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Outflow Obstruction (outflow + obstruction)
Kinds of Outflow Obstruction Selected AbstractsSevere Right Ventricular Outflow Obstruction by Right Sinus of Valsalva AneurysmECHOCARDIOGRAPHY, Issue 3 2010Anil Avci M.D. Aneurysms of the sinus of Valsalva are rarely diagnosed cardiac anomalies, occurring in 0.14%,0.96% of patients who have undergone open heart surgical procedures. The most common congenital anomalies accompanying sinus of Valsalva aneurysm (SVA) are ventricular septal defect, bicuspid aortic valve, atrial septal defect, and coarctation of aorta. We report a patient with an unruptured right SVA presenting with severe right ventricular outflow tract (RVOT) obstruction, and coexisting patent foramen ovale (PFO) with a right to left shunt. It could be assumed that the increase in right atrial pressure due to RVOT obstruction had led to a right to left shunt across the patent foramen ovale. (Echocardiography 2010;27:341-343) [source] Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: The Kyoto experienceLIVER TRANSPLANTATION, Issue 8 2006Yasumasa Shirouzu Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P = 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P = 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT. Liver Transpl 12:1224,1232, 2006. © 2006 AASLD. [source] Regional hydrodynamic gene delivery to the rat liver with physiological volumes of DNA solutionTHE JOURNAL OF GENE MEDICINE, Issue 6 2004Xiaohong Zhang Abstract Background The major barrier to the clinical application of hydrodynamic gene delivery to the liver is the large volume of fluid required using standard protocols. Regional hydrodynamic gene delivery via branches of the portal vein has not previously been reported, and we have evaluated this approach in a rat model. Methods The pGL3 plasmid with the luciferase reporter gene was used at 50 µg/ml in isotonic solutions, and was administered with a syringe pump for precise control of the hydrodynamic conditions evaluated. Gene expression was individually measured in six anatomically distinct liver lobes. The effect of systemic chloroquine to promote endocytic escape and a (Lys)16 -containing peptide to condense the DNA into ,100-nm nanoparticles was also evaluated. Results Hydrodynamic conditions for excellent gene delivery were obtained by using 3-ml volumes (,12 ml/kg) of isotonic DNA solution delivered at 24 ml/min to the right lateral lobe (,20% of the liver mass). Under these conditions, >95% of gene delivery usually occurred in the targeted right lateral lobe. Outflow obstruction was essential for gene delivery, both at optimal and at very low levels of hydrodynamic gene delivery. The use of systemic chloroquine to promote endocytic escape did not augment hydrodynamic gene delivery, while condensation of DNA in non-ionic isotonic solutions (5% dextrose) to nanoparticles of ,100 nm completely abolished gene delivery. Conclusions Regional hydrodynamic gene delivery via a branch of the portal vein offers a physiological model of liver gene therapy, for experimental and clinical application. Copyright © 2004 John Wiley & Sons, Ltd. [source] Myocardial growth before and after birth: clinical implications,ACTA PAEDIATRICA, Issue 2 2000AM Rudolph Perinatal changes in myocardial growth have recently evoked considerable interest with regard to cardiac chamber development with congenital cardiac lesions and to myocardial development in preterm infants. It is suggested that cardiac chamber development is influenced by blood flow. Experimental pulmonary stenosis in fetal lambs may induce either greatly reduced or markedly increased right ventricular volume. Ventricular enlargement appears to be associated with a large ventricular volume load resulting from tricuspid valve regurgitation. A small competent tricuspid valve is associated with reduced flow through the ventricle due to outflow obstruction and a small right ventricle. Postnatal growth of the ventricles in congenital heart disease is discussed. Increase in myocardial mass prenatally is achieved by hyperplasia, both during normal development and when myocardial mass is increased by right ventricular outflow obstruction. Postnatally, increases in myocardial mass with normal growth, as well as with ventricular outflow obstruction, are largely due to hypertrophy of myocytes. Myocardial capillary numbers do not increase in proportion with myocyte numbers in ventricular myocardium in association with outflow obstruction. The postnatal effects of these changes in congenital heart lesions are considered. Studies in fetal lambs suggest that the late gestational increase in blood cortisol concentrations is responsible for the change in the pattern of myocardial growth after birth. The concern is raised that prenatal exposure of the premature infant to