Acute myocardial infarct caused by a muscle bridge of the anterior interventricular ramus: complicated course with vascular perforation after stent implantation

A 47-year-old male patient was admitted to our hospital with acute anterior myocardial infarction. Immediate coronary angiography was carried out, which showed proximal occlusion of the left anterior descending artery (LAD). After mechanical recanalization, a reduction in vessel caliber at the site of occlusion was visible, and balloon angioplasty with consecutive stent implantation because of vessel wall dissection was performed. After the procedure, diameter reduction of the entire vessel segment distal to the stent and muscular bridging with subtotal systolic obliteration of the LAD and one diagonal branch were demonstrated. Diastolic coronary flow did not appear to be limited (TIMI 3). Dipyridamole-thallium cardiac imaging revealed an incomplete perfusion defect of the anteroseptal region and a reversible perfusion reduction of the anterolateral region. For definitive treatment, we decided to implant a 3.0 mm-stent at the site of muscular bridging. Although balloon sizing was adapted to the diameter of the proximal reference segment, measured by quantitative coronary angiography, coronary perforation into the right ventricular outflow tract due to balloon oversizing in the distal dilation segment occurred. The patient remained asymptomatic at rest as well as under exercise testing, and hemodynamics remained stable. Coronary re-angiography after 1 week demonstrated a persistent fistula with complete opacification of the LAD and normal coronary flow (TIMI 3). Within the following 3 months, the coronary fistula closed spontaneously. CONCLUSIONS: Muscular bridging is a rare cause of acute myocardial infarction. Balloon angioplasty and stent implantation in the bridged segment may be complicated by coronary artery perforation due to balloon oversizing. Risks and benefits of this therapeutic option, therefore, have to be critically evaluated, and careful selection of balloon size using measurements of proximal and distal reference diameter assessed by intravascular ultrasound is recommended. Coronary artery perforation into the myocardium with subsequent development of a fistula may be treated conservatively as long as the patient remains asymptomatic. The frequency of spontaneous closure of the fistula is high.     

Amplitude Doppler US: slow blood flow detection tested with a flow phantom

Unidirectional blue light directs the rhizoid-thallus axis in the apolar zygotes of Fucus and Pelvetia. Here, it is shown that blue light (but not red light) increased cyclic GMP levels of Pelvetia zygotes by about a factor of 2. When the increase in cyclic GMP was blocked by a guanylyl cyclase inhibitor, photopolarization was also blocked. Bathing the cells in a permeant cyclic GMP analog, which should tend to collapse intracellular cyclic GMP gradients, reduced the degree of photopolarization. Growing the cells in the dark in a gradient of the analog caused the rhizoids to tend to form on the low concentration side. It appears that the stimulation of the blue light photoreceptors on the side nearer the light activates guanylyl cyclase and results in a transcytoplasmic cyclic GMP gradient that is necessary for polarization.     

Correlation between evoked motor response of the sciatic nerve and sensory blockade

OBJECTIVE: The development of collateral microvessels following therapeutic angiogenesis with vascular endothelial growth factor (VEGF) was investigated using a new system of microangiography that employs monochromatic synchrotron radiation (SR) and a high definition video system to visualize arteries with a spatial resolution of 30 microns. METHODS: Ischemia was induced in the hindlimb of 20 rats by excision of the femoral artery, followed by transfection of the plasmid (400 micrograms) encoding VEGF or beta-galactosidase (control) into limb muscles. Microangiography was used to assess the development of collaterals in the ischemic limb four weeks after treatment. RESULTS: Gene transfer of VEGF produced morphologically similar, but significantly more extensive, collateral networks at the microvascular level as compared with the naturally occurring collateral arteries in the control animals (angiographic score: 0.88 +/- 0.08 versus 0.54 +/- 0.05, p < 0.01). No adverse vascular effects such as hemangiomas and/or arteriovenous (AV) fistulae were observed following VEGF treatment. The vasodilator effect of papaverine was evident in relatively large vessels in both groups. At the microvascular level (diameter < 100 microns), however, papaverine induced significant vasodilation in the VEGF-treated animals, and almost no vasodilation in the controls. CONCLUSIONS: SR microangiography allowed us to assess the development of small collateral arteries following VEGF-gene transfer. The information obtained may provide new insights regarding the collateral microcirculation and therapeutic angiogenesis.     

