Inderjit S. Gill

The use of adenosine for repair of penetrating cardiac injuries: a novel method

The use of intravenous administration of adenosine to expedite cardiorrhaphy in penetrating cardiac trauma by inducing temporary asystole is described. It is quicker, more effective, and safer than the traditional methods.

Invasive pulmonary mucormycosis with ruptured pseudoaneurysm

A 67-year-old man presented with a dry cough. His medical history was notable for diabetes, prior cadaveric kidney transplantation, and immunologic suppression with daily prednisone and FK-506. Admission chest radiography demonstrated a pulmonary infiltrate. Subsequent bronchoalveolar lavage cultures were positive for methicillin-resistant Staphylococcus aureus. Despite antibiotics he developed hemoptysis, increasing infiltrates, and an enlarging left-sided pleural effusion. Chest computed tomographic scan demonstrated a large, heterogeneous intraparenchymal pulmonary mass consistent with a hematoma and free intrapleural fluid (Fig 1). Pulmonary arteriography confirmed the diagnosis of pseudoaneurysm of the pulmonary artery (Fig 2). During the operation, the pleural space was filled with fresh clot. Proximal control of the pulmonary artery, followed by evacuation of hematoma and left lower lobectomy with lingulectomy were performed. The large defect in the pulmonary artery was excised with the specimen, and the vessel was transected through grossly normal tissue. An intercostal muscle flap was used to separate the arterial and vascular closures. Intraoperative cultures were positive for methicillin-resistant Staphylococcus aureus, Enterococcus faecalis, and zygomyces. Pathologic work-up demonstrated invasive mucormycosis within the arterial walls. Figure 3 shows a cross-section of pulmonary artery with fungal hyphae invading wall (Gomori 61 second methemamine silver stain, original magnification 500). He was treated with antibiotics, amphotericin B, discontinuation of immunologic suppression, and hemodialysis. He was discharged from the hospital on postoperative day 26. Mucormycosis is an opportunistic invasive fungal infection generally affecting immunocompromised patients [1–3]. Classic presentation is a cavitary pulmonary lesion on chest radiograph [2]. Invasion into surrounding structures including vessels and bronchi is common. Pseudoaneurysm develops after invasion and contained rupture of a pulmonary vessel. Diagnosis is usually delayed and frequently is established postmortem [1, 2]. Upon diagnosis amphotericin B should be started immediately [3]. Resection of localized disease improves survival, but despite aggressive treatment the mortality rate still approaches 80% [4].

Aortoesophageal fistula associated with a Kommerell diverticulum and right-sided aortic arch

risk of paraplegia. Although the priority of CT assessment in acute aortic dissection is not in dispute, TEE may be a useful adjunct to overcome its limitations. Reference 1. Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006;166:1350-6. Brief Communications