glucocorticoids, administered to the mother to attempt to prevent hyaline membrane disease in the infant, may inhibit myocyte proliferation and result in a heart with fewer than normal myocytes. This would necessitate that each myocyte would have to hypertrophy abnormally to achieve a normal cardiac mass postnatally. [source] Expanding field of purinergic signalingDRUG DEVELOPMENT RESEARCH, Issue 1-2 2001Geoffrey Burnstock Abstract This article attempts to paint a broad picture of the extraordinary explosive recent developments in the purinergic signaling field. After a brief historical review and update of purinoceptor subtypes, the focus is on the physiological roles of purines and pyrimidines. These are considered both in terms of short-term signaling in neurotransmission, secretion, and vasodilatation and in long-term (trophic) signaling in development, regeneration, proliferation, and cell death. Examples of trophic signaling include cartilage development in limb buds, glial cell proliferation, development of skeletal muscle, changes in receptor expression in smooth-muscle phenotypes, maturation of testicular spermatids, and bone remodeling. Plasticity of purinoceptor expression in pathological conditions is described, including the increase in the purinergic component of parasympathetic nervous control of the human bladder in interstitial cystitis and outflow obstruction and in sympathetic cotransmitter control of blood vessels in hypertensive rats, the appearance of P2X7 receptors in the glomeruli of the kidney from diabetic and transgenic hypertensive animal models, and up-regulation of P2X1 and P2Y2 receptor mRNA in hearts of rats with congestive heart failure. The role of P2X3 receptors in nociception is considered, and a new hypothesis about purinergic mechanosensory transduction in the gut is explored. A personal view of some of the areas ripe for future development concludes this article, including a discussion of different strategies that could lead to the development of purinergic therapeutic agents. Drug Dev. Res. 52:1,10, 2001. © 2001 Wiley-Liss, Inc. [source] Effect of Alcohol-Induced Septal Ablation on Left Atrial Volume and Ejection Fraction Assessed by Real Time Three-Dimensional Transthoracic Echocardiography in Patients with Hypertrophic CardiomyopathyECHOCARDIOGRAPHY, Issue 7 2008Fadi G. Hage M.D. Alcohol-induced septal ablation (AISA) is an accepted treatment for hypertrophic cardiomyopathy (HCM) patients with left ventricular (LV) outflow obstruction who are unresponsive to medical therapy. As left atrial (LA) enlargement has been correlated with increased morbidity and mortality in HCM, we assessed LA volumes and ejection fraction (EF) prior to and after AISA using real time three-dimensional (3D) transthoracic echocardiography (TTE) in 12 patients (9 women; mean age 52 ± 15 years; 11 Caucasian). All patients underwent successful AISA with no complications and their resting left ventricular outflow gradients decreased from 40.5 ± 22.2 to 9.1 ± 17.6 mmHg (P < 0.001) while their gradients with provocation decreased from 126.2 ± 31.7 to 21.8 ± 28.0 mmHg (P < 0.001). All patients showed improvements in their New York Heart Association (NYHA) functional class. Both the LA end-systolic (45.2 ± 12.9 to 37.2 ± 13.7 ml, P < 0.0001) and end-diastolic (79.6 ± 18.9 to 77.1 ± 18.6 ml, P = 0.001) volumes decreased after AISA. The LA EF increased from 43.1 ± 9.0 to 52.5 ± 8.8% (P = 0.001). The increase in LA EF correlated with the decrease in the resting left ventricular outflow gradient (R =,0.647, P = 0.03). In conclusion, 3D echocardiography can be utilized to follow LA function after AISA for HCM. AISA results in clinical improvement in patients with HCM and in improvement of LA EF that is correlated with the decrease in the left ventricular outflow gradient. [source] ECHO ROUNDS: Percutaneous Balloon Valvuloplasty for Pulmonic Stenosis: The Role of Multimodality ImagingECHOCARDIOGRAPHY, Issue 2 2008Davinder S. Jassal M.D., F.R.C.P.C. Pulmonic valvular stenosis represents the most frequent cause of right ventricular outflow obstruction. Transthoracic echocardiography is the imaging modality of choice in the diagnosis, evaluation and longitudinal follow-up of individuals with pulmonic stenosis (PS). Although valvular PS is usually diagnosed by two-dimensional imaging, Doppler echocardiography allows for the quantification of severity of the valvular lesion. In patients with limited acoustic windows, computed tomography and cardiac magnetic resonance imaging may provide complementary anatomical characterization of the pulmonic annulus and valve prior to percutaneous balloon valvuloplasty. [source] Critical Left Ventricular Outflow Tract Obstruction Due to Accessory Mitral Valve TissueECHOCARDIOGRAPHY, Issue 2 2000RAFFAELE CALABRO M.D. Left ventricular outflow tract (LVOT) obstruction due to