ABSTRACT: During early embryonic development, absorption ofpulmonary venous network by theleft primitive atrial chamber results in opening of four pulmonaryveins which drain independently into its chamber. The extent of absorption and hence, the number ofpulmonaryveins which open intotheleftatrium, may vary. Here we report a variationinthe opening oftheLeft upper (superior) pulmonary vein intotheLeftatrium. A total of six openings observed.
The connection ofthe anomalous pulmonary venous return, commonly called total anomalous connection ofpulmonaryveins (TAPV) is a rare congenital disease that encompasses a group of changes in which thepulmonaryveins (PV) connect directly to the systemic venous circulation, and not theleftatrium (LA) . According to the anatomical characteristics, it can be classified into supracardiac, infracardiac or mixed, with the possible use of various surgical techniques for correction ofthe defect [2,3]. Regardless ofthe technique used, it is known that the PV can be compromised and do not present proper development, both because the tissue and the constitution ofthe common pulmonary vein (CPV) or suture lines used during the procedure. This situation is a late complication of most concern because it has important clinical consequences and compromises the prognosis [4,5].
Approach by longitudinal median sternotomy with establishment of cardiopulmonary bypass by introducing cannulas intothe following: aorta, superior and inferior vena cava was performed. The sites of incision at the right atrium were marked. The right atrium was opened with a longitudinal incision toward the inferior vena cava. Resection of interatrial septum, opening oftheleftatrium along the right pulmonaryveins (Figure 2A), and suture ofthe bovine pericardium below the mitral valve, by isolating thepulmonaryveins (Figure 23B), which was named first plane, were performed. Together with the right atrium lateral wall, a suture was initiated along the valve of inferior vena cava (Eustachian valve), thus, forming the tunnel of inferior vena cava. This procedure was performed inthe same very
characterized by the presence of a stenosing ring inthe form of a shelf-like membrane above the mitral valve. This membrane has 1 or 2 small orifices, which obstruct theleft atrial outflow. The mitral valve may be normal or deformed. This condition has to be distinguished from abnormal partition oftheleftatrium (cor triatriatum), in which a membrane divides this cavity into 2 chambers: a dorsal chamber, that receives thepulmonaryveins and a ventral chamber that gives rise to theleft atrial appendage.
Venous abnormalities ofthe thorax may involve either systemic or pulmonaryveins, ranging from incidental findings to compo- nents of more complex abnormalities, most frequently congenital heart disease (1) . How- ever, complete absence ofpulmonary venous drainage intotheleftatrium is a rare condition and may affect a whole lung, without associated anomalous drainage (2) . Atresia may be divided into common, in- dividual or unilateral (3) ; the latter is a rare condition corresponding to the absence ofpulmonaryveinsin one ofthe lungs.
We report on the rare caseof partial anomalous return of four pulmonaryveinsinthe right atrium and superior vena cava with intact interatrial septum in a five-year-old child. There were few symptoms in contrast with theleft ventricular output dependent on the flow oftheleft upper lobe vein and from the lingula. Reduced compliance to theleft led to a severe picture ofpulmonary venocapillary hypertension inthe immediate postoperative period, mitigated by an 8-mm interatrial septal defect. The patient progressed well after the intervention.
Fig. 2 - A – right atrium open where the right pulmonaryveins can be seen draining intotheleftatrium and the flow towards the superior sinus venosus interatrial communication. B – Interatrial connection closed with a bovine pericardial patch. C and D – Enlargement ofthe superior vena cava with tissue from the right atrium open in a “V-Y” shape.
ofthepulmonaryveins for reducing the indices of late recurrence of atrial fibrillation. In this regard, the benefit ofthe treatment was evident, which makes it an effective and recommendable therapeutic option. However, when clinically relevant atrial ta- chycardias were considered (including atrial fibrillation and flutter) and their occurrence was assessed, no significant differences inthe incidence were identified between the 2 groups studied. The frequent manifestation of atrial flutter inthe treated group patients was the determinant factor of this finding. And considering the hypothesis that theleft atrial incisions were the cause, the benefits ofthe treatment could not be clearly defined in a perspective of global clinical advantages. The size ofthe sample studied may have contributed to this type of result. On the other hand, it is worth noting that atrial flutter is a tachycardia depending on a well-defined substrate, even when depending on a scar, which may be eliminated by use of catheter ablation 40-42 , a characteristic
Bronchovascular fistulas are a very dangerous complication of airway anastomoses. The type or form of treatment depends on early diagnosis and is based on re-operation or stent placement. Even though it is a very rare condition, improved evaluation ofthe factors that contribute to istula formation must be developed and always considered during follow-up evaluations of lung transplant patients. In addition, surveillance bronchoscopy should be routinely performed in order to identify patients at risk for developing istulas.
