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Helpful differentiating features of osteosarcoma from myxoma include a broad base of attachment and signs of aggressive behavior including involvement of regional veins impotence definition inability discount 100/60mg viagra with dapoxetine, pericardium erectile dysfunction 9 code purchase viagra with dapoxetine, and mitral valve erectile dysfunction drugs with the least side effects purchase viagra with dapoxetine 50/30 mg amex. C erectile dysfunction in young males causes buy cheap viagra with dapoxetine 50/30mg line, Surgical specimen of opened left atrium shows a polypoid mass occupying the chamber with components of necrosis, hemorrhage, and cystic change. Manifestations of Disease Clinical Presentation Clinical presentation includes symptoms of dyspnea, congestive heart failure, mitral valve obstruction, pulmonary hypertension, and syncope. Manifestations of Disease Clinical Presentation Clinical presentation varies because the tumor may arise in any part of the heart, extend into the nearest chamber, and ultimately cause valvular obstruction. Histologic appearance of the tumor is essentially indistinguishable from cardiac metastasis of skeletal osteosarcoma, but metastatic osteosarcoma is usually deposited in the right atrium, whereas primary cardiac osteosarcoma arises in the left atrium. Ultrasonography Transesophageal or transthoracic echocardiography may reveal intramural involvement by rhabdomyosarcoma (solitary or multifocal), intracavitary extension, and the impact on an adjacent cardiac valve. These tumors tend to enhance heterogeneously after contrast medium administration, with focal nonenhancement in necrotic areas. Mean age at presentation ranges from 14 to 30 years, which is decades younger than other sarcomas. Sexual predilection (male-to-female) is contradicted in separate case series (2: 4 or 3: 2) and is inconclusive. Pathology On gross examination, these tumors are located within the myocardium and tend to exhibit necrotic areas. Cardiac transplantation may be considered, but is excluded when distal metastases are present. Rhabdomyosarcoma has no site predilection in the heart and may be multifocal at presentation (60% of cases). In contrast to most other primary cardiac sarcomas, pericardial involvement by rhabdomyosarcoma is unusual, but valvular invasion is common. Imaging Techniques and Findings Radiography Chest radiography may be unremarkable, or the cardiac silhouette may be enlarged. A liposarcoma metastatic to the heart occurs much more frequently than primary cardiac liposarcoma. Cardiac transplantation may be considered, but is not indicated when distal metastases are present. Fat density is not always appreciated on radiologic imaging of cardiac liposarcoma, which may manifest as a heterogeneous soft tissue mass. Metastatic liposarcoma to the heart is much more common than primary cardiac liposarcoma (<1% of cardiac sarcomas). Note polypoid intracavitary extension (arrows) and pericardial involvement (arrowhead). B, Gross autopsy photograph confirms expansion of the interatrial septum by an infiltrative, pale yellow soft tissue mass (asterisk). Ultrasonography Echocardiography may reveal hypoechoic masses of the right atrium and ventricle, pericardial effusion, and, occasionally, diastolic collapse of the right heart chambers when cardiac tamponade is present. Primary cardiac tumors are far less common than metastatic disease, and most are benign histologically. Any cardiac tumor may produce, however, life-threatening cardiac rhythm disturbances, valvular entrapment, pulmonary or systemic embolization, heart failure, or sudden cardiac death. Radiologic detection, localization, morphologic assessment, and tissue characterization are crucial for the differential diagnosis and treatment planning of a cardiac mass. Important considerations include patient age, lesion location, mobility, and internal components (including calcium, fat, and necrosis). Autopsy confirmed extensive nodularity of the pericardium compatible with contiguous lymphomatous involvement. Although there are exceptions, one must also recognize the potentially distinguishing imaging features of benign versus malignant cardiac tumor. Findings suggestive of benignancy include left-sided location, well-defined lesion margins, pedunculated mural attachment (when intracavitary), and lack of associated pericardial effusion or thickening. Features suspicious for malignancy are right-sided heart location; ill-defined tumor margins; wide-based mural attachment (when intracavitary); heterogeneity (necrosis); and, most importantly, the invasion of regional structures including valves, pericardium, regional vessels, or mediastinum. Multifocal intracardiac lesions and pulmonary metastases also suggest an underlying malignant etiology. A simplified approach to the differential diagnosis of cardiac tumors is provided in Table 67-1 with helpful differentiating features listed in parentheses. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. Incidental finding of a papillary fibroelastoma on the aortic valve in 16 slice multi-detector row computed tomography. Images in cardiovascular medicine: papillary fibroelastoma of the aortic valve: appearance in 64-slice spiral computed tomography, magnetic resonance imaging, and echocardiography. Papillary fibroelastoma of the aortic valve: evaluation with transesophageal echocardiography and magnetic resonance imaging. Images in cardiovascular medicine: papillary fibroelastoma of the tricuspid valve seen on magnetic resonance imaging. Images in cardiovascular medicine: myocardial fibroma in Gorlin syndrome by cardiac magnetic resonance imaging. Images in cardiovascular medicine: late enhancement of a left ventricular cardiac fibroma assessed with gadolinium-enhanced cardiovascular magnetic resonance. Association between cardiac tumors and tuberous sclerosis in the fetus and neonate. Fetal rhabdomyoma: prenatal diagnosis, clinical outcome, and incidence of associated tuberous sclerosis complex.