anomalous tissue tag arising from the mitral valve is a rare congenital cardiac anomaly. It generally becomes symptomatic during the first decade of life as exercise intolerance, chest pain, or syncope at effort. To date, only a few cases of critical systemic obstruction due to isolated mitral valve anomaly in neonates have been reported. We report the case of a neonate who was a few hours old and was referred in severe clinical condition due to critical left ventricular outflow obstruction resulting from an anomalous tissue tag of mitral valve origin. [source] Botulinum toxin injection therapy in the management of lower urinary tract dysfunctionINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2006A. K. PATEL Summary We have great pleasure in introducing this supplement containing a collection of articles reviewing the contemporary clinical management of functional disorders of the lower urinary tract (LUT) with particular emphasis on the potential role of botulinum toxin injection therapy. Detrusor sphincter dyssynergia (DSD), detrusor overactivity (DO), painful bladder syndrome (PBS) and LUT symptoms consequent on bladder outflow obstruction (LUTS/BPH) have all been treated by the injection of botulinum toxin. This treatment can be administered as a minimally invasive, outpatient procedure which on the initial trials for DO (particularly of neurogenic aetiology) shows a remarkable efficacy with effects lasting up to a year after a single treatment with few significant side effects. Success has been reported with the management of detrusor sphincter dyssynergia and preliminary series report positive outcomes in the management of PBS and LUTS/BPH. However, most of the studies to date include small numbers and have a recruitment bias with few randomised controlled trials having been reported. The answers to some of the key questions are addressed with reference to our contemporary knowledge. It is clear that considerable work both clinical and basic science still needs to be performed to answer the many remaining questions with regard to this treatment modality but undoubtedly it will be a major future treatment option in those with intractable symptoms or those unable to tolerate medications. Currently, all botulinum toxin use for urological conditions is off-label and unlicensed, therefore caution should be exercised until future large randomised studies are reported. [source] A 5-year audit of haemodialysis accessINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 7 2005J. A. Akoh Summary This is a review of our experience with vascular access procedures over a 5-year period at Derriford Hospital, Plymouth, UK. The aims of the study were to examine the outcome of vascular access procedures and factors influencing access survival. Between April 1995 and March 2000, 151 patients who underwent 221 vascular access procedures were studied. Of these, 136 had autogenous arteriovenous fistulae, whereas 85 had prosthetic AV grafts (41% in the thigh). The overall primary failure rate was 21% whereas the 1- and 5-year cumulative access survival rates were 60 and 41%, respectively. Thigh grafts have a mean survival of 36 months compared with 32 months for prosthetic upper limb and 43 months for autogenous fistulae. Age, diabetes and predialysis status did not significantly influence access survival. Thrombosis was responsible for access failure in 62 cases (28%). Avoiding subclavian vein canulation and performing vessel mapping prior to access placement should reduce the risk of access failure due to outflow obstruction. [source] ,1 -Adrenoceptor subtypes and lower urinary tract symptomsINTERNATIONAL JOURNAL OF UROLOGY, Issue 3 2008Debra A Schwinn Abstract: Benign prostatic hyperplasia (BPH) is a common cause of urinary outflow obstruction in aging men leading to lower urinary tract symptoms (LUTS). ,1 -Adrenoceptors (,1ARs) antagonists (blockers) have become a mainstay of LUTS treatment because they relax prostate smooth muscle and decrease urethral resistance, as well as relieving bladder LUTS symptoms. A review of key recent clinical trials suggests new insights into the role of specific ,1AR subtypes in the treatment of LUTS. [source] The Results of Probe Technique for Transatrial Repair of Tetralogy of FallotJOURNAL OF CARDIAC SURGERY, Issue 6 2002Ahmet Turan Yilmaz M.D. The most critical point in transatrial repair of TOF is infundibular dissection. Right atrial approach provides better surgical exposure for parietal extension of the infundibular septum when compared to a right ventricular approach. However, it is not always easy to determine the localization and amount of muscle bundles to be resected and this surgical maneuver requires experience. Methods: Nineteen patients were reviewed who had repair of isolated TOF by this technique from 1993 to 2001. The mean age of patients was 5 ± 2 