The vertebral arteries begin inthe root ofthe neck as the first branches ofthe supero-posterior aspect ofthe subclavian arteries. The vertebral arteries ascend the neck to enter the cranial cavity to supply blood to the brain. The two vertebral arteries are usually unequal in size; theleft is frequently larger than right one . The vertebral arteries pass through the foramina transversaria ofthe first six cervical vertebrae on both sides, penetrate the posterior atlanto-occipital membrane and enter the cranial cavity through the foramen magnum. Vertebral arteries unite at the caudal border ofthe pons to form unpaired basilar artery. This vessel courses along the ventral aspect ofthe brainstem [2–4]. The different variations ofthe branches arising from the arch of aorta are well known and documented by several authors . CaseReport
Despite the RHT and the findings of impending systemic embolism, the cardiovascular surgeon refused to perform surgical thrombectomy because ofthe simultaneous, heavy clot burden on thepulmonary arteries. In addition, the size ofthe thrombus at theleftatrium raised concerns
dings. The corpus luteum was located on theleft ovary. The- re was no bleeding from the fimbria bilaterally. The perito- neum was opened above the described mass using the ultra- cision, and evacuation of ovulary tissue was started, but suddenly significant bleeding appeared and urgent laparotomy was immediately performed. There was about 500 mL of fresh blood inthe abdomen. The bleeding was controlled by two finger digital compression oftheleft broad ligament and the remaining ovulary tissue was removed. There were no macroscopic signs of communication or fistu- la between the described mass and the uterine cavity or theleft Fallopian tube. Hemostasis was completed with hemosta- tic sutures and the abdomen was closed with drainage placed inthe pouch of Douglas. Postoperative course was unevent- ful. Serum β-HCG levels decreased to 750 mU/mL two days after the surgery and became negative after seven days. The histopathology report confirmed ectopic gravidity (Figure 5).
Urethral leiomyomas are also rare, with only 40 cases reported inthe literature. Ovarian hormones are believed to influence the growth of leiomyomas. We reportthe genitourinary presentation of 2 separate disease entities with known hormonal influence in a postmenopausal woman receiving estrogen replacement therapy. We believe the patient’s hormonal milieu affected the development of her concurrent pathology.
the system by the operator (tab. III). The device was with- drawn within the delivery catheter and discarted. A new de- vice with the same diameter was successfully placed une- ventfully. Inthe 3rd patient, the retrieval cord was inadver- tently tractioned together with the withdrawal ofthe man- drel after proper locking ofthe disks. There was traction ofthe device that was already well positioned inthe interatrial septum leading to erasure of its configuration (tab. III). With traction movements inthe retrieval cord and rotation ofthe delivery catheter, the device was withdrawn toward the catheter inside the inferior vena cava and withdrawn outside the body without problems (fig. 4). A new device with the same diameter was successfully implanted. Inthe 4th patient, the operator did not maintain enough traction inthe mandrel during the locking ofthe disks, leading them far from the interatrial septum, with an unsatisfactory final appearance. Using the retrieval cord, the device was with- drawn from the septum with erasure of is configuration and was withdrawn within the delivery catheter as already des- cribed. In a second attempt, accentuated tension inthe man- drel was applied during locking ofthe disks, causing incom- plete locking with the “eyelet” ofthe proximal disk excluded from the locking hook. Still connected inthe retrieval cord, the device was dismantled, and retrieved from the body as previously described. A third device, with the same diame- ter (25 mm), was successfully implanted (tab. III). Inthe other patients, the devices were implanted at the first attempt, without technical problems. Inthe patient with 2 ASDs, both devices were successfully implanted at the first attempt without problems. The inferior atrial septal defect was initially approached followed by the superior. The device used inthe anterior-superior hole was greater than desirable because a smaller device was not available for implantation at that time. Thus, the superior part ofthe distal disk was in contact with the roof oftheleftatrium leading to mild prolapse towards its interior, but with satisfactory final results (fig. 6). Inthe 3 patients with patent foramen ovale, immediate echocardiography with microbubbles and Valsalva’s maneuver (hyperinflation with ambu ± abdominal compression) was negative without passage of contrast from the right to theleft side (tab. II). Immediate residual shunt was present in 4 patients with atrial septal defects inthe catheterization laboratory (tab. IV). In these patients, the
Follow-up after treatment should initially be done every three to four months and should include phy- sical and x-ray tests on the affected bone. This will enable any recurrence to be detected at an early stage. CT or MRI are useful for clarifying a suspected recur- rence. After two to three years, the follow-up should be every six months, and then annually after five years of treatment. Chest x-ray should be requested in each follow-up visit due to the risk ofpulmonary metastasis. Chest CT can be performed on diagnosis to check for early signs ofpulmonary metastasis since CT is more sensitive than x-ray. Subsequently, inthe absence of lesions, the patient is followed-up with x-ray at the above-mentioned intervals (7) .
