July

222

Brief Communications

Amarican

Heart

1990

Journal

Fig. 3. A, Grossspecimenof recurrent right atria1 myxoma in case2. Note lobulated surfaceand jelly-like consistencyof tumor. 3, Typical area of myxoma with loosestrands of collagen, amorphousground substance,numerousmesenchymalcells, and vascular channels.(Hematoxylin & eosinstain; original magnification X80.)

formed during surgery. Relapse-freeintervals of only 6 and 18months(lomonths afteranormalpostoperativeechocardiographic study, respectively) indicate the potential for rapid growth and recurrence of cardiac myxomas in this specialgroup with associatedfeatures. Thesefindings suggest that closefollow-up with serial echocardiography in these patients and their family membersis mandatory.

aria1 myxoma shown by echocardiography. Br Heart J 1987; 58:413-6. 9. Hedinger C. Kombination von Herzmyxomen mit primtirer nodul;irer Dysplasie der Nebennierenrinde, fleckfijrmigen Hautpigmentierungen und myxomartigen Tumoren anderer Lokalisation-ein eigenartiger familiiirer Symptomenkomplex (“Swiss Syndrome”). Schweiz Med Wochenschr 1987;117:591-4.

REFERENCES

1. St John Sutton myxomas, Clin Proc 2. 3.

4. 5.

6.

I.

8.

MG, Mercier a review of clinical 1980;55:371-6.

LA, Giuliani ER, Lie LT. experience in 40 patients.

Atria1 Mayo

Markel ML, Wailer BF, Armstrong WF. Cardiac myxoma. A review. Medicine (Baltimore) 1987:66:114-25. Dein JR, Frist WH, Stinson EB, Miller DC, Baldwin JC, Oyer PE, Jamieson S, Mitchell RS, Shumway NE. Primary cardiac neoplasms. Early and late results of surgical treatment in 42 patients. J Thorac Cardiovasc Surg 1987;93:502-11. Walton JA, Kahn DR, Willis PW. Recurrence of left atria1 myxoma. Am J Cardiol 1972;29:872-6. McCarthv PM. Piehler JM. Schaff HV. et al. The significance of multiile. recurrent, anh “complex” cardiac micomas. J Thorac Cardiovasc Surg 1986;91:389-96. Schweizer-Caeianut M. Salomon F. Hedineer CE. Primarv adrenocortical nodular dysplasia 6th Cusvhing’s syndrome and cardiac myxomas. A peculiar familial disease. Virchows Arch (A) 1982;397:183-92. Carney JA, Gordon H, Carpenter PC, Shenoy BV, Go VLW. The complex of myxomas, spotty pigmentation, and endocrine overactivity. Medicine (Baltimore) 1985;64:270-83. Roudaut g, Grosse P, Dallocchio M. Rapid growth of a left

Percutaneous transluminal balloon angioplasty in Takayasu’s aortitis: Persistent benefit over two years V. Dev, S. Shrivastava,

and M. Rajani. New Delhi,

India

Aortoarteritis is an inflammatory diseasethat involves the aorta and its major branches.l In the chronic stage sympFrom the Cardiothorscic Centre, All India Institute of Medical Sciences, New Delhi, India. Reprint requests: Dr. S. Shrivastava Dept. of Cardiology, A.I.I.M.S., New Delhi-110029 India. 414120469

Volume Number

120 1

Brief Communications

223

1. Descendingaortic angiogramsin anteroposterior view before angioplasty (A), immediately after angioplasty (B), and at 1 year follow-up (C), show relief of obstruction after angioplasty with further improvement at 1 year in the lumen caliber. Fig.

