Frank N. Ritter

Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages.

The characteristics, diagnosis, and management of oropharyngeal and digestive passage lesions due to ingestion of caustic agents are presented. Previous experimental and clinical studies are reviewed with discussion of the peculiar qualities of the newer caustics. Differentiation in treatment of burns caused by solid and liquid agents is stressed.

Treatment of caustic injuries of the esophagus: a ten year experience.

The methods of managing 32 patients sustaining caustic injuries to the esophagus are assessed. Treatment of these patients must be individualized according to the type of caustic ingested, the degree of burn and other clinical signs. While an aggressive approach is favored for second and third-degree burns in the form of early esophago-gastrectomy with subsequent colon interposition, operation is not necessary in all patients, particularly those with first-degree burns. The use of antibiotics is recommended as soon as the diagnosis of esophageal injury is established. The efficacy of steroids in preventing stricture formation, especially with third-degree burns, is questioned.

Aggressive surgical treatment for caustic injury of the esophagus and stomach.

Abstract Two patients with severe liquid alkali burns of the esophagus and stomach are reported in whom an early esophagogastrectomy was performed. The value is stressed of an early exploratory operation as a diagnostic as well as therapeutic tool in patients with a history of ingestion of strong liquid alkali.

Questionable Methods of Foreign Body Treatment

Foreign bodies of the air and food passages have been removed safely for years by endoscopic means. Recently new nonendoscopic techniques have been introduced to remove these foreign bodies and some have resulted in severe complications. One example is papain which has been advocated for dissolving esophageal meat impaction; and, while successful in some patients, this method has led to two deaths. Coins have been successfully extracted from the esophagus by using a distended Foley catheter, but such a technique could result in aspiration. Bronchial foreign bodies have been expelled by placing the patient in a head down position and taping the chest to dislodge them. This produced a cardiorespiratory arrest in one patient and after resuscitation, temporary blindness. It would appear that these newer techniques are more dangerous statistically than time honored and proven endoscopy.

Vocal cord paralysis in postpoliomyelitis syndrome

Postpoliomyelitis syndrome is characterized by new neuromuscular symptoms, including weakness, developing years after recovery from acute polio. Bilateral vocal cord paralysis is presented as a new manifestation of this syndrome. Other clinical features of post‐poliomyelitis syndrome in this report are discussed. The etiology of this syndrome is unknown, though attrition or immune‐mediated destruction of collateral muscular innervation appears likely. The pathologic findings include scattered individual muscle fiber atrophy as well as evidence of chronic denervation and reinnervation. This form of motor deterioration is not life‐threatening, but potentially may cause increasing disability in a large number of polio survivors. Proper supportive care of facial, laryngeal, and pharyngeal weakness is crucial in the management of these patients.

Tonsillectomy and Adenoidectomy: Indications and Complications

Recurrent attacks of tonsillitis, peritonsillar or cervical abscess, and debris in deeply fissured tonsils are the most common indications for tonsillectomy. Adenoid hypertrophy and recurrent suppurative otitis media are indications for adenoidectomy. Tonsils and adenoids are usually removed in one operation, even though the procedure is done chiefly for either tonsillar or adenoid disease. Careful preoperative evaluation and postoperative observation are necessary to reduce the morbidity and complications of this operation.

Transapical transcatheter aortic valve implantation followed by transfemoral transcatheter edge-to-edge repair of the tricuspid valve using the MitraClip system – a new treatment concept for an inoperable patient with significant aortic stenosis and severe tricuspid valve regurgitation

Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis. The benefits of both methods have been confirmed in large cohort studies [1–4]. Recently, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system was described for high surgical risk or inoperable patients [5–7].

Simultaneous transfemoral transcatheter mitral and tricuspid valve edge-to-edge repair (using MitraClip system) completed by atrial septal defect occlusion in a surgically inoperable patient. First-in-human report.

Transcatheter transfemoral mitral valve repair using the MitraClip system (Abbott Vascular, USA) is used in high-risk or inoperable patients with severe mitral regurgitation. We report the first-in-human simultaneous transfemoral clipping of the mitral and tricuspid valve completed by occlusion of an atrial septal defect (ASD). The procedure was performed in an 84-year-old patient in October 2015. After effective reduction of mitral and tricuspid regurgitations using the MitraClip system a PFO Occluder (St. Jude Medical, USA) was implanted. Transfemoral simultaneous mitral and tricuspid valve repair using the MitraClip system with ASD occlusion seems to be an effective therapy for high-risk or inoperable patients.