ABSTRACT: Aneurysm ofleftatrium may involve theleft atrial wall or left atrial appendage. Aneurysm ofleft atrial appendage is usually acquired in etiology secondary to mitral valve disease, whereas its congenital variant is a rare developmental anomaly. Congenital left atrial appendage aneurysm is very rarely reported entity. They lead to complications like systemic emboli, arrhythmias and worst as death. They are usually misdiagnosed most ofthe times as a mediastinal mass or cardiac tumour on Chest X-ray. USG provides an easily accessible modality in providing a provisional diagnosis, in confirming the location and its communication with the mediastinal vascular structures. Cardiac and coronary CT and MR help in providing a conclusive diagnosis and earlier surgical intervention thereby preventing further mortality or morbidity. We report a caseof 20 year old female incidentally diagnosed with left atrial appendage aneurysm.
Acute pulmonary embolism (PE) is considered a cardiovascular emergency because it can lead to acute life-threatening right ventricular failure. It has been reported that approximately 5% of patients with acute PE present with right heart thrombus (RHT), (1-3) which occasionally straddles
As we know that to find the area of sector the angle made by the chord (that is chord which divides the circle) is required. But inthe below method we find the ratio ofthe segments ofthe circle. Thus by relating the area of segment to the area of sector the area of sector could be found. The ratio of area of segments is related to tangents that are drawn through diameter on either side.
The principle of divine control is very important in discussions con- cerning the relation between the Creator and His creatures. These seem to be based on two assumptions. The irst assumption is that God can achieve all His purposes inthe created world (divine providence) if and only if He controls every existing being. Therefore, divine control must be perfect and unrestricted (divine volitions must be determined in every respect). Maximal possible control consists inthe fact that God creates ex nihilo every being and subsequently conserves them. The second assumption is Anselmian: God is the greatest possible being one can conceive. A perfect being has everything under its control and a perfect being controls everything inthe most perfect way possible. Furthermore, the best way to control everything is to create every being out of nothing and to create it as absolutely depen- dent in existence and nature upon God’s will. Omnipotence thus means to conserve continuously all created beings. Continuous creation is the best way to express divine perfection: perfect power and perfect will. Therefore, all contingent beings exist this or that way as long as divine power is acting and divine will wills itself to act upon a given being.
Therapy with vancomycin, gentamycin and rifampin was started, and the patient was taken to the operation room. The prostheses as well as the intervalvular fibrosa area were carefully examined. During the transvalvar aortic and transvalvar septal explorations, a cavity that communicates with the outflow tract oftheleft ventricle was found. It was located at the same site ofthe TEE abscess imaging suggesting spontaneous drainage ofthe abscess with an aneurysm formation. Moreover, neither valve dehiscence nor instability ofthe prostheses was noticed. Considering these findings along with the high morbidity and mortality associated with a fourth valve replacement, this procedure was not performed. The patient presented a progressive improvement and became afebrile. Six weeks after the beginning ofthe antibiotics, a new TEE strongly suggested that the mitral- aortic intervalvular fibrosa abscess had evolved into an aneurysm (Figure 2).