Axillary Silicone Granulomas in Patients With Melanoma. / Siliconomas axilares en pacientes con melanoma.

Subcutaneous lesions may be detected during follow-up of patients with melanoma. The main entities that should be contemplated in the differential diagnosis in such cases are in-transit and regional lymph node metastases. We describe 2 cases of women with breast implants who developed palpable subcutaneous lesions in the axillary region during follow-up of melanoma. In both cases, the ultrasound study showed diffuse hyperechoic signals forming the characteristic snowstorm sign in the subcutaneous tissue. Ultrasound proved to be a key diagnostic tool for ruling out melanoma-related disease, such as in-transit metastases and regional lymph node metastases.

Tampa Bay catheter: a new guiding catheter for endomyocardial biopsy via femoral approach.

Initially, endomyocardial biopsies were obtained almost exclusively using the jugular vein approach. Lately, the femoral vein route has gained popularity and in many centers, including ours, it is preferred. Despite this, guiding catheters specifically designed for endomyocardial biopsy via femoral vein approach are not available. Here, the experience with the Tampa Bay catheter, designed for endomyocardial biopsy using the femoral vein is described. From 1-1-89 to 1-31-90, a total of 486 endomyocardial biopsies were performed in 78 post-heart transplant patients (1-17, mean 6 per patient); 106 were performed via internal jugular vein (22%) and 380 (78%) via femoral vein. Of these, 100 were performed using the Tampa Bay catheter. The remaining 280 biopsies were done using a long sheath or a Judkin's right coronary angioplasty guiding catheter. Biopsy specimens were adequate for diagnosis of rejection in all 106 biopsies performed via internal jugular vein (100%) in 99 of 100 biopsies via femoral vein using the Tampa Bay catheter (99%) and in 274 of the 280 (98%) biopsies using the long sheath or the right Judkin's coronary angioplasty guiding catheter (NS). The femoral vein is larger and easier to find than the internal jugular vein. More important, complications such as right pneumothorax, Horner's syndrome, recurrent laryngeal nerve paralysis, and right phrenic nerve paralysis, known to occur when the internal jugular vein approach is used, can be completely avoided when the femoral vein approach is used.

Value of ventricular premature complex (VPC) morphology in the diagnosis of hypertrophic cardiomyopathy.

Experimental and clinical studies have established the value of ventricular premature complexes (VPC) with a QR pattern in the diagnosis of occult antecedent myocardial infarction. However, the clinical significance of a QR pattern VPC in patients with hypertrophic cardiomyopathy has not been previously evaluated. In order to study this, we examined the ECGs and 24-hour Holter monitor records of 45 consecutive patients with hypertrophic cardiomyopathy and 106 consecutive patients with various other diseases. A QR pattern VPC in the precordial leads with a Q greater than or equal to 40 ms and a Q/R ratio greater than or equal to 0.20 had a specificity of 97%, a sensitivity of 29% and a predictive value of 80% in the diagnosis of hypertrophic cardiomyopathy. We conclude that a QR pattern VPC may be of value in the eclectic diagnosis of hypertrophic cardiomyopathy and that it is not specific for antecedent myocardial infarction as previously reported.

Postextrasystolic changes in systolic time intervals in the assessment of hypertrophic cardiomyopathy.

To determine if postextrasystolic changes in systolic time intervals can be used to estimate the severity of resting or provocable left ventricular outflow pressure gradient, we studied the cardiac catheterisation records of 42 patients with hypertrophic cardiomyopathy looking for instances of a single premature beat preceded by a control sinus beat and followed by a postpremature sinus beat. There were 75 such instances in 25 patients. In comparison to the control beat, the pre-ejection period in the postpremature beat was shorter by deltaPEP = -20 +/- 11 ms in 73 of 75 instances, and remained unchanged in two. The ejection time in the postpremature beat was invariably longer by deltaET = 37 +/- 20 ms (range: 10 to 85 ms) and the pre-ejection period/ejection time ratio lower than control by delta(PEP/ET) = -0 . 10 +/- 0 . 05 (range: -0 . 01 to -0 . 25). Total electromechanical systole in the postpremature beat was shorter (11/75), the same (10/75), or longer (53/75) than in the control beat, the overall change being deltaEMS = -18 +/- 22 ms. Both deltaPEP and delta(PEP/ET) correlated poorly with the systolic peak left ventricular-aortic pressure gradient in either the control beat (Gc) or the postpremature beat (Gx), and also with the change in gradient (delta G) from the control to the postpremature beat. In contrast, significant linear correlations were found between delta EMS and either Gc, Gx, or delta G; and also between deltaET and either Gc, Gx, or deltaG. Since internal and external measurements of ejection time are known to be almost identical, the regression equation (deltaG = 1 . 65 delgaET -9) relating deltaET and deltaG should be useful for the non-invasive assessment of the magnitude of provocable left ventricular outflow pressure gradient in patients with hypertrophic cardiomyopathy with spontaneous or externally-induced premature beats.

Clinical significance and hemodynamic correlates of the third heart sound gallop in aortic regurgitation. A guide to optimal timing of cardiac catheterization.

