Severe anaphylaxis to a new disinfectant: polyhexanide, a chlorhexidine polymer

We describe the cases of an 18-year-old female and a 15-year-old male who developed severe anaphylaxis following contact of surgical wounds with the disinfectant Lavasept, containing polyhexanide, a polymerised form of chlorhexidine, during orthopaedic interventions. According to the manufacturer, this product is the only polyhexanide containing medical disinfectant, has recently been commercialised and is only available in Switzerland. One of the patients denied previous contact with this compound but both patients were previously exposed to chlorhexidine. Immediate-type hypersensitivity to polyhexanide was suggested by positive skin prick tests in the two patients and by negative skin tests in control individuals. Skin tests with chlorhexidine in the patients remained negative. We conclude that contact with the new disinfectant Lavasept can trigger anaphylactic reactions, even in the absence of previous history of exposure to this compound. It remains to be established whether this new disinfectant is a frequent anaphylactogen.     

Coronary artery spasm in the denervated transplanted human heart: a clue to underlying mechanisms

The mechanism of coronary artery spasm has been poorly understood but there has been some suggestion that cardiac autonomic innervation may play an important role. We report coronary artery spasm in a 43 year old man two years after he had received a transplant. Provocative pharmacologic testing suggested functional denervation of the patient's heart. Thus, coronary artery spasm can occur in the transplanted, denervated human heart. Autonomic innervation of the heart is not essential in all cases of coronary spasm, and circulating catecholamines and/or metabolic of hormonal products may play an important role.     

Coronary artery spasm during anesthetic induction in a patient with bronchial asthma

A 68-year-old man was scheduled for subtotal gastrectomy. He had bronchial asthma, but had no history of ischemic heart disease and showed normal ECG. He stopped taking antiasthmatic drugs after the admission. His operation had been postponed for 10 days for an attack of bronchial asthma. The asthmatic attack was suppressed by infusing aminophilline. Before the operation, general anesthesia combined with epidural anesthesia (mepivacaine; 60 mg) was induced. At the time of the insertion of a stomach tube, bradycardia (48 bpm) and hypotension (48/30 mmHg) with an elevation of ST-segment in ECG were observed. We administrated 10 mg of isosorbide dinitrate followed by continuous intravenous injection (0.5 mg.kg-1.min-1) of dopamine (6 mg.kg-1.min-1). After 20 minutes, increases of both blood pressure (82/49 mmHg) and heart rate (89 bpm) were achieved and ST-segment in ECG was reversed. The operation was postponed again. Although the patient had refused to take coronary angiogram, the episode was explained by coronary artery spasm. Pathogenesis of the spasm was likely to be 1) elevation of endogenous cathecolamine due to asthma, 2) inhibition of cardiac sympathetic system by epidural anesthesia and 3) stimulation of vagal system by the insertion of a stomach tube.     

Coronary obstruction secondary to direct cannulation

Four patients are reported with obstruction of the proximal left main coronary artery that developed following prosthetic replacement of the aortic valve. Angina pectoris and ventricular arrhythmias were the presenting clinical manifestations. Anterior descending coronary artery bypass was used in 3 of the patients and vein patch angioplasty in the fourth. One patient died in the hospital. The 3 survivors achieved reflief from angina and ventricular arrhythmias. One patient died from nephropathy 2 1/2 years later. Two patients remained asymptomatic 1 1/2 and 3 years later, respectively. This review emphasizes the need for prompt coronary angiography in patients experiencing angina pectoris after aortic valve replacement, and it shows that coronary revascularization can be performed with satisfactory results.     

Coronary artery revascularization in an adult with coronary aneurysms probably secondary to childhood Kawasaki disease

Kawasaki disease is an acute febrile illness affecting mainly infants and children. The fatal complication of Kawasaki disease is coronary involvement pertaining to coronary artery aneurysms. Surgical experience of adults that had childhood Kawasaki disease with coronary lesion has been rarely reported. We experienced coronary artery bypass grafting in a 44 year old man with no risk factors for atherosclerosis but with coronary lesions possibly secondary to Kawasaki disease. Coronary artery sequelae of Kawasaki disease may become part of a cause of coronary disease in young adults and we should recognize this condition in such patients with coronary disease but no coronary risk factors.     

Coronary artery spasm with ventricular tachycardia after administration of methoxamine during cervical epidural anesthesia--a case report

Intrapartum transmission of group A streptococcus has not been well documented. As the incidence of severe infections due to this organism has recently increased, it is important to assess if such transmission occurs. We observed two cases of severe neonatal infections due to group A streptococcus, one of which was fatal, that appeared to have been transmitted from the mother during birth. Perinatal prophylaxis, which has been recommended for infections due to group B streptococcus, should be evaluated for infections due to group A streptococcus.     