years . Transatrial-transpulmonary approach was performed for all patients. To make the infundibular muscle-bundle resection easier and to determine the localization and amount of muscle bundle to be resected, we placed a Hegar dilator into the right ventricle through pulmonary arteriotomy. The muscle bundles between the dilator and the anterior leaflet annulus of the tricuspid valve were totally excised until the intraventricular part of the dilator and pulmonary annulus became completely visible. The area between the Hegar dilator and the margins of the ventricular septal defect (VSD) was left untouched. None of the patients had transannular patch. Tricuspid valve detachment in order to improve the exposure was done in 11 patients. All patients were followed up in our clinic at regular six-month intervals by echocardiography. Results: There was no early or late mortality nor reoperation for residual VSD or residual right ventricle (RV) outflow obstruction. All patients were in NYHA class I. RV on the echocardiography was spared late dilatation and had a good late functional status. Eighteen patients had no or mild pulmonary regurgitation. One patient who had undergone tricuspid anterior leaflet detachment showed mild tricuspid insufficiency. Conclusions: On the basis of hemodynamic outcomes, this procedure for elective repair of TOF in selected cases gives excellent early and mid-term results.(J Card Surg 2002;17:490-494) [source] Unusual hepatic-portal-systemic shunting demonstrated by Doppler sonography in children with congenital hepatic vein ostial occlusionJOURNAL OF CLINICAL ULTRASOUND, Issue 4 2004Maha Barakat MD Abstract Purpose This report describes unusual changes in the hepatic vasculature in 3 children presenting with upper gastrointestinal hemorrhage. Methods The study included 3 children (ages 5,8 years) who presented with hematemesis. All had mild hepatosplenomegaly and normal liver function. Esophageal varices were demonstrated in all on upper endoscopy. Color and spectral Doppler sonography was performed to assess the hepatic vasculature, including the hepatic veins (HVs), portal vein (PV), hepatic artery (HA), and inferior vena cava (IVC). Results The HVs were all patent but with ostial occlusion at the point of their communication with the IVC. Complete flow reversal was shown inside the HVs, with blood draining into collateral vessels at the liver surface and paraumbilical vein. In one patient, the paraumbilical vein could be traced to its communication with the right external iliac vein. In all children, the direction of flow in the PV, HA, and IVC was normal. After endoscopic sclerotherapy, all children were shown to be in good general condition and to have normal liver function for a follow-up period of 15,36 months. Conclusions Ostial occlusion of the HV is a rare cause of hepatic outflow obstruction in children. Doppler sonography is a valuable, noninvasive imaging technique for evaluation of the hepatic vasculature and the accompaning shunting pathways in such cases. © 2004 Wiley Periodicals, Inc. J Clin Ultrasound 32:172,178, 2004; Published online in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/jcu.20019 [source] Color Doppler sonographic signs of respiration-dependent hepatofugal portal flowJOURNAL OF CLINICAL ULTRASOUND, Issue 2 2004Christian Görg MD Abstract Purpose The role of respiration in modulating blood flow in the portal vein is unclear. The aim of this study was to investigate the phenomenon of respiration-dependent periodic hepatofugal portal venous blood flow as detected on color Doppler sonography. Methods Within 1 year, we identified 13 patients with respiration-dependent reversal of blood flow in the portal vein that was diagnosed on color Doppler sonography. This phenomenon was investigated by color Doppler sonographic examination of the portal venous flow during both mid-inspiration breath-holding and a respiratory cycle including deep inspiration; evaluation of hepatic vein Doppler waveforms as normal (triphasic) or decreased (flattened); and echocardiographic examination to determine the presence or absence of tricuspid regurgitation. Results The patients' median age was 53 years (range, 26,87 years). Seven of the 13 patients had heart disease (tricuspid regurgitation) with or without liver disease, 3 had liver disease without heart disease, and 3 had other diseases with no evidence of heart or liver disease. On Doppler sonography, 10 of the 13 patients had increased portal venous pulsatility (7 of the 10 had tricuspid regurgitation; the other 3 did not); the remaining 3 patients had neither increased pulsatility nor tricuspid regurgitation. Sonographic follow-up within 4 weeks in 4 of the 13 patients revealed loss of the respiration-dependent hepatofugal portal flow. Conclusions Respiration-dependent hepatofugal portal flow is a rare finding