Citations

During pregnancy, when surgically reparable heart disease can no longer be medically manged, open- or closed-heart surgery is the procedure of choice without prior therapeutic abortion. Cyanotic congenital heart disease in a pregnant patient when completely correctable surgically may be an indication for surgery in itself. Available data suggest that pregnancy per se does not increase the maternal risk of heart surgery with use of extracorporeal circulation. Fetal mortality in our series was 33%.

Complete surgical correction of transposition of the great arteries associated with subvalvular pulmonary stenosis carries a high mortality rate. A new surgical technique that achieves redirection of the ventricular outflows and relieves pulmonary stenosis by bypassing it, was successfully used to repair complete transposition of the great arteries associated with ventricular septal defect (VSD) and valvular and subvalvular pulmonary stenosis in a 14½-year-old patient. The repair consists of (1) division of the pulmonary artery, the cardiac end of which is oversewn, (2) repair of the VSD with a patch in such a way as to connect the left ventricle with the aorta, and (3) reconstruction of the pulmonary artery with an aortic homograft, including the aortic valve, which is anastomosed between the distal end of the pulmonary artery and the right ventricle. A review of the cases in which the current techniques were used indicates that the location and nature of the obstruction in the left ventricular outflow tract defies successful repair in most instances. Localized ridges and diffuse hypoplastic outflow tracts are recognized causes of obstruction, but anomalies of the mitral valve commonly contribute to or are the primary cause of subvalvular obstruction.

Left ventricular (LV) performance was studied during mild exercise (100 kg-m/min for 3 minutes) in 19 cases of coronary artery disease (CAD). Each patient suffered from a severe anginal syndrome. None had ventricular aneurysm, cardiomegaly, or clinical heart failure. Mean resting values follow: LV end-diastolic pressure (LVEDP), 19 ± 7 mm Hg; LV systolic pressure (LVSP), 150 ± 16 mm Hg; stroke volume index (SVI), 48 ± 10 ml/beat/m 2 ; and LV stroke work index (LVSWI), 81 ± 19 g-m/m 2 . During exercise LVEDP rose to 30 ± 8 mm Hg ( P ≤0.001) and LVS to 160 ± 20 (not significant [NS]); SVI diminished to 46 ± 11 (NS) and LVSWI, to 76 ± 24 (NS). Patients with decreased or asynchronous areas of LV myocardium identified on cine left ventriculograms had higher mean LVEDPs during exercise than did those with normal ventriculograms (34 ± 10 versus 26 ± 4 mm Hg; P ≤0.05). The difference between responses to exercise of patients who experienced angina during the study and of those who did not was NS. Administration of nitroglycerin reduced the increase in LVEDP during exercise. An abnormality in LV performance-a significant rise in LVEDP without a significant increase in SVI or LVSWI-was observed in 13 of 19 cases of CAD.

Confocal laser endomicroscopy (CLE) is one of several novel methods that provide real-time, high-resolution imaging at a micron scale via endoscopes. CLE has the potential to be a disruptive technology in that it can change the current algorithms that depend on biopsy to perform surveillance of high-risk conditions. Furthermore, it allows on-table decision making that has the potential to guide therapy in real time and reduce the need for repeated procedures. CLE and related technologies are often termed “virtual biopsy” as they simulate the images seen in traditional histology. However, the imaging of living tissue allows more than just pragmatic convenience; it also allows imaging of living tissue such as active capillary circulation, cellular death, and vascular and endothelial translocation, thus extending beyond what is capable in traditional biopsy. Immediate potential applications of CLE are to guide biopsy sampling in Barrett's esophagus and inflammatory bowel disease surveillance, evaluation of colorectal polyps, and intraductal imaging of the pancreas and bile duct. Data on these applications is rapidly emerging, and more is needed to clearly demonstrate the optimal applications of CLE. In this paper, we will focus on the role of CLE as applied to colorectal polyps detected during colonoscopy.