Uncommon but significant complications associated with ductal closure include proximal left pulmonary Outcomes and Complications Transcatheter ductal closure procedural success has been extremely high food erectile dysfunction causes viagra with dapoxetine 100/60mg with visa, with rates of complete closure above 96% drugs for erectile dysfunction in nigeria discount 50/30mg viagra with dapoxetine amex. If left pulmonary artery stenosis is confirmed on echocardiography erectile dysfunction pump review order viagra with dapoxetine online pills, a nuclear medicine pulmonary flow scan should be obtained to evaluate the physiologic significance of the obstruction impotence test order viagra with dapoxetine 100/60 mg mastercard. Coarctation is most often a discrete narrowing of the proximal descending thoracic aorta just distal to the origin of the left subclavian artery at the site of the ductus ligamentum. It represents 7% of all patients with congenital heart disease and results in upper extremity hypertension, left ventricular hypertrophy, and eventually ventricular failure if it is left untreated. Although it is much less common, coarctation of the distal thoracic aorta or abdominal aorta does occur, often in association with vasculitis or genetic syndromes such as Williams syndrome. It should be considered during the initial evaluation of systemic hypertension and can easily be diagnosed on physical examination by decreased femoral pulses with a delay compared with radial pulses and blood pressure differential between the arms and legs. The narrowing is due to thick intimal and medial ridges that protrude posteriorly and laterally into the aortic lumen. Cystic medial necrosis with disarray and loss of medial elastic tissue occurs commonly in the adjacent aorta and may extend to the ascending aorta as well. Enlargement of the intercostal arteries due to this collateral flow is the mechanism for rib notching seen on chest radiography in older patients with severe native coarctation. Indications Any coarctation with a gradient of more than 10 mm Hg and significant upper body hypertension or left ventricular hypertrophy without additional cause should be treated. For mild coarctation, it is imperative to use stent implantation to ensure complete resolution of the mild obstruction. Mild coarctations with a gradient of less than 20 mm Hg without hypertension or left ventricular hypertrophy should be considered for stent repair if collaterals are present or the patient has an abnormal blood pressure response to exercise. Stent implantation for repair of coarctation was performed sporadically in the early 1990s in children; it was first reported in adults in 1995 with very promising results. Procedural success has been reported in more than 95% of patients, with residual obstruction of less than 20 mm Hg. Recurrent stenosis has been extremely rare, occurring in fewer than 5%, usually in younger patients, and is generally mild. Complications have been reported in up to 20% and include aneurysm, perforation, stroke, and death in fewer than 3%. Imaging Findings Preoperative Planning Echocardiography is useful to confirm the diagnosis and to evaluate location and severity of the obstruction. Special attention should be paid to the surrounding aortic diameter, including the distal transverse arch, the coarctation diameter, and the location relative to the carotid and left subclavian arteries, as well as to the presence of existing aneurysm, poststenotic dilation, and calcification. Final assessment of the coarctation is performed during the procedure with biplane angiography, including during and after balloon dilation or stent implantation. Patients with mild coarctation (<20 mm Hg) without upper body hypertension should have blood pressure checks every 6 to 12 months with ongoing surveillance for the development of left ventricular hypertrophy. Contraindications Patients with coarctation gradients of less than 20 mm Hg with no evidence of collateral flow, hypertension, left ventricular hypertrophy, or abnormal blood pressure response to exercise do not need treatment. Patients with significant hypoplasia and obstruction of the transverse aortic arch in the area of the origin of the carotids should be excluded. Stent repair with jailing of the carotids may be appropriate in the rare patient at extremely high surgical risk; however, for the majority of patients with this lesion, surgical repair should be