Table

I. Hemodynamics Angiographic Doppler gradient (mm Hg)

Before Immediately 1 yr later 2 yr later

after

32 6 4 0

Cath. gradient (mm Hgl 33 5 0 -

toms result from the obstructive lesions.Although the diseaseis diffuse and involves multiple areasof the proximal arterial tree, in some patients arterial lesions are &Iiciently localized to be amenableto surgery2or to treatment with balloon angioplasty.3,4Although balloon angioplasty of the aorta hasbeen widely usedfor coarctation of aorta5 (congenital or following surgery) and atherosclerotic obstructive disease,‘j experience with it in aortitis is limited.3p4In this communication we describe a case of symptomatic descendingaortic obstruction due to aortitis in a young woman whose symptoms were successfully relieved by balloon angioplasty with benefits that persisted for more than 2 years. Doppler echocardiography accurately predicted gradients before and after angioplasty and on follow-up. A 21-year-old womanwasfirst seenwith history of claudication of lower limbs during heavy exertion. The blood

Above

stenosis 8.6 8.6 9.0 -

size Stenosis 3.2 6.0 1.5 -

of aorta

(mm) Below

stenosis 9.2 9.2 10.0 -

pressuremeasurementsin her upper and lower limbs were 130175and 901’70mm Hg, respectively. There was a loud bruit in the abdomen.Examination of the rest of the cardiovascularsystemwasnormal. Ultrasound examination of the aorta on Ultramark 8 machine (Advanced Technology Laboratories, Inc., Bothell, Wash.) with 3 MHz transducer showeda narrowed segmentbelow the renal arteries. Doppler echocardiographyshoweda high-velocity signal at the site of obstruction with a predicted gradient of 32 mm Hg acrossthe obstruction. The patient wastaken to the laboratory for catheterization and balloon angioplasty. The procedurewascarried out with the patient in a fasting state and under sedation. After introducing a valved sheath in the femoral artery by meansof the Seldinger technique, a multipurpose catheter was introduced, pressures were measuredboth aboveand belowthe site of obstruction, and aortogramswere performed in anteroposterior and lateral

224

Brief Communications

views. An aortogram showeda segmentof narrowing (3.0 cm in length) belowthe renal arteries. Measurementsof the aorta above, below, and at the site of obstruction were 8.6, 9.2, and 3.2 mm, respectively. An exchangeguide wire (260 cm, 0.038inch in diameter) waspositioned abovethe lesion through the multipurpose catheter. An 8 mm size balloon dilatation catheter wasintroduced over the guide wire and positioned acrossthe obstruction. Three inflations of 30 secondseach were done. Repeat pressuremeasurements and aortogramswere performed. Hemodynamic data (Table I) showed a pressure gradient of 32 mm that was reduced to 6 mm after angioplasty. The aortogram (Fig. 1) showedrelief of obstruction. A follow-up aortogram (Fig. 1) and pressuredata (Table I) at 1 year showedpersistent relief. Clinical follow-up and two-dimensional and Doppler echocardiographicevaluation at 2 years showedcomplete relief of obstruction. Angiographic appearance at 1 year was even better than that immediately after angioplasty (Fig. 1). This is possibly related to late remodelling of the lesion. Aortoarteritis is a commondiseasein the Orient. In the chronic stage,morbidity and mortality are related to arterial obstructive lesions1The standard modeof therapy has been surgery.2With the advent of the balloon angioplasty procedure, a new approachto relief of obstructions in aortoarteritis has emerged.3The experience with this technique, however, is limited. Khalilullah et al3 presented data on four patients who had dilatation of descending aortic obstructions. Hemodynamic data showedsignificant fall in gradients after angioplasty and a further fall at 2 months in three patients subjected to recatheterization.3 Gu et a1.4have reported similar results in their patients4 Resultsin our patient alsoindicate long-term efficacy of the procedureswith the relief of obstruction 2 years after angioplasty. Interestingly, the narrowest diameter of the aorta at the site of angioplasty further increasedover 1 year of follow-up as seenin the late aortogram. This may suggesta beneficial remodelling of the lesionsafter angioplasty. Doppler and cross-sectionalechocardiography accurately predicted the site and severity of obstruction before angioplasty as well asthe relief of obstruction after angioplasty and on follow-up. Balloon angioplasty is a safe and effective therapeutic technique with long-term benefits in patients with discrete obstruction causedby aortoarteritis. Doppler echocardiography accurately measuresgradients in abdominal aortic obstruction and can be used for their diagnosisand follow-up after angioplasty. REFERENCES