associated with periodic portal hypertension in patients with right heart insufficiency and liver disease. Its clinical significance is unclear. Among our patients, its occurrence was predominantly associated with an increased venous pulsatility index due to tricuspid regurgitation or venous outflow obstruction. Further study is needed to investigate whether periodic respiration-dependent hepatofugal portal flow is predictive of the occurrence of continuous flow reversal. © 2004 Wiley Periodicals, Inc. J Clin Ultrasound 32:62,68, 2004 [source] An Analysis of Possible Mechanisms of Unexpected Death Occurring in Hydatid Disease (Echinococcosis)JOURNAL OF FORENSIC SCIENCES, Issue 4 2009Roger W. Byard M.B.B.S. Abstract:, Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis. [source] Median liver lobe of woodchuck as a model to study hepatic outflow obstruction: a pilot studyLIVER INTERNATIONAL, Issue 9 2008Uta Dahmen Abstract Background: Hepatic vein outflow obstruction represents an important clinical problem in living-liver transplantation. An animal model is required to study the influence of outflow obstruction on the intrahepatic regulation of liver perfusion and the subsequent effects on liver injury and recovery during liver regeneration. The size of woodchucks enables the use of standard clinical imaging procedures. Aim: This study aims at describing hepatic vascular and territorial anatomy of the woodchuck liver based on a virtual three-dimensional (3D) visualization of the hepatic vascular tree. Methods: Woodchucks (n=6) were subjected to an all-in-one computed tomography (CT) after contrasting the vascular and the biliary tree. CT-images were used for 3D-reconstruction of hepatic and portal veins and calculation of the corresponding portal and hepatic vein territories and their respective volume using hepavision (MeVisLab). A virtual resection was performed following the Cantlie-line and territories at risk were calculated. Results: The median lobe of the woodchuck liver has a similar vascular supply and drainage as the human liver with two portal (right and left median portal vein) and three hepatic veins (left, middle and right median hepatic vein). The corresponding portal and hepatic vein subterritories are of a similar relative size compared with the human liver. Virtual splitting of the median lobe of the woodchuck liver revealed areas at risk of focal outflow obstruction, as observed clinically. Conclusion: The median liver lobe of the woodchuck represents, to a small extent, the hepatic vascular anatomy of the human liver and is therefore a suitable potential model to correlate repeated imaging of impaired liver perfusion with histomorphological findings of liver damage and regeneration. [source] Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left-sided lobe grafts: Kyoto university experience,LIVER TRANSPLANTATION, Issue 10 2010Seisuke Sakamoto The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left-sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left-sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient-to-donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor-recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long-term patency of stents and stent-related complications. New stenting devices, such as drug-eluting and biodegradable stents, may be promising for the management of HVOO. Liver Transpl 16:1207,1214, 2010. © 2010 AASLD. [source] Sclerosing peritonitis and mortality after liver transplantationLIVER TRANSPLANTATION, Issue 4 2009Kristin Mekeel Sclerosing peritonitis describes the development of a peel or rind of fibrosis that spreads over the peritoneal surface and can lead to recalcitrant ascites, bowel obstruction, and sepsis. It is well described as a complication of peritoneal dialysis, especially with episodes of bacterial peritonitis. It is also a complication of end-stage liver disease with ascites and liver transplantation. This article describes 3 cases of sclerosing peritonitis present at the time of liver transplantation or soon after. All 3 patients had massive refractory ascites with episodes of spontaneous bacterial peritonitis prior to transplantation. Two patients had evidence of a fibrous peel at the time of transplantation. Postoperatively, all 3 patients continued to have refractory ascites and episodes of peritonitis, along with partial small bowel obstructions, abdominal pain, and malnutrition. Two patients also had constriction of the graft, including biliary obstruction and inferior vena cava and outflow obstruction, which has not been previously described. All 3 patients eventually died from complications related to the sclerosing peritonitis. Liver Transpl 15:435,439, 2009. © 2008 AASLD. [source] Venous outflow obstruction in liver transplantation is associated with the anastomotic techniqueLIVER TRANSPLANTATION, Issue 