In situ central pulmonary artery thrombosis in primary pulmonary hypertension.

A rare case of extensive in situ central pulmonary artery thrombosis in primary pulmonary hypertension (PPH) is presented. The differentiation from chronic thromboembolic pulmonary arterial hypertension (CTEPH) is of paramount importance because of different therapeutic strategies. In this case, the presence of mural thrombus in the central pulmonary arteries on computed tomography made the distinction difficult. However, the possibility of in situ thrombosis was suggested on the basis of absence of other findings of CTEPH (abrupt narrowing/truncation of segmental arteries, variation in size of segmental vessels, arterial webs, mosaic attenuation, pulmonary infarcts, and dilated bronchial arteries), and this was confirmed on final pathology.

Postinfarct cardiac free wall rupture: the relationship of rupture site to papillary muscle insertion.

The objective of this study was to examine for any relationship between the sites of papillary muscle insertion in left ventricular free wall (LVFW) and the site of LVFW rupture postinfarct. Twenty-five consecutive patients with LVFW rupture (12 men and 13 women, mean age 72.3 yr, range = 48 to 93) at the University of Ottawa Heart Institute during the period of July 1, 1988 to 1992 were studied. Clinical charts were reviewed, and the Formalin-fixed hearts were re-examined grossly and microscopically. Each patient died of tamponade or after surgery for tamponade. Eight (32%) of the 25 infarcts were anteroseptal or anterior, 11 of 25 (44%) were lateral, and 6 of 25 (24%) were inferior or inferoseptal. Four (16%) of the 25 infarcts were less than 2 days old, 9 of 25 (36%) were 2 to 5 days old, and 12 of 25 (48%) were 5 to 10 days old. A separate pre-existent and healed infarct was noted in 36% of patients; however, rupture adjacent to these areas of old infarct occurred in only 8% of cases. In 15 of 25 (60%) cases, free wall rupture occurred in the lateral wall between and at the level of the two papillary muscles. In a further 5 of 25 (20%) cases, the rupture was beside one of the papillary muscles but in anterior or posterior walls. In 20 of 25 (80%) cases, the endocardial tear associated with the LVFW rupture was within 1 cm of the base of one of the papillary muscles as they inserted in LVFW.(ABSTRACT TRUNCATED AT 250 WORDS)

Noncalcific cusp thickening in Ionescu-Shiley cardiac valvular bioprostheses.

This study was undertaken to examine the morphological basis for noncalcific cusp thickening in 20 standard-profile Ionescu-Shiley bovine pericardial cardiac valvular bioprostheses (16 aortic, four mitral) with primary valve failure due to cusp tears. The patients included 17 males and three females, with a mean age of 52.0 years; their valves had been implanted for a mean of 105.8 months. All cases had variable degrees of "plasma insudation" without correlation to identifiable patient parameters. This was accentuated in individual valves in the cusp with the most extensive tears. In addition, the three valves with the thickest cusps were grossly distorted by massive deposits of amyloid (identified as AL-amyloid in two index cases studied). Two other valves had incidental amyloid deposits, identifiable only by electron microscopy. Amyloid involvement of pericardial bioprostheses has not been previously reported. The literature pertaining to amyloid involvement and plasma insudation of bioprostheses is reviewed.

Splenic rupture resulting from acute pancreatitis after cardiac surgery with intra-aortic balloon pumping: case report.

A very unusual cause of splenic rupture is described in a 73-year-old man with severe coronary artery disease. A transthoracic intra-aortic balloon pump (IABP) was inserted during coronary artery bypass grafting and was used for 3 days. However, his hypotension continued, and ischemic changes in his hand were thought to be due to the use of the pump. He died 7 days later of cardiac arrest. Autopsy revealed multiorgan failure associated with a preoperative myocardial infarct. Numerous systemic arterial atheroemboli, likely resulting from IABP-related aortic trauma and hypotension, had given rise to severe acute pancreatitis. The necrotizing process within the pancreatic tail had extended to the splenic hilum, eroding its capsule and causing splenic rupture and hemoperitoneum.

Pathology of radiofrequency catheter ablation of the atrioventricular node.

Catheter ablation of the atrioventricular node is now the treatment of choice for definitive management of some supraventricular tachyarrhythmias. Radiofrequency current is used as the energy source in most centers. We describe a 67-year-old woman who had rheumatic mitral valve disease and chronic atrial fibrillation with rapid ventricular response. She underwent successful radiofrequency catheter ablation of the atrioventricular node, followed by permanent pacemaker insertion. She required mitral valve replacement 16 months later and died postoperatively of left ventricular failure. At autopsy, there were patches of organized endocardial thrombus and discrete endocardial and myocardial fibrous scar at the ablation sites, replacing most of the atrioventricular node. The long-term pathologic changes after atrioventricular node ablation with radiofrequency current, used in a clinical setting, have not been previously described and are illustrated here.