1. Ishikawa K. Natural history and clarification of occlusive thrombolytic aortopathy (Takasyasu’s disease). Circulation 1978;57:27-38. 2. Bloos RS, Duncan JM, Coolex DA, Leatherman LL, Schnee MJ. Takayasu’s arteristis: surgical considerations. Ann Thorat Surg 1979,27:574-g. 3. Khalilullah M, Tyagi S, Lochan R, Yadam BS, Nair M, Gambhir DS, Khanna SK. Percutaneous transluminal balloon angioplasty of the aorta in patients with aortitis. Circulation 1987;76:597-600. 4. Gu ZM, Lin G, Yi JR, Li JM, Zhou J, Pan WM. Transluminal catheter angioplasty of abdominal aorta in Takayasu’s arteritis. Acta Radio1 1988;29:509-13.

American

July 1990 Heart Journal

5. RaoPS, Najjar HN, Maratini MK, Solymar 6.

L, Thapar MK. Balloon angioplasty for coarctation of aorta: Immediate and long term results. AM HEART J 1988;115:637-65. Charlebota N, Saint George G, Hudon G. Percutaneous transluminal angioplasty of the lower abdominal aorta. Am J Roentgen01 1986;146:369-71.

Left sinus of Valsalva aneurysm with rupture into the left ventricular outflow tract: Diagnosis by color-encoded Doppler imaging Robert M. Rothbart, MD, and Robert A. Chahine, MD. Miami, Flu.

Before the advent of noninvasive cardiac imaging, the antemortem diagnosisof sinus of Valsalva aneurysms was generally achieved only in patients in whom signsor symptomsrelated to rupture prompted cardiac catheterizati0n.l Unruptured or asymptomatic aneurysmswere rarely identified except at postmortem examination.2During the past decade, however, these anomalieshave frequently been detected by two-dimensionalechocardiography,a*4often in the absenceof appreciable shunts or symptoms. Sinus of Valsalva aneurysmsare most commonly congenital, generally originate from the right coronary sinus, and tend to rupture into the right atrium or ventricle. The patient described in this report had an unusual aneurysm of the left coronary sinus,which developedas a complication of bacterial endocarditis and ruptured into the left ventricular outflow tract. Color-encoded Doppler imaging identified the aortic-to-left ventricular shunt, a finding that wasunrecognized in the initial interpretation of the aortic root angiogram. The patient, a 42-year-old Hispanic man, wasfirst seen at JacksonMemorial Hospital 3.5yearsbefore the echocardiographic study discussedin this report with a 2-week history of weaknessand malaise. On evaluation in the emergency room, tachycardia (heart rate 124 beats/min) and hypotension (blood pressure 80/40 mm Hg) were present. Respirations were 24/min, and the patient was afebrile. Other significant findings included marked jugular venousdistention, an S3gallop, an early diastolic murmur, and rales throughout both lung fields. Two-dimensional echocardiographic findings included mild left ventricular dilation, global hypokinesis with an estimated ejection fraction of 0.45, and a 5 mm vegetation attached to the left coronary cusp of the aortic valve. Premature closureof the mitral valve suggestedsevereacute aortic in-

From the Division of Cardiology, Reprint requests: Robert Rothbart, of Colorado Health Denver, CO 80262.

4/4/20473

Sciences

University

of Miami

School

MD, Division of Cardiology, Center, Campus Box B-130,4200

of Medicine. University E. 9th Ave.,

Percutaneous transluminal balloon angioplasty in Takayasu's aortitis: persistent benefit over two years.

July 222 Brief Communications Amarican Heart 1990 Journal Fig. 3. A, Grossspecimenof recurrent right atria1 myxoma in case2. Note lobulated sur...
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