12 2007James D. Perkins M.D. Special Editor The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation. [source] Isolated right hepatic vein obstruction after piggyback liver transplantationLIVER TRANSPLANTATION, Issue 5 2006Federico Aucejo The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms. Liver Transpl 12:808,812, 2006. © 2006 AASLD. [source] Amelioration of hypertrophic cardiomyopathy using nonsurgical septal ablation in a cirrhotic patient prior to liver transplantationLIVER TRANSPLANTATION, Issue 2 2005Anil S. Paramesh A 53-year-old male with hepatitis C cirrhosis, who had been refused liver transplantation because of hypertrophic cardiomyopathy (HC), underwent nonsurgical septal ablation using alcohol with resolution of his ventricular outflow obstruction. This patient was able to subsequently undergo a successful deceased donor liver transplantation. This is the first reported case of alcohol induced septal ablation being performed in a cirrhotic patient with HC. Such nonsurgical procedures may be attractive in cirrhotic patients who are refused access to liver transplantation because of high surgical risk. (LiverTranspl 2005;11:236,238.) [source] Live donor liver transplantation for fulminant hepatic failure in childrenLIVER TRANSPLANTATION, Issue 11 2003Chi-Leung Liu The mortality rate among children with fulminant hepatic failure (FHF) on the waiting list for cadaveric donor liver transplantation (CDLT) is high. Results of emergency CDLT in this situation often are unsatisfactory, and a long-term survival rate less than 30% has been reported. Live donor liver transplantation (LDLT) for FHF in children has been advocated, but is reported rarely. We present our experience with LDLT in children with FHF. Between September 1993 and December 2002, primary LDLT was performed for 26 children; 8 of these children had FHF. Patient demographics, clinical and laboratory data, surgical details, complications, and graft and patient survival are reviewed. Four boys and four girls received left-lateral segment (n = 7) and full left-lobe (n = 1) grafts. Mean age was 2.9 ± 1.2 years (range, 3 months to 11 years). Causes of FHF were drug induced in 2 patients and idiopathic in 6 patients. One child received a blood group-incompatible graft. Two patients died; 1 patient of cytomegalovirus infection at 8.6 months and 1 patient of recurrent hepatitis of unknown cause at 2.8 months after LDLT. The child who received a mismatched graft had refractory rejection and underwent a second LDLT with a blood group-compatible graft 19 days afterward. He eventually died of lymphoproliferative disease. Another patient developed graft failure related to venous outflow obstruction and survived after retransplantation with a cadaveric graft. With a median follow-up of 13.2 months (range, 2.8 to 60.3 months), actuarial graft and patient survival rates were 50% and 62.5%, respectively. Survival results appear inferior compared with those of 18 children who underwent LDLT for elective conditions during the same study period (graft survival, 89%; P = .051; patient survival, 89%; P = .281). Although survival outcomes are inferior to those in elective situations, LDLT is a timely and lifesaving procedure for children with FHF. [source] Outflow reconstruction in recipients of right liver graft from living donorsLIVER TRANSPLANTATION, Issue 2 2002Yasuhiko Sugawara MD Right-lobe transplantation is now a commonly used procedure in living donor liver transplantation (LDLT) to adult recipients. However, the risk for outflow obstruction is still an issue in LDLT. The right hepatic vein (RHV) was anastomosed end to end to the graft hepatic vein without unfavorable tension on the anastomosis. The anterior wall of the recipient hepatic vein was incised longitudinally, and a V-shaped vein graft was patched to form a wide and long orifice. This new hepatic venoplasty was used in 14 adult patients who received right liver grafts and gave good results without stenosis of the hepatic venous anastomosis or other complications. Our new technique may be useful in recipients of a right liver graft when the recipient or graft RHV is not long enough. [source] Clinical and experimental aspects of Adreno-muscarinic synergy in the bladder base and prostate,,NEUROUROLOGY AND URODYNAMICS, Issue 8 2009Alexander Roosen Abstract Recent clinical trials have shown that combination therapy using an alpha-receptor antagonist and an antimuscarinic is more effective than either agent alone in improving quality of life and objective urodynamic variables in men with bladder outflow obstruction. There appear to be no negative effects on bladder function. The mode of action of this combination is unknown but presumed to be an antimuscarinic reduction in detrusor overactivity and the alpha-receptor antagonist reduced outflow tract resistance. We have shown with in vitro experiments that in smooth muscles influencing outflow tract resistance (prostate, trigone) there is a profound contractile synergy between adrenergic and muscarinic pathways. We propose the hypothesis that both arms of the combination therapy reduce contractile tone of the outflow tract and that their simultaneous attenuation has a disproportionately large effect on outflow tract resistance. Our data from trigone muscle suggest that adrenergic and muscarinic receptor activation increase the intracellular [Ca2+] but the adrenergic pathway also operates through Ca2+ -sensitisation of the contractile apparatus, primarily through a PKC-dependent pathway. Neurourol. Urodynam. 