Michael S. Bruno

Laser coronary angioplasty: experience with 9 cadaver hearts.

Experience with laser angioplasty in 16 coronary arteries in 9 cadaver hearts is presented. Coronary obstructions were due to experimentally created thrombi as well as to naturally occurring calcified plaques. Successful laser angioplasty was achieved in 14 of 15 arteries. One artery was sacrificed to determine factors necessary for deliberate perforation of the arterial wall. This procedure required more than 30 seconds of laser energy at 3.0 W with the catheter tip almost perpendicular to the wall. Penetration of the arterial wall occurred only in the second left anterior descending artery which was plaque-occluded because of operator inexperience.

Progressive multifocal leukoencephalopathy in a male homosexual with T-cell immune deficiency.

AN acquired immune deficiency in male homosexuals that is manifested by infection with one or more opportunistic microorganisms has recently been recognized. These agents have included cytomegalovi...

Natural history of combined right bundle branch block and left anterior hemiblock (bilateral bundle branch block)

Abstract One hundred fifteen patients with combined right bundle branch block (RBBB) and left anterior hemiblock (LAH) were separated into two groups depending upon whether RBBB and LAH was associated with acute myocardial infarction (group I, 32 patients) or was a chance electrocardiographic finding (group II, 83 patients). In 10 patients in group I complete heart block developed and in six patients high grade second degree atrioventricular (A-V) block developed. The incidence of serious arrhythmia was twice and mortality was three times the average for the coronary care unit (CCU). The majority of patients in group II had clinical evidence of advanced myocardial disease as manifested by congestive heart failure, healed myocardial infarction and left ventricular dyskinesia. During a cumulative observation period of 262 patient years, complete heart block developed in only two patients, whereas second-degree A-V block of sufficiently high degree to necessitate permanent cardiac pacing developed in three patients. It is concluded that (1) combined RBBB and LAH usually reflects advanced myocardial disease, (2) the clinical course is determined more by the myocardial disease than by the conduction disorder, (3) prophylactic cardiac pacing is not warranted in chronic RBBB and LAH, and (4) cardiac pacing has little impact on mortality when RBBB and LAH are associated with acute myocardial infarction.

The role of intra-aortic ballon counterpulsation in patients undergoing percutaneous transluminal coronary angioplasty

Between June, 1979, and July, 1982, 14 patients required an IABP in conjunction with PTCA. The clinical indications for balloon counterpulsation, in the performance of PTCA were (1) clinically unstable situations where PTCA might otherwise be contraindicated, e.g., left main stem disease, multivessel coronary artery disease, unstable anginal syndromes, and cardiogenic shock; (2) preoperative insertion of an IABP for added safety following unsuccessful angioplasty; (3) abrupt vessel closure during a PTCA procedure in which the patient becomes hemodynamically unstable; and (4) late vessel closure following an initially successful angioplasty resulting in hemodynamic compromise. Of the 14 cases requiring balloon counterpulsation, 13 survived hospitalization and were alive at the time this report was submitted. We conclude that IABP is a useful adjunct to PTCA in a variety of clinical circumstances.

Hemoglobin S-C disease with fat embolism: Report of a patient dying in crisis; autopsy findings

Abstract 1.1. A case of hemoglobin S-C disease in a twenty-eight year old Negro man dying in crisis is presented. 2.2. Postmortem examination revealed extensive intravascular sickling with the formation of conglutinative thrombi in the lungs, liver, kidneys, adrenals and brain. Acute infarction of the bone marrow by sickled erythrocytes was present. Extensive dissemination of embolic fat and marrow elements was found in the lungs, and fat emboli were present in the brain and glomeruli. The spleen was shrunken, showing extensive autoinfarction and siderofibrotic nodules. 3.3. The variability of the clinical picture of S-C disease is dependent upon the proportion of hemoglobin S that is present. The severity of the crisis and the fatal outcome in this patient is explained by the unusually high concentration of hemoglobin S, namely 62 per cent. 4.4. Crisis in this disease is due to intravascular sickling. A possible pathogenetic sequence is suggested, emphasizing the release of fat from infarcted bone marrow, resulting in increased viscosity of the blood, systemic hypoxia as a result of the capillary-alveolar block produced by pulmonary fat embolism, and further intravascular sickling in the lung and other organs as a result of both local deoxygenation and systemic hypoxia. The nature of the initial insult to the bone marrow remains obscure.

A lambda light chain cold agglutinin-cryomacroglobulin occurring in Waldenström's macroglobulinemia

Abstract A high titered cold agglutinin-cryomacroglobulin with the unusual feature that it contained only lambda light chains was found in an elderly woman with Waldenstroms macroglobulinemia. Both the cold agglutinin and cryoglobulin activities resided in the same gamma M globulin. No specificity in the l/i system was demonstrated for the cold hemagglutinin. The cryoprotein was also present in the patients cerebrospinal fluid which had a cold agglutinin titer of 100,000 at 4 °C. Immunoelectrophoresis of the patients urine revealed only lambda light chains.

Current status of intra-aortic balloon counterpulsation in critical care cardiology.

Retrospective analysis revealed that intra-aortic balloon counterpulsation was attempted in 321 patients at our institute from August 1, 1974, to July 1, 1982. The intra-aortic balloon pump (IABP) was successfully inserted in 298 cases (93%). Indications for an IABP included: cardiogenic shock (84 cases), preoperative hemodynamic coverage (15 cases), low-output syndrome (73 cases), pre- and postinfarction angina (75 cases), intractable congestive heart failure (12 cases), refractory ventricular arrhythmia (9 cases), percutaneous transluminal coronary angioplasty (14 cases), cardiac arrest (7 cases), and a miscellaneous group (9 cases). The overall major complication rate was 9%. The data from this experience support aggressive management of cardiogenic shock, i.e., early balloon insertion, angiography, and cardiac surgery, which significantly increases the survival rate (83%) over medical therapy combined with balloon counterpulsation alone. The IABP was also extremely effective in managing other high-risk categories when combined with some form of definitive mechanical correction, e.g., coronary revascularization, valve replacement, or percutaneous transluminal coronary angioplasty. Left ventricular (LV) function was a significant indicator of long-term survival in our series. Patients with normal or moderately impaired LV function had higher survival rates (95% and 82%, respectively) than patients with poor LV function (42%).

Central pontine myelinolysis

Abstract Central pontine myelinolysis is a recently recognized clinical and pathologic entity. The lesion is a solitary focus of myelin destruction with relative preservation of nerve fibers, located symmetrically in the center of the pons. It occurs in patients who have previously had a debilitating disease. The development of the pontine lesion is accompanied by the appearance of a fulminating picture of central nervous system involvement and death in ten days to three weeks. A patient with this condition is described in detail. The antecedent illness was an extensive frontal sinusitis with subdural and intradural abscess. Death followed thirteen days after the onset of an acute episode which suggested viral encephalitis. The lesion was similar to those described in previously reported cases [1].

Fatal Intravascular Sickling in a Patient with Sickle-Cell Trait.

SICKLE-cell trait is a heterozygous state characterized by the presence of hemoglobin A plus hemoglobin S, the latter usually in a concentration of less than 40 per cent. It is present in 8 to 10 p...

Fulminating Idiopathic Hemochromatosis Presenting as Constrictive Pericarditis

Excerpt Congestive heart failure is the most frequent cause of death in idiopathic hemochromatosis, but the course is usually protracted (1). We report here a patient with fulminating idiopathic he...