1/13. Echocardiographic diagnosis of sinus Valsalva aneurysm rupture in two pediatric patients.Sinus Valsalva aneurysm rupture (SVAR) is a rare cardiac abnormality that requires surgical correction when diagnosed. Previously, cardiac catheterization and angiography were thought to be necessary for its diagnosis. We present two pediatric cases of SVAR with subarterial ventricular septal defect (VSD) diagnosed noninvasively by echocardiography; surgical findings confirmed the diagnosis. In both of our cases the origin of SVAR was the right coronary sinus. The first case was ruptured into the right ventricular cavity; the second was ruptured into the right ventricular outflow tract. Continuous murmurs heard during follow-up of children with VSD must alert the physician to this pathology. Combined two-dimensional, Doppler and color-Doppler echocardiography is an accurate, noninvasive method for diagnosis of SVAR.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/13. Clinical considerations in the chiropractic management of the patient with marfan syndrome.OBJECTIVE: To describe the chiropractic management of a patient with whiplash-associated disorder and a covert, concomitant dissecting aneurysm of the thoracic aorta caused by marfan syndrome or a related variant. CLINICAL FEATURES: A 25-year-old man was referred by his family physician for chiropractic assessment and treatment of neck injuries received in a motor vehicle accident. After history, physical examination, and plain film radiographic investigation, a diagnosis of whiplash-associated disorder grade I was generated. INTERVENTION AND OUTCOME: The whiplash-associated disorder grade I was treated conservatively. Therapeutic management involved soft-tissue therapy to the suspensory and paraspinal musculature of the upper back and neck. Rotary, manual-style manipulative therapy of the cervical and compressive manipulative therapy of the thoracic spinal column were implemented to maintain range of motion and decrease pain. The patient achieved full recovery within a 3-week treatment period and was discharged from care. One week after discharge, he underwent a routine evaluation by his family physician, where an aortic murmur was identified. Diagnostic ultrasound revealed a dissecting aneurysm measuring 78 mm at the aortic root. Immediate surgical correction was initiated with a polyethylene terephthalate fiber graft. The pathologic report indicated that aortic features were consistent with an old (healed) aortic dissection. There was no evidence of acute dissection. Six month follow-up revealed that surgical repair was successful in arresting further aortic dissection. CONCLUSION: The patient had an old aortic dissection that pre-dated the chiropractic treatment (which included manipulative therapy) for the whiplash-associated disorder. Manipulative therapy, long considered an absolute contraindication for abdominal and aortic aneurysms, did not provoke the progression of the aortic dissection or other negative sequelae. The cause, histology, clinical features, and management considerations in the treatment of this patient's condition(s) are discussed.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
3/13. Reversal of end-stage renal disease after aortic dissection using renal artery stent: a case report.BACKGROUND: Medical management is the conventional treatment for Stanford Type B aortic dissections as surgery is associated with significant morbidity and mortality. The advent of endovascular interventional techniques has revived interest in treating end-organ complications of Type B aortic dissection. We describe a patient who benefited from endovascular repair of renal artery stenosis caused by a dissection flap, which resulted in reversal of his end-stage renal disease (ESRD). CASE PRESENTATION: A 69 y/o male with a Type B aortic dissection diagnosed two months earlier was found to have a serum creatinine of 15.2 mg/dL (1343.7 micromol/L) on routine visit to his primary care physician. An MRA demonstrated a rightward spiraling aortic dissection flap involving the origins of the celiac artery, superior mesenteric artery, and both renal arteries. The right renal artery arose from the false lumen with lack of blood flow to the right kidney. The left renal artery arose from the true lumen, but an intimal dissection flap appeared to be causing an intermittent stenosis of the left renal artery with compromised blood flow to the left kidney. Endovascular reconstruction with of the left renal artery with stent placement was performed. Hemodialysis was successfully discontinued six weeks after stent placement. CONCLUSION: Percutaneous intervention provides a promising alternative for patients with Type B aortic dissections when medical treatment will not improve the likelihood of meaningful recovery and surgery entails too great a risk. Nephrologists should therefore be aggressive in the workup of ischemic renal failure associated with aortic dissection as percutaneous intervention may reverse the effects of renal failure in this population.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/13. Descending thoracic aneurysm rupture with a known abdominal aortic aneurysm.The association of abdominal aortic aneurysms with aneurysmal disease of the thoracic aorta is well established. However, rupture of a descending atherosclerotic thoracic aortic aneurysm in association with an infrarenal abdominal aortic aneurysm can present a difficult diagnostic and therapeutic problem to the treating physician. This article presents a case of rupture of an atherosclerotic descending thoracic aortic aneurysm in the face of what clinically appeared to be a leaking or ruptured abdominal aortic aneurysm.