28:938,943, 2009. © 2009 Wiley-Liss, Inc. [source] The effect of familial aggregation on the children with primary nocturnal enuresisNEUROUROLOGY AND URODYNAMICS, Issue 5 2009Qing Wei Wang Abstract Objective To evaluate the effect of familial aggregation on the children with PNE by evaluating nocturnal urine output, bladder, and arouse function. Patients and Methods According to whether relatives of family of probands over three generations were affected by PNE, forty-five children with familial aggregation PNE (FPNE), seventy children with sporadic PNE (SPNE) and ten children with normal lower urinary tract function but waiting for operation (control group) were included. Questionnaire of arousal from sleep (AS scores), bladder diary and daytime urodynamic studies were performed in all patients. Results The incidences of severe PNE and nonmonosymptomatic PNE in FPNE group were significantly higher than those in SPNE group. The nocturnal urine output and AS scores in both PNE groups was significantly higher, maximal voided volume significantly smaller than those in control group. Moreover, the incidences of small bladder in FPNE group was 44%, significantly higher than that in SPNE group (21%), but no significantly difference was found in nocturnal polyuria and arousal AS scores between two PNE groups. There were 53% patents with daytime detrusor overactivity and 60% patents with urodynamic functional bladder outflow obstruction in FPNE group, significantly higher than those in SPNE group (19% and 37%). Maximum cystometric capacity significantly decreased from control group to FPNE group. Conclusion Familial aggregation has significant effects on the children with PNE, and FPNE are more likely to be severe symptoms and bladder dysfunction. It would be beneficial to have an urodynamic study for their diagnosis and treatment. Neurourol. Urodynam. 28:423,426, 2009. © 2008 Wiley-Liss, Inc. [source] Update on the neurology of Parkinson's disease,NEUROUROLOGY AND URODYNAMICS, Issue 1 2007Clare J. Fowler Abstract The differential diagnosis of a patient with apparent Parkinson's Disease (PD) and bladder symptoms is considered and the bladder dysfunction of Multiple System Atrophy (MSA) is reviewed. Recent insights into the progression of the neuropathology of PD have enabled thinking about the stage of the disease at which bladder dysfunction is likely to occur and the expected clinical context of the problem. Bladder symptoms of neurological origin are likely in a patient who has had treated motor symptoms for some years and in whom the ongoing neuropathology has progressed beyond involvement of the basal ganglia, so that symptoms due to cortical dysfunction as well as the adverse effects of dopaminergic medication are also confounding factors. Bladder symptoms in a man with lesser neurological disability should be investigated to exclude underlying outflow obstruction. Possible management options are considered. Neurourol. Urodynam. © 2006 Wiley-Liss, Inc. [source] Management of critically ill children with traumatic brain injuryPEDIATRIC ANESTHESIA, Issue 6 2008GILLES A. ORLIAGUET MD PhD Summary The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra-cranial injuries. Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans-cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure , intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age-related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation,analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first-tier ICP-specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second-tier therapy (profound hyperventilation with PaCO2 < 35 mmHg, high-dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan. [source] Successful stent placement for hepatic venous outflow obstruction in pediatric living donor liver transplantation, including a case series reviewPEDIATRIC TRANSPLANTATION, Issue 4 2009Seisuke Sakamoto Abstract:, HVOO may lead to graft dysfunction in LDLT. Balloon angioplasty is the first treatment for HVOO. However, some cases with recurrent HVOO need multiple interventions and require stent placement. The authors describe a pediatric case with