Pseudoxanthoma elasticum of the internal mammary artery.

A case of pseudoxanthoma elasticum of the left internal mammary artery from a 61-year-old male who underwent coronary artery bypass grafting is reported. Intraoperative evaluation of the left internal mammary artery revealed partial stenosis. Histologically, the stenotic portion showed pseudoxanthoma elasticum. This represents the first reported case of pseudoxanthoma elasticum in the internal mammary artery.

Circulating endotoxin and cytokines after cardiopulmonary bypass: differential correlation with duration of bypass and systemic inflammatory response/multiple organ dysfunction syndromes.

Cardiopulmonary bypass constitutes an injury that may cause postoperative pathophysiological changes due to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). These complications include coagulopathy, hypotension, capillary leakage, and multiple organ injury. To investigate the role of endotoxin and cytokines in the response to bypass injury, we measured plasma levels of endotoxin and proinflammatory cytokines in 20 pediatric patients before and after bypass. Clinical data, including duration of injury and tests indicative of SIRS/MODS, were collected. Levels of endotoxin, TNF-alpha, IL-6, and IL-8 but not IL-1 beta were significantly increased after bypass. Most of the cytokines have been found to correlate with each other. Endotoxin did not correlate with duration of bypass, cytokines, or SIRS/MODS. In contrast, TNF-alpha and IL-8 correlated with duration of bypass and were associated with SIRS/MODS. Certain clinical complications were associated with specific cytokines. Understanding the role of cytokinemia in SIRS/MODS may lead to better prognostic assessment and therapeutic modalities.

Heart valve surgery in a young predominantly rheumatic population.

Between August 1988G and August 1992G, 802 Saudi patients underwent 1,171 open valve surgical procedures at King Faisal Specialist Hospital and Research Centre (KFSH&RC). The mean age was 32.4 years (range one to 90). The etiology was rheumatic in 66.3%, congenital in 12.8%, degenerative in 8.7%, infective in 5.9% and ischemic in 2%. The mean preoperative New York Heart Association (NYHA) functional class was 2.94 and 74% of the patients were in sinus rhythm. Multiple valve procedures were required in 39.4% of the cases and 718 valves (64.6%) were repaired. The overall hospital mortality was 4.48%. The mortality for isolated mitral valve repair was 1.8% against 3.48% for replacement. For isolated aortic repair, it was 0 against 8.5% for replacement. The follow-up of our patients was 98.1%. During the follow-up period of 1,171.06 patient years, the total incidence of thromboembolic events was 2.35% or 1.53% pt-yrs. Reoperation was required in 7.3% of the patients. The main cause was dysfunction of the rheumatic mitral repairs in the young patients. The late mortality was 3.78%. The actuarial survival for the total 802 operated patients was 86.27%. This survival was 91.10% for those undergoing repair versus 82.10% for those with replacement (P<0.005). It is concluded that a careful and complete follow-up of our patients is essential to determine the value of the available surgical techniques. The young rheumatic patient, so prevalent in our population, remains a surgical challenge. New surgical alternatives are needed.

Spontaneous esophageal perforation in herpes simplex esophagitis.

A 32-yr-old, previously healthy man with severe chest pain of sudden onset was found to have purulent pericarditis and pleural effusions. Several days later, an esophagogram revealed a perforation of the thoracic esophagus. Endoscopy showed a picture highly suggestive of a late stage of an extensive herpes simplex virus (HSV) esophagitis. Biopsies revealed evidence of massive HSV infection, confirmed by immune microscopy and virus culture. At surgery, a mediastinal abscess was found, and an esophageal perforation was identified. These findings suggest that the etiology of the perforation was an unusually severe herpetic infection. To our knowledge, HSV esophagitis has not previously been implicated as the cause of spontaneous esophageal perforation.

Duodenal varices as a cause of massive upper gastrointestinal bleeding.

Duodenal varices are an uncommon but serious manifestation of portal hypertension. Our management of three patients with massive bleeding due to duodenal varices stimulated a review of this subject. Thirteen cases of this condition were previously reported. Endoscopic examination of the entire duodenal mucosa is essential to document bleeding from duodenal varices. Medical therapies, including vasopressin and endoscopic sclerotherapy, have had limited success in controlling active duodenal variceal bleeding. Duodenal varix suture ligation or resection also resulted in a high rate of rebleeding. End-to-side portocaval shunt was the most effective procedure in stopping acute and subsequent bleeding in patients with duodenal varices. Despite therapy with or without portosystemic shunt, mortality risk is high in Child's class C patients and in patients with emergency duodenal variceal bleeding.