“All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human

Address for correspondence: Marek Kowalski MD, PhD, Department of Cardiology, Schüchtermann-Klinik, Ulmenallee 5-11, 49214 Bad Rothenfelde, Germany, phone: +49 542464130023, e-mail: MKowalski@schuechtermann-klinik.de Received: 16.10.2017, accepted: 25.11.2017. Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis [1, 2]. Furthermore, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system has recently been described for high-risk patients with tricuspid regurgitation [3]. This valvular dysfunction is mainly caused by right ventricular dilatation driven by volume or pressure overload secondary to heart failure, mitral disease and/or aortic valvular disease [4]. Thus, most of these patients suffer from multivalvular disease. However, simultaneous transapical TAVI and transfemoral clipping of the mitral as well as tricuspid valve with MitraClip completed by occlusion of an atrial septal defect has not been described so far. We report hereby this firstin-human intervention in a high-risk patient. An 81-year-old male patient with a history of biventricular heart decompensation suffered from severe dyspnea on admission (New York Heart Association functional class III), lower leg edema, pleural effusions and stage III chronic kidney disease. Echocardiography revealed severe aortic stenosis (aortic valve area = 0.7 cm2) (Fig. 1). In addition, severe regurgitation of the tricuspid valve (effective regurgitation orifice area (EROA) = 0.88 cm2) and mitral valve (EROA = 0.44 cm2) with tethered leaflets was found (Fig. 2). Left and right ventricular function were reduced (ejection fraction of 50% and 35%, respectively). Elevated systolic pulmonary artery pressure could be documented (65 mm Hg). As a result of heart team discussion the patient was declared as surgically inoperable and qualified for transapical transcatheter aortic valve implantation – not suitable for a transvascular approach – followed by transfemoral edgeto-edge repair of mitral and tricuspid valves using the MitraClip system within one simultaneous procedure. All interventions were performed on July, 4th, 2017 under general anaesthesia using twoand three-dimensional transesophageal echocardiography (TEE) (iE 33, Philips Healthcare, Netherlands) and fluoroscopy guidance (Axiom Artis Zeefloor AXH 1604, Siemens, Germany). Unfractionated heparin was administered aiming at an activated clotting time (ACT) of 250–300 s throughout the procedure. For the transapical TAVI the left ventricular apex was surgically exposed (anterolateral minithoracotomy) and the apical suture was prepared. The apex was then punctured and a guidewire was placed in the left ventricular cavity and advanced through the aortic valve into the ascending aorta. Using the guidewire, a 5 Fr Impulse Femoral Right 4 Angiographic Catheter (Boston Scientific, USA) was introduced via the ventricular cavity in the descending aorta. Next a guide wire was placed (Amplatzer Super Stiff, Boston Scientific, USA) through the apex into the descending aorta. After that the 18 Fr sheath was introduced (Certitude, Edwards, USA) followed by the crimped valve (Sapien 3 TA 26 mm Aortic Bioprosthesis, Edwards, USA) and the device was positioned in the aortic valve annulus. The valve was implanted under aortic angiographic control and rapid pacing. The apex was closed after removing the introducer system. The procedure resulted in correct positioning of the aortic bioprosthesis with minimal aortic regurgitation (Fig. 3). Echocardiography showed a mean gradient of 5 mm Hg and an aortic valve area of 3.1 cm2. Then the mitral valve edge-to-edge repair using the MitraClip system was performed. After puncture of the right femoral vein and reaching the left atrium via transseptal puncture the steerable guiding catheter was placed into the left atrium and the clip delivery system (CDS) was introduced into the guiding catheter. The next step of the maneuver consisted of advancing the MitraClip device into the left atrium, opening both arms, navigation and advancing the system into the left ventricle. By retracting the MitraClip device both leaflets of the mitral valve were grasped and closed to coapt. Doing so, an effective reduction of mitral regurgitation could be achieved and the clip was deployed. The clip delivery system was evacuated. “All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human