recurrent HVOO requiring multiple stent placements. Her symptoms related to HVOO finally disappeared after the third stenting. A year later, follow-up liver biopsy did not show any dramatic change in perivenular fibrosis. From a review of our pediatric cases with HVOO requiring stent placement, the majority of them lost the grafts, because the timing of stent placement was too late to prevent the progression of fibrosis. In conclusion, stent placement should be considered in select cases of HVOO. Serial liver biopsies evaluating the degree of fibrosis are essential in determining the timing of stent placement. [source] Disturbed morphogenesis of cardiac outflow tract and increased rate of aortic arch anomalies in the offspring of diabetic ratsBIRTH DEFECTS RESEARCH, Issue 12 2004Daniël G.M. Molin Abstract BACKGROUND Maternal diabetes (MD) is a risk factor for offspring to develop cardiovascular anomalies; this is of growing clinical concern since the number of women in childbearing age with compromised glucose homeostasis is increasing. Hyperglycemia abrogates cardiovascular development in vitro; however, a link to cardiovascular defects in diabetic offspring remains to be investigated. METHODS We have studied cardiovascular development in offspring of MD rats by examining serial histological sections of GD 12.0,18.0 offspring. Development of pharyngeal arch artery malformations was analyzed and related to intracardiac anomalies. RESULTS Pharyngeal arch artery and intracardiac defects were present in 27 of 37 MD GD 13.0,18.0 offspring. Early sixth arch arteries showed abrogated arteriogenesis, whereas fourth arch artery defects developed as a result of abnormal remodeling. Morphometrical analysis showed increased apoptosis in regressing artery segments and reduced apoptosis in persisting artery segments. Double outlet right ventricle with infundibular stenosis (tetralogy of Fallot) was predominantly found in combination with sixth artery defects and pulmonary atresia. As confirmed by morphometric analysis and three-dimensional (3D)-reconstructions, outflow tract defects coincided with endocardial cushion hypoplasia. Cases with teratology of Fallot additionally showed a shorter outflow tract. No relation with apoptosis or disturbed neural crest cell migration was found. CONCLUSIONS Our data uniquely demonstrate mechanistic differences involved in the development of sixth and fourth artery anomalies. Whereas increased apoptosis induces fourth artery anomalies, pulmonary outflow obstruction abrogates sixth artery differentiation independent of apoptosis. The model presented allows analysis of diabetic conditions on cardiovascular development in vivo, essential for elucidating this teratology. Birth Defects Research (Part A), 2004. © 2004 Wiley-Liss, Inc. [source] The comparative pressure-flow plot properties of radiological bladder neck and prostatic obstructionBJU INTERNATIONAL, Issue 11 2009Sanjin Idriz OBJECTIVES To test the hypotheses that: (i) significant differences should exist in pressure/flow data between radiologically determined bladder neck and prostatic obstruction; (ii) these differences should inform understanding of the pathophysiology of male outflow obstruction. The biomechanics of the voiding/pressure/flow plot imply that a urodynamic assessment trace should identify outflow obstruction and characterise the urethral viscoelastic properties. Micturating cystourethrograms (MCUG) images might provide a useful diagnostic dichotomy for testing these assumptions. MATERIALS AND METHODS The pressure/flow data from 71 men who also provided video-urodynamic imaging data that a radiologist could classify unequivocally as showing bladder neck obstruction (42) or prostatic obstruction (29) were analysed. The following variables were recorded: the detrusor pressure at initiation of voiding (Pdet.open); the detrusor pressure at the end of voiding (Pdet.close); the detrusor pressure at maximum flow rate (Qmax), (Pdet.Qmax), and Qmax. The urethral resistance relation (URR) was drawn onto the pressure-flow plot and the gradient of the URR, ,Pdet/,Q, was calculated. RESULTS There were significant between group differences in Pdet.open (95% confidence interval of the difference 5.2,28.6, U = 352, P = 0.003); Pdet.close (0.2,15.0, U = 428, P = 0.034); Pdet.Qmax (0.0,18.9, U = 439, P = 0.05); Qmax and ,Pdet/,Q did not distinguish between the MCUG groups (95% confidence interval of the difference 2.3,18, U = 111; P = 0.004). The best-fit model from linear combinations of the data achieved an area under the receiver operator curve of 0.72 for discriminating between the MCUG groups. CONCLUSIONS The urodynamic assessment identified interesting and coherent biomechanical differences, and could distinguish between the obstructions with a moderate degree of accuracy. [source] | |||||||||||||||||||||||||||||||