Lenny K.A. Tan

Coronary Artery-Left Ventricular Fistula

Coronary artery-left ventricular fistulae are exceedingly rare and to date only 19 cases have been reported in the literature. We describe another four cases which we encountered recently. The first patient was a 10-year-old asymptomatic Indian male who was referred because of a to-and-fro murmur. Haemodynamic and angiographic studies revealed an aneurysmally enlarged right coronary draining into the left ventricle. The fistula was ligated and the patient has remained well over a 21/2-year follow-up period. The second patient was a 13-year-old asymptomatic Chinese female referred also because of a to-and-fro murmur. Haemodynamic and angiographic studies showed a grossly enlarged right coronary artery draining into the left ventricle. This patient refused operation and has remained well over a 2-year follow-up period. The third patient was a 43-year-old Chinese male who presented with a 3-year history of angina pectoris and was admitted to hospital because of crescendo angina. The resting electrocardiogram showed marked ischaemic changes and the treadmill exercise stress test was also positive. Selective coronary angiography showed markedly dilated right and left coronary arteries. Multiple fistulae from the three major coronary arteries were seen to communicate with the left ventricle. It was elected to treat this patient medically with propranolol. He has remained well over a 6-month follow-up period. The fourth patient was a 5-year-old asymptomatic Chinese girl. Cardiac catheterization and selective coronary angiography revealed marked dilatation of the branches of the left coronary artery which communicated via a maize of fine vessels into the left ventricle. This patient has remained well over a 5-year follow-up period. The clinical presentation, investigations and treatment of coronary artery-left ventricular fistula are discussed and the literature regarding this subject is reviewed.

Giant congenital aneurysm of the right coronary artery

Giant congenital aneurysm of the coronary arteries is rare. In a patient with such an aneurysm of the right coronary artery the diagnosis was made preoperatively and surgical treatment with aneurysmectomy and closure of the aneurysm was successful.

A comparison of iohexol and iopamidol for lumbar myelography.

The use of iopamidol and iohexol for lumbar myelography is compared in this study. Fifty-eight patients were examined, the contrast media being allocated on a randomised double-blind basis. Radiographic quality was good with both media. Headache and an increase of back pain were the most frequent symptoms, though the incidence of side-effects was slightly but significantly greater with iohexol. We conclude from our study that while the radiographic quality is comparable, iopamidol seems to be slightly better tolerated.

U wave inversion in unstable angina due to left main coronary artery stenosis.

A 50-year-old male was admitted to hospital for repeated episodes of chest pain due to unstable angina. Serial electrocardiograms were all normal except for one electrocardiogram, recorded during chest pain, which showed isolated U wave inversion in leads I, V4 and V5. Subsequently, selective coronary arteriography showed isolated 99% stenosis of his left main coronary artery.

Internal mammary artery-innominate vein fistula--case report.

Case Report A twenty-year-old, asymptomatic, Oriental female was referred to us because of a grade 3/6 continuous murmur, which was loudest at the first and second right intercostal space. The blood pressure was 130/85 mm Hg. The chest x-ray and 12-lead ECG yielded findings within normal limits. A clinical diagnosis of an arteriovenous fistula was made. Right-heart catheterization showed normal pressures. Oxygen sampling of the right heart chambers and pulmonary artery did not reveal a left-to-right shunt. Aortic angiography suggested a right-sided IMA fistula. Selective right IMA arteriography showed a tortuous communicating artery arising from the proximal IMA and draining into the right IV (Figure 1). Embolization of the fistula was then performed using a coil device. Following this, injection of

Total Anomalous Pulmonary Venous Drainage

Abstract A 15 year old Indian boy was discovered to have a very loud continuous murmur over the right supraclavicular region. Cardiac catheterization findings demonstrated an atrial septal defect and a left to right shunt at the level of the right innominate vein. At thoracotomy, total anomalous pulmonary venous drainage was found. The dilated vertical vein arising from the common pulmonary vein was narrowed to about 1.2 cm in diameter at its site of entry into the right innominate vein, causing blood to flow into the latter vessel in a jet-like fashion, thus producing the loud continuous murmur.

Treatment of primary liver cancer in Singapore A review of 3200 cases seen between January 1, 1977, and July 31, 1987

SummaryBetween January 1977 and July 1987, 3200 patients with hepatocellular carcinoma (HCC) were studied in Singapore. HCC formed 90% of primary liver cancers seen in Singapore and is the second most common fatal malignancy seen in men in the country. Extensive clinical and basic research has defined certain treatment strategies. Of importance is the prompt detection of early nodular tumours, which can be resected. Resection, ‘targetting’ with anticancer drugs and, in selected cases, synchronised direct hepatic irradiation with adriamycin, used as a radiosensitiser, have been promising treatment methods. Biological modifiers, such as interferons and interleukins, offer potential for the future. Preliminary pilot studies suggest that interferons may prevent the development of HCC, but more studies are required. Similarly, selective localisation of anticancer agents with radio-isotopical agents opens opportunities for treatment.

Successful Angioplasty of Renal Artery Stenosis due to Aorto-Arteritis

A 24-year-old Chinese female who suffered from hypertension and acute myocardial infarction was found to have aorto-arteritis on angiographic examination, with total occlusion of her right coronary artery and subtotal occlusion of her right renal artery. Transluminal angioplasty of her right renal artery was successfully performed and this normalized her blood pressure from 165/105 to 135/85 mm Hg.

Ruptured Aneurysms of the Aortic Sinus of Valsalva

Aneurysms of the aortic sinus of Valsalva (ASV) are uncommon. This study describes eight cases of ruptured aneurysms of the congenital variety observed over a 10-year period in Singapore. Although ASV is classically diagnosed at the time of rupture, only one patient in this series presented with acute chest pain and dyspnea. All eight patients had continuous murmurs. The clinical diagnosis was confirmed by cardiac catheterization and angiography in eight patients and by thoracotomy in six. In six patients, the aneurysm had ruptured into the right ventricle and in two into the right atrium. In the five patients where the site of the aneurysm could be definitely determined, four arose from the right coronary and one from the noncoronary sinus. This marked preponderance of right coronary sinus over noncoronary sinus aneurysm in Singapore is more in accordance with the Japanese rather than the Western experience. A systolic gradient due to the aneurysm pressing on the right ventricular outflow tract was established in four patients during cardiac catheterization and angiography and confirmed in three patients at thoracotomy. Six patients underwent operation and were alive and well from 7 months to 3 years later.

Adipose Venolymphatic Transfer for Management of Postradiation Lymphedema

The method of adipose venolymphatic transfer is described in a patient who had postradiation lymphedema after excision of a liposarcoma. The technique involved transferring adipose tissue containing lymphatic vessels surrounding the long saphenous vein from the normal healthy leg to the irradiated leg with the creation of an arteriovenous fistula. This technique has the advantages of: (a) transferring lymphatic vessels to provide new drainage without microlymphatic anastomosis; and (b) bypassing the irradiated area when lymphatic vessels are blocked. Two years’ follow-up showed there is a reduction in volume of the edematous leg. Postoperative lymphangiogram showed there is evidence of cross-lymphatic drainage from the recipient leg to the opposite normal groin.