Retrograde left-ventricular hemodynamic assessment of mechanical aortic and mitral valve gradients using a high-fidelity pressure wire: a case series.

Noninvasive assessment of mechanical heart valve function with echocardiography is challenging. There are important safety issues when considering placing a standard catheter across a mechanical valve with for invasive hemodynamic measurements. The feasibility of using a high-fidelity micromanometer coronary pressure guide wire to assess hemodynamics across mechanical valves has been reported. Although this method appears feasible, safe, and free of major complication, its application and utility remains obscure and underappreciated. We report a series of two patients with mitral and aortic (St. Jude and Björk-Shiley) mechanical valves in which we successfully used this pressure wire technique to assess valvular function in patients evaluated for repeat surgical valve replacement. We include the first report of this guide wire technique to assess hemodynamics across a Björk-Shiley single-tilting disk valve.

Interatrial shunt closure devices in patients with nickel allergy.

We assessed outcomes in nickel allergic patients treated with percutaneous interatrial shunt device closure with the Helex device. Nickel toxicity has been well described in patients undergoing interatrial shunt closure with the Amplatzer device, which has a nitinol design. There have been no reports using Helex in nickel allergic patients. Ninety-five consecutive patients underwent percutaneous interatrial shunt closure at a single US center by one operator. In those with possible nickel allergy, patch testing with the North American Contact Dermatitis Group standard series and a metal series was performed. The mean age was 48 +/- 16 years (range 18-81), 48% were male, 21 (22%) had atrial septal defect, and 74 (78%) had patent foramen ovale. Six patients had a positive skin test to nickel and underwent successful closure with Helex. Of the remaining 89 patients, 88 were closed with Amplatzer and one with Helex. All procedures were successful with no deaths, myocardial infarctions, strokes, or systemic emboli at six-month followup. None of the Helex patients developed an allergic reaction, significant chest pain, or arrhythmia. Of those without pre-procedural known nickel allergy, 12% had palpitations, 5% had atrial fibrillation, and 13% had chest pain. When compared with a published report that 89% of nickel-allergic patients developing an allergic reaction to the Amplatzer or Premere device, Helex appeared far safer in nickel allergic patients (P < 0.001). In patients with nickel allergy, percutaneous interatrial shunt device closure with Helex device is safe, and is not associated with allergy to nickel.

Nocardiosis in cancer patients.

Nocardiosis (NOC) is an important cause of infection in immunocompromised patients. However, large series in patients with cancer have not been described. We review the records of patients with cancer and NOC who were evaluated at The University of Texas M. D. Anderson Cancer Center, Houston, Texas, between 1988 and 2001, and we describe the incidence, microbiologic and clinical characteristics, treatment, and outcome of NOC in this population. Forty-two patients with a total of 43 episodes of NOC were identified (incidence of 60 cases of NOC per 100,000 admissions). Twenty-seven patients (64%) had hematologic malignancies. In 13 patients, NOC complicated bone marrow transplantation. Neutropenia was observed in 4 (10%) of 40 episodes with information available, and lymphopenia in 20 (50%) of 40 episodes. Patients had received steroids for 25 episodes (58%) and had received chemotherapy for 10 episodes (23%) within 30 days before the onset of NOC. Nine episodes of breakthrough NOC were identified in 7 (23%) of the 40 patients with information available. Pulmonary NOC was seen in 30 (70%) of 43 cases; soft-tissue NOC in 7 (16%); central venous catheter-related nocardemia in 3 (7%); and disseminated NOC, central nervous system NOC, and a perinephric abscess each in 1 (2%). Twenty-three percent of patients with pulmonary NOC had an acute presentation. complex was the most common causative species (77%). Therapy for NOC was mainly concurrent trimethoprim/ sulfamethoxazole and either a tetracycline or a beta-lactam. The median duration of treatment was 113 days (range, 10-600 d). Nine (60%) of 15 patients with outcome data died from NOC. NOC, although infrequent, is an important cause of morbidity and mortality in patients with cancer. It has pleomorphic manifestations, and it can be seen as a breakthrough infection. The present study confirms that timely diagnosis, the site of NOC, the type of, the presence of comorbidities, and cytomegalovirus coinfection influence the outcome of patients with cancer and NOC.

Breast implant infection caused by Trichosporon beigelii.

We describe herein an immunocompetent patient who developed a breast implant infection caused by Trichosporon beigelii. To our knowledge, this is the first reported case of such an infection.