aortic valve and ascending aorta using a composite conduit and coronary artery reimplantation, in 44 patients, from 1 January 1981 to 30 June 1988. The mean age at operation was 48 years. Annuloaortic ectasia was the most common indication for operation in 24 patients (54%). There were three hospital deaths (7%). Forty-one patients were discharged from hospital and were followed up for a total of 1,106 patient months (mean = 26.5 months). There were three late deaths (7%). One death was due to a new dissection, one to a cerebrovascular accident and one to a drug overdose. So far, no patients have required reoperation. Of the 36 surviving patients available for follow-up, 28 are in New York Heart Association class I, seven patients are in class II and one in class III. Composite graft replacement reduces the risk of recurrent dissection and aneurysm formation and of periprosthetic leak. In the present experience, it is the method of choice in patients with degenerative lesions in the ascending aorta and aortic valve and particularly for annuloaortic ectasia. The exact surgical technique currently used has been the result of an evolution of different techniques.