The hemodynamic and clinical data of 42 patients with chronic significant aortic regurgitation and 31 normal subjects were examined. Of the patients with aortic regurgitation, 28 had a third heart sound (S3) gallop and 14 did not. There was no significant difference in the severity of regurgitation between the patients with or without an S3 gallop. However, all patients with an S3 gallop had an abnormality increased left ventricular residual volume and depressed contractile state. These findings were supported by the hemodynamic data of two patients who underwent cardiac catheterization before and after the development of an S3 gallop. We conclude that the S3 gallop in patients with chronic AR reflects left ventricular dysfunction, rather than more severe degrees of regurgitation per se, and may therefore be useful for selecting patients for cardiac catheterization and consideration for prosthetic aortic valve replacement.

Echocardiographic features of cor triatriatum.

A patient is presented who had cor triatriatum documented with angiography and surgery. On echocardiographic study, an abnormal, dense linear echo on "sector scan" was consistently seen to traverse the left atrial cavity obliquely; the ends of the echo were attached to the posterior aortic and lateral walls of the left atrium. In addition, high frequency oscillatory movements were evident in the echo of the posterior mitral cusp. Both echocardiographic features disappeared promptly after successful resection of the intraatrial fibrinous membrane. This experience indicates that in the presence of strong evidence of mitral stenosis, an unexpectedly normal mitral valve echogram should initiate a thorough echographic search for cor triatriatum, a treatable cardiac malformation whose diagnosis can easily be missed on "routine" echocardiographic studies.

Echocardiographic features of cardiac compression by a thymoma simulating cardiac tamponade and obstruction of the superior vena cava.

A patient with a large tumour of the superior mediastinum, detected by routine chest X-ray examination, is presented. Compression of the heart and the superior mediastinum produced the clinical picture of cardiac tamponade and obstruction of the superior vena cava and trachea. The solid nature of the tumour was established by echocardiography which, in addition, showed: (1) posterior displacement of the heart; (2) diminished dimensions of the left atrium and left ventricle; (3) prominent respiratory variation in the position of the interventricular septum, the dimensions of both ventricles, and the duration of systolic separation of the aortic valve cusps; and (4) 'pseudo-prolapse' of the mitral valve. All abnormal clinical signs and echocardiographic findings disappeared promptly after surgical resection of the tumour which was found to be a thymoma.

Reproducibility of echocardiographic estimates of left ventricular dimensions.

Although echocardiography is ideally suited for repetitive use on a patient for evaluation of left ventricular function, the value of this application is minimised by the uncertainty as to whether changes in left ventricular dimensions observed on a patient at different times or by different observers are real or result from the ultrasonic beam penetrating the left ventricle at different angles. Accordingly, an instrument was designed and constructed in our laboratory to improve the reproducibility of echocardiographic measurements of left ventricular dimensions. The instrument represents an orthogonal reference frame by means of which the spatial orientation of the ultrasonic beam relative to the chest is determined and reproduced in subsequent studies, while the point of entrance of the beam is marked on the chest wall. Using this instrument, left ventricular echograms were initially recorded on a group (I) of 23 subjects with or without heart disease and the study was repeated 8 hours to 49 (mean 7) days later by the same observer and also, in 16 cases, by an independent observer. The average values from 2 to 6 (mean 4) heart cycles were used for the left ventricular end-diastolic dimension (Dd), end-systolic (Ds) dimension, and their difference (delta D). Differences in all three variables between studies were random and statistically insignificant, never exceeding 3-5 mm for Dd or Ds, and 4 mm for deltaD. For comparison, left ventricular internal dimensions were also obtained in a seprate group (II) of 14 subjects by the standard method of using the mitral valve as an internal landmark, without the benefit of this instrument. All 14 subjects had the initial study repeated within 8 hours to 11 (mean 3-8) days later by the same and also by an independent observer. Though in the group as a whole there was no significant difference in left ventricular dimensions between studies, individual variations reached 11 mm for Dd, 9 mm for Ds, and 9 mm for deltaD, and the degree of scatter was significantly larger than in group I. This initial experience indicates that the use of this instrument improves the reproducibility and enhances the reliability of estimates of echocardiographic left ventricular dimensions and function on a patient examined at different times by the same or independent observers.

Detection of unstable angina by 99m technetium pyrophosphate myocardial scintigraphy.

99mTechnetium stannous pyrophosphate has been shown to accumulate in acutely infarcted myocardium. To determine if the isotope is also taken up by severely ischemic, but not necrotic myocardium, we performed myocardial scintigraphic studies in 17 patients with chest pains. Seven of the patients satisfied conventional clinical, electrographic, and laboratory criteria for the diagnosis of unstable angina and showed no electrocardiographic or enzymatic evidence of myocardial necrosis. Five of these seven patients with unstable angina demonstrated abnormal localized patterns, and one showed a borderline picture. Myocardial scintiscans were normal in all of a control group of ten patients with stable angina. Thus, scanning with 99mtechnetium stannous pyrophosphate is shown to be of value in the objective demonstration of myocardial abnormality in unstable angina.