Coronary artery fistulas (CAF) are rare, and are most often diagnosed by echocardiography or by coronary angiography. The incidence of this disease is very low, with a more frequent occurrence of fistulas originating in the right coronary artery. There is a higher incidence of CAF to right heart chambers, with CAF to the left ventricle (LV) being rare. Treatment can be surgical or percutaneous [1]. This report describes a case of CAF to the right ventricle (RV) resulting in severe pulmonary hypertension, in a patient with end-stage renal disease (ESRD) on hemodialysis and rheumatoid arthritis [2]. The patient had a history of hypertension for over 30 years [3]. Computed tomographic pulmonary angiography ruled out pulmonary embolism, but it suggested a coronary fistula to the RV cavity.A 61-year-old woman was referred for cardiac evaluation for chest pain and worsening dyspnea. The patient was on maintenance hemodialysis for the prior 2 years owing to ESRD. Clinical examination revealed tachycardia, crackles at both bases with no wheezes, rhonchi, or other adventitious sounds, a blood pressure of 160/70 mmHg. The patient had a radio-cephalic fistula constructed at the left wrist between the radial artery and the cephalic vein, using end-to-end anastomosis. An electrocardiogram showed evidence of a right bundle branch block, and signs of ventricular overload. Cross-sectional echocardiography with Doppler interrogation revealed a left ventricular ejection fraction of 55 %, and there was evidence of diastolic dysfunction, without important calcification or regurgitation of the valves.The right atrium and ventricle were dilatated ( Fig. 1a) with an abnormal flow jet pointed to the RV (Fig. 1b), and evidence of severe systolic pulmonary hypertension (PHT) (Fig. 1c) estimated to be 80 mmHg on continuous wave Doppler. There was moderate tricuspid regurgitation with RV function moderately depressed (tricuspid anular plane systolic excursion: 13 mm) [4]. To obtain precise information on the cause of the PHT, a 64-slice multidetector computed tomography (MDCT) was performed. MDCT confirmed right heart dilatation and revealed a CAF connecting the anterior descending artery to the RV cavity without any evidence of pulmonary thromboembolism (Fig. 1d). A coronary angiography showed an enlarged and tortuous aneurysm with a CAF (Fig. 1e) that protruded into the RV, with immediate closure percutaneous with a detachable helical coil (Fig. 1f). We doubt that it was a secondary form, manifested as a result of treatment of hemodialysis causing right heart failure.
Hypothesis/Introduction: The aim of this study was to assess the antihypertensive efficacy and safety of aliskiren versus ramipril or losartan in hypertensive patients with type 2 diabetes mellitus, microalbuminuria and uncontrolled hypertension, despite the use of optimal conventional antihypertensive therapy. Materials and methods: In this open-label active comparator study, 126 patients were randomly assigned to receive 24 weeks of additional therapy with aliskiren (Group A) or either losartan or ramipril (Group B), according to whether a patient was already treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, respectively. Results: After 24 weeks, both treatment groups experienced a significant reduction of systolic blood pressure (−11.37% and −8.47%, respectively; both p <0.001 vs. baseline) and diastolic blood pressure levels (−10.67% and −9.28%, respectively; both p <0.001 vs. baseline), with a greater reduction of mean systolic values in Group A compared with Group B (p <0.001). Furthermore, after six months microalbuminuria was significantly decreased in both treatment groups (−67.62% and −49.1%, respectively; both p <0.001), with a reduction rate in Group A significantly higher than in Group B (p<0.001). Conclusions: The addition of aliskiren to optimal conventional therapy provided a higher reduction of blood pressure and urinary albumin excretion when compared with the addition of losartan or ramipril.
Two observations of intrinsic third ventricle craniopharyngiomas, both involving males in the fifth decade, are reported. Histologically, the tumours, one entirely solid and the other one chiefly cystic, were composed of squamous epithelium with microcysts and no calcifications. In the literature primary third ventricle craniopharyngiomas are considered to be exceedingly rare. However, if a more precise preoperative diagnosis, using computerised axial tomography, were made as a matter of routine, to verify third ventricular masses, it might demonstrate that these tumours are more common than previously believed. In both cases striking clinical pictures of normal pressure hydrocephalus were observed. The relations between intracranial pressure, CSF circulation and ventricular size are discussed. On mechanical grounds, it is very difficult to explain the poastoperative reduction in ventricular size, since there was no significant change in intracranial pressure.
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