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/13. Cardiac surgical emergencies.Cardiac surgical emergencies are broken down into three categories: cardiac trauma, aortic dissection, and surgery for acute myocardial infarctions. Emphasis is given to describing the presentation of patients with such problems, and to the salient aspects of the clinical strategies for managing each problem. An important goal of each section is focusing the critical care physician on the early recognition of cardiac surgical emergencies and providing him with some rationale for instituting an expeditious plan of therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/13. aortic aneurysm in a 74-year-old man with coronary disease and obstructive lung disease: is double jeopardy enough?A previous decision analysis examined a patient with severe CAD, diminished ventricular function, and an abdominal aortic aneurysm and also concluded that CABG followed by aneurysm repair was optimal. This patient, who had well-preserved cardiac function but severely compromised pulmonary status, stood to gain less from CABG than would a patient with more severe coronary disease, thus accounting for the "close-call" between the CABG-AAA and AAA only strategies. Nevertheless, the analysis did emphasize the benefit of aneurysm repair, whether done alone or after CABG. The analysis also highlighted the significant risk of aneurysm rupture the patient is exposed to while recovering from CABG surgery. The operative mortality risks of the two procedures are similar; thus, the patient's total operative risk is approximately doubled if he undergoes both procedures rather than aneurysm repair alone. The key question raised by the analysis is whether this double jeopardy is more than compensated by the degree to which prior CABG reduces both short-term cardiac risk at subsequent aneurysm repair and long-term cardiac mortality. For this patient, who had good cardiac function, the gains appeared sufficient to offset the interval risk of aneurysm rupture and the additional risk associated with a surgical procedures. THE REAL WORLD The patient indeed underwent and tolerated CABG, although he had a stormy prolonged postoperative course due to pulmonary failure. After discharge from the hospital, he declined readmission for repair of the aneurysm. We did not model that possibility, clearly an inadequacy in our tree. Some six months later, the patient was still alive and was, reluctantly, readmitted for aneurysmorrhaphy. At that time, however, his pulmonary function had deteriorated and both the anesthesiologist and the pulmonary consultant stated unequivocally that further surgery was now impossible. In retrospect, the expected utility of CABG without aneurysm repair (thus providing only a decrease in the long-term mortality risk from his CAD) would have been 1.95 (DEALE) or 2.06 (Markov) years. Sensitivity analysis revealed that, even if long-term cardiac risk were completely eliminated by CABG, immediate aneurysm repair would have been a better approach had the patient's physicians known he would be likely to refuse or not be a candidate for the second operation. In summary, although the patient's comorbidities did indeed place him at significant operative risk for either aneurysmorrhaphy alone or two sequential procedures, the benefits to be gained were shown to far outweigh the risks when compared with expectant observation.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/13. Abdominal aortic aneurysms presenting as low back pain: a report of two cases.Two reports are given of patients presenting to a chiropractic physician's office with the chief complaint of low back pain. Both patients' conditions were ultimately diagnosed as abdominal aortic aneurysms. These two reports demonstrate the importance of listening to a patient's case history, as well as the need for a thorough physical examination by the use of diagnostic tools. A brief review of the anatomy and clinical presentation is also presented.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/13. Prediction of the development of sigmoid ischemia on the day of aortic operations. Indirect measurements of intramural pH in the colon.A deviation in an indirect measurement of intramural pH below the limits of normality (6.86) was used as a diagnostic test for sigmoid ischemia in 25 high-risk patients undergoing abdominal aortic operations. The clinical diagnosis of ischemic colitis was made by the attending physicians in only two of the 25, on the day after operation in one and three months after operation in another. In neither was the ischemic colitis considered to have been a causative factor in their subsequent deaths. In contrast, six patients developed pH evidence of ischemia on the day of operation. All six subsequently developed a transient episode of guaiac-positive diarrhea, four developed physical signs consistent with ischemic colitis, and four died. Of 19 who did not develop pH evidence of ischemia, none developed guaiac-positive diarrhea, none developed any signs of ischemic colitis, and none died. Stepwise logistic regression showed the duration of pH evidence of ischemia on the day of operation to be the best predictor for the symptoms and signs of ischemic colitis and for death after operation.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/13. Aortoesophageal fistula. review of clinical, radiographic, and endoscopic features.Primary aortoesophageal fistula is a rare cause of severe and often fatal gastrointestinal bleeding. The classic diagnostic triad consists of midthoracic pain and sentinel hemorrhage, followed by fatal exsanguination. A prompt, definitive diagnosis at the time of the initial bleeding episode is essential for timely, life-saving surgery. Any combination of low-grade, intermittent hematemesis, with midthoracic chest pain, dysphagia, or a mediastinal mass, should alert the physician to this diagnosis, and an aggressive diagnostic and therapeutic approach. In this article, we report a case of aortoesophageal fistula and present photographs.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/13. Aortic dilation, dissection, and rupture in patients with turner syndrome.We report two patients with turner syndrome who had aortic dissection and rupture, one with prior repair of coarctation. We also note the high incidence (8.8%) of unrecognized aortic root dilation in a group of 57 patients with turner syndrome whom we prospectively evaluated by echocardiography. Our analysis and review of previously reported cases suggests that multiple risk factors may exist for aortic dissection, including coarctation, bicuspid aortic valve, and systemic hypertension, but that these need not be present. Aortic root dilation may be an additional finding that suggests the patient with turner syndrome is also at risk. When it is present, magnetic resonance imaging visualizes the entire aorta and allows quantification of the site and degree of dilation. In patients with dissection, the aorta often exhibits pathologic evidence of cystic medial necrosis similar to the finding in patients with marfan syndrome. Therapeutic methods to decrease risk, such as those directed toward prevention of bacterial endocarditis, blood pressure control, and perhaps prophylactic beta blockade or surgical reconstruction, may need to be considered. patients with turner syndrome, their families, and the physicians who care for them should be aware of the significance of unexplained chest pain, dyspnea, or hypotension as potential manifestations of aortic dissection or rupture.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
| | Next -> |