Investigation of endogenous neurotransmitters of guinea pig gallbladder using nicotinic agonist stimulation

Gallbladder motility is modulated by intrinsic nerves, the identities of which are not well established. The aim of this study was to determine the effect of nicotinic receptor stimulation of intrinsic nerves on gallbladder muscle contractility. Guinea pig gallbladder muscle strips were studied in vitro. Histamine 1 microM was used to increase baseline tone. The nicotinic receptor agonist, 1,1-dimethyl-4-phenylpiperazinium (DMPP), produced a biphasic response characterized by an initial transient contraction followed by a sustained relaxation. The initial contraction was inhibited by the neural blocker tetrodotoxin, the nicotinic antagonist hexamethonium, and the muscarinic antagonist atropine, but not by a substance P receptor antagonist or a bombesin receptor antagonist. The relaxation response to DMPP was not affected by tetrodotoxin, but was reduced by hexamethonium and omega-conotoxin GVIA, an inhibitor of neurotransmitter release. The relaxation response was reduced by the nitric oxide synthase inhibitor L-NAME, but not by a vasoactive intestinal peptide antagonist or propranolol. DMPP produces a biphasic response in the guinea pig gallbladder. The initial contractile response is mediated by nicotinic receptors on the cell body or axon of cholinergic nerves. The relaxation response appears to result, in part, from activation of nicotinic receptors on nerve terminals of nitric oxide-releasing nerves. These results suggest nicotinic receptors have heterogeneity in location depending on excitatory or inhibitory neuronal function.     

Littoral cell angiosarcoma of the spleen. Morphologic, immunohistochemical findings and consideration of histogenesis of a rare splenic tumor

A case of primary splenic angiosarcoma with involvement of two accessory spleens is presented. The tumor cells are immunoreactive for endothelial markers (CD 31, CD 34, factor VIII associated antigen) and express also histiocytic antigens (CD 68, lysozyme, Cat-hepsin D, alpha-1-antitrypsin, alpha-1-anti-chymotrypsin) as well as CD 8. This marker profile suggests that the presented angio-sarcoma originates from sinus cells with histiocytic and endothelial differentiation and may be regarded as the malignant variant of littoral cells angioma.     

Transmural care. A new approach in the care for terminal cancer patients: its effects on re-hospitalization and quality of life

The pharmacological properties of non-adrenergic non-cholinergic (NANC) inhibitory neurotransmission were investigated in the rabbit choledocho-duodenal junction (CDJ), using the microelectrode and tension recording methods. L-NAME (10(-4) M) and apamin (5 X 10 (-6) M) suppressed NANC relaxation evoked by electrical field stimulation (EFS) in the presence of atropine and guanethidine (each 10(-6) M) to a similar extent (to about 40% of the initial control). However, combined application of L-NAME (10(-4) M) and apamin (5 X 10(-6) M) did not abolish it. EFS also evoked biphasic inhibitory junction potentials (IJPs) consisting of initial fast and slow sustained components in the presence of atropine and guanethidine (each 10(-6) M). Apamin (5 X 10(-8)-5 X 10(-6) M) dose-dependently suppressed the initial fast component by about 70%. In contrast, L-NAME (10(-4) M) did not affect either the amplitude of IJP or the resting membrane potential. PACAP-38 (> 10(-8) M) dose-dependently hyperpolarized the smooth muscle membrane of rabbit CDJ followed by a slow repolarization to the original level. After pretreatment with apamin (5 X 10(-7) M), PACAP-38 (10(-6) M) failed to evoke membrane hyperpolarization. During repolarization in the continued presence of PACAP-38, the amplitude of initial fast component of IJP was reduced to about 40-60% of control value, while that of the slow one was unaffected. A similar suppression of initial fast component of IJP (about 40% of the control value) also occurred after application of PACAP (6-38), a PACAP antagonist, or prolonged treatment with monoclonal antibodies to PACAP-27 or PACAP-38. Furthermore, the substantial part of residual fast IJP in the presence of PACAP (6-38) was suppressed by desensitization to alpha,beta-methylene ATP (10(-3) M). These results indicate that in rabbit CDJ NANC relaxation consists mainly of apamin- and L-NAME-sensitive components, which occur in a membrane potential dependent (through membrane hyperpolarization) and independent fashion, respectively. It has further been suggested that PACAP, together with a smaller contribution of ATP, may be involved as the principal apamin-sensitive transmitter in NANC relaxation of this muscle.