The surgical anastomoses after orthotopic heart transplantation: clinical complications and morphologic observations.

From May 1984 through June 1993, 162 patients have undergone orthotopic heart transplantation at the University of Ottawa Heart Institute. Thirty-three deaths occurred, and postmortem examinations were performed in 29 of these cases. This study evaluated the surgical anastomoses of these patients' hearts, an aspect of orthotopic heart transplantation that has not been well described in the literature. The major findings encountered were two cases of stenosis at the left atrial anastomosis, one case of aortic anastomotic tear, one case of pulmonary artery anastomotic kinking, one case of left atrial suture line mural thrombus and possible coronary embolism, and one case of extramural compression of a coronary artery by an anastomotic suture. Other findings when the suture lines were examined included residual native valve remnants, protruding tissue tags or other tissue remnants, mural thrombi, and protruding free suture ends. These findings are described, illustrated, and discussed in the context of the published literature on the subject.

Analysis of deaths after heart transplantation: the University of Ottawa Heart Institute experience.

This study reviews the clinical outcome of the 132 orthotopic heart transplantations performed at our institute from 1984 through 1991 and focuses on the pathology of those patients who died. The study comprised 124 adults (mean age, 45.6 +/- 0.9 years) and eight children. Twenty-six adult and one pediatric deaths occurred. Operative mortality (within 30 days) was 10.6%, with 84.8% of patients surviving to discharge. Actuarial probabilities of survival at 1 and 5 years were 84% +/- 3% and 71% +/- 6%, respectively. Of the 27 deaths, six (22.2%) occurred in the operating room (from hemorrhage, graft failure, and hyperacute rejection); 14 (51.9%) occurred in-hospital after surgery (from sepsis, rejection, cytomegalovirus disease, or myocardial infarct), and seven (25.9%) occurred after discharge (from rejection and/or recurrent coronary artery disease). Two groups of patients were at higher risk: patients in cardiogenic shock requiring pretransplantation mechanical support, with in-hospital mortality of 39.1%; and patients with previous valve replacement who were taking oral anticoagulants, with intraoperative mortality of 50.0%. Pathologic examination revealed occasional instances of unsuspected coronary artery disease in the donor hearts with more than 50% stenoses of the left anterior descending coronary arteries in three of 21 (14.3%) of cases. Complications of the transplantation or related therapeutic procedures were common among those who died. The complications ranged from functionally insignificant anatomic curiosities to life-threatening problems. These complications are tabulated and shown.

Suprasellar xanthomatous Rathke's cleft cyst.

A case of a symptomatic suprasellar Rathke's cleft cyst in a 35-year-old woman is presented. The cyst wall and contents showed large collections of xanthomatous cells. With the exception of a few pituitary hormone-positive cells, immunohistochemical and ultrastructural features of the lining epithelium in this case of Rathke's cleft cyst were indistinguishable from colloid cysts of the third ventricle with similar secondary changes.

The University of Ottawa Heart Institute Cardiac Transplant Program: the first 100 transplants. A pathologic study of the explanted hearts.

Since 1984, 122 orthotopic heart transplants have been performed at the University of Ottawa Heart Institute. Of the 114 adult patients, 100 (87.8%) were males and 14 (12.2%) females, with mean ages of 45.8 and 47.9 yr, respectively. The hearts of these adults were pathologically diagnosed as chronic ischemic heart disease (CIHD) in 55 (48.2%), acute ischemic heart disease (AIHD) in 17 (14.9%), dilated cardiomyopathy (DC) in 30 (26.3%), valvular heart disease in five (4.4%), congenital heart disease in three (2.6%), myocarditis in three (2.6%), and other in one (0.9%) of the cases. The adult hearts (94) among the first 100 transplants were studied morphologically, to look for differences among the three major groups with clinical "end-stage" heart failure. The mean heart weights were 435, 356, and 463 gm in the CIHD, AIHD, and DC groups, respectively, with AIHD less than CIHD or DC (p less than 0.01). The ventricular wall thicknesses were similar in CIHD and DC, but the left ventricular (LV) wall thicknesses in AIHD were more than in CIHD or DC (p less than 0.01). The ventricular diameters were greater in DC than in CIHD or AIHD (p less than 0.01) and greater in CIHD than in AIHD (p less than 0.01). The mean LV cavity volumes were 158, 94, and 200 ml in CIHD, AIHD, and DC, respectively, with DC greater than in CIHD or AIHD (p less than 0.01) and CIHD greater than in AIHD (p less than 0.01). The relative differences in AIHD compared to CIHD and DC are referrable to the shorter duration of disease in the acute ischemic group.2+ off