Coronary artery ectasia

Coronary artery ectasia is an uncommon expression of coronary artery atherosclerosis and other diseases. It occurs in about 1.4 percent of the adult population. It is not distinguishable from obstructive coronary artery disease in severity of angina, clinical presentation, electrocardiograms, mortality, or outcome of coronary artery surgery. Although there is debate, treatment is indicated in the form of chronic warfarin anticoagulation to prevent coronary thrombus formation and its sequelae. Aspirin therapy may suffice in asymptomatic individuals.     

Coronary artery reoperation

Coronary artery reoperation has been performed in 51 patients (4%) including 5 second reoperations among 1,245 CABGs during past 9 years. There were 40 males and 11 females with a mean age of 58 year old ranging from 19 to 75 year old. Extent of coronary artery disease were; single vessel disease in 2 patients, double vessel disease in 18 patients, triple vessel disease in 22 patients and left main disease in 9 patients. Preoperative ejection fraction ranged from 0.24 to 0.69 (mean 0.48) and 21 patients (41%) showed unstable angina. Interval between primary CABG and reoperation ranged from 1 month to 20 years with a mean of 6 years. There were two groups which had early reoperation at the mean of 6 months (14 patients) and late reoperation at the mean of 9 years (37 patients) after primary CABG. Causes of reoperation varied from graft failure (29 patients), progression of native CAD (2 patients), both of them (19 patients), and incomplete revascularization (1 patient). There were 32 patients who had patent old graft at the time of reoperation. Re-entry approaches used were midsternal in 41 patients and left thoracotomy in 10 patients. The ITA, GEA, IEA and SV grafts were used in 30, 38, 5 and 28 patients, respectively. There were 4 patients who underwent CABG without cardiopulmonary bypass. The mean number of bypass was 2.1 and the mean duration of aortic crossclamp and cardiopulmonary bypass were 63 minutes and 114 minutes, respectively. As a result, there were 4 early and 1 late death. Postoperative angiography revealed that patency rate of ITA, GEA, IEA and SV grafts were 100% (22/22), 97% (30/31), 75% (3/4) and 87% (20/23), respectively. In conclusion, risk of coronary artery reoperation is still high and use of arterial graft is important to obtain high patency rate and low reoperation rate.     

Coronary artery disease

Those who have IGT (impaired glucose tolerance) are thought to be highly risky to atherosclerotic coronary artery disease (CAD), probably because of the frequent association with insulin resistance or hyperinsulinemia, obesity or abdominal fat accumulation, hypertriglyceridemia and so on. Whether insulin resistance which is one of the major causes of IGT, following hyperglycemia itself or both is really responsible for CAD is remained to be clarified. Furthermore, IGT is also an apparent candidate for NIDDM in future. Thus, IGT should be intensively treated to prevent or delay the onset of NIDDM and also to minimize the adverse events by atherosclerotic CAD.     

Action of intracoronary nitroglycerin in refractory coronary artery spasm

Coronary artery spasm usually responds to sublingual nitroglycerin. This report describes four patients with variant angina and one patient with rest angina who had coronary spasm that was refractory to sublingual or i.v. nitroglycerin. In four patients, spasm occurred spontaneous and in one patient after 0.05 mg of ergonovine. In each case, 25-100 micrograms of intracoronary nitroglycerin promptly (30-45 seconds) resulted in reopacification of the vessel involved in spasm and resolution of evidence for ischemia. Thus, intracoronary nitroglycerin can reverse coronary artery spasm that does not respond to systemic nitroglycerin administration.     

Left coronary artery-left ventricle fistula with right coronary artery spasm

A 72-year-old woman was admitted to our hospital for evaluation of chest pain. Coronary angiography showed a left coronary artery-left ventricle fistula. An acetylcholine provocation test induced vasoconstriction of the right but not the left coronary artery. Her chest pain was not relieved by combined therapy with isosorbide dinitrate, diltiazem and nicorandil. Because of the coronary spasm, beta-blockers could not be used. However, her chest pain was relieved after the administration of a minor tranquilizer. Thus, the patient's chest pain was unlikely to be associated with either the fistula or the coronary spasm.     

Acute myocardial infarction during pregnancy caused by coronary artery spasm

A 33-year-old pregnant woman suffered from acute anteroseptal myocardial infarction at the 19th gestational week. Despite periodic attacks of myocardial ischaemia after admission, the coronary arteriograms under the use of nitroglycerin were normal. Thereafter, she remained free from the ischaemic events with diltiazem hydrochloride and delivered a healthy baby. The coronary arteriography at puerperium also showed no organic narrowing. However, the provocative test with acetylcholine chloride caused severe spasm of the left anterior descending coronary artery. These findings strongly suggest that acute myocardial infarction in this pregnant woman was caused by coronary artery spasm.