performed. Covered thoracic stents may have a role in this setting, although there are limited data at present. Aortic wall dissection, aneurysm, and rupture associated with stent implantation are uncommon but increase in frequency with the age of the patient and the degree of aortic calcification associated with the coarctation. Postoperative Surveillance Most patients are discharged on the day after the implantation or dilation, and chest radiography should be performed before discharge to ensure stable stent placement. Because late aneurysms may occur in up to 7% as late as 10 years, ongoing imaging surveillance is required. Normal distribution of pulmonary flow is 55% to the right lung and 45% to the left lung. Patients with a reduction of more than 15% of flow or an absolute flow of less than 1 L/min/m2 in the affected lung should be considered for stent repair. Patients with any degree of contralateral pulmonary artery hypertension, right ventricular hypertension, or right ventricular hypertrophy should be aggressively treated to prevent progression, as should patients with significant pulmonary insufficiency associated with the branch pulmonary artery stenosis. Contraindications Adult patients after repair of complex congenital heart disease such as tetralogy of Fallot or truncus arteriosus are complex, often with multiple anatomic, hemodynamic, and arrhythmia issues in addition to their branch pulmonary artery stenosis. It is critical that these patients are evaluated completely and that a comprehensive plan is made in coordination with a cardiologist familiar with congenital heart disease and involving an electrophysiologist, cardiothoracic surgeon, and interventionalist. If surgical revision of the underlying repair is required, a surgical approach to the branch pulmonary artery stenosis may be preferable. Outcomes and Complications Balloon dilation of branch pulmonary artery stenosis was initially described in 1983 by Lock and colleagues27; however, only 50% of lesions responded, with a significant restenosis rate. With the availability of larger peripheral stents in the early 1990s and their application to pulmonary artery branch stenosis,28 stent placement has rapidly become the treatment of choice in school-age children and adults because of improved success and low restenosis rates. Complications are rare, occurring in fewer than 4% of cases overall, and include hemoptysis, aneurysm, perforation, refractory ventilation-perfusion mismatch, and death. Technical issues, such as device malposition and embolization, have been reported in less than 2% and are quite rare with recent improvements in balloon and stent technology. Recent use of cutting balloons has further improved results to more than 90% success for segmental pulmonary artery stenosis resistant to standard dilation and stenting techniques. Branch pulmonary artery stenosis is a rare congenital lesion in isolation but is often associated with complex congenital heart lesions after surgical repair, especially tetralogy of Fallot.
As the knowledge continues to evolve erectile dysfunction age 18 order viagra with dapoxetine 100/60mg amex, it is important for the reader to review current literature to ensure being aware of recent observations erectile dysfunction doctor boca raton buy 100/60 mg viagra with dapoxetine otc. It has been identified in patients from a variety of ethnic backgrounds from North and South America erectile dysfunction medicines order viagra with dapoxetine australia, Europe broccoli causes erectile dysfunction order cheap viagra with dapoxetine on line, Asia and Australia with the majority of reported cases occurring in the United States. The current concepts on the underlying causative factors are the combination of two factors: severe renal impairment and exposure to gadolinium. All standard, nonprotein interacting Gd-chelates are virtually entirely excreted via the kidneys; therefore any impairment leads to increased in vivo retention and circulation times. If there is no residual urine output, the only way such agents can exit the body is through dialysis. In patients with normal kidney function, the Gd-chelates are considered safe because the bond between the toxic Gd atom and its ligand molecule is very strong; however, differences between agents are established. There is a small risk that Gd atoms can unbind from their carrier ligands and the unbound "free" Gd reacts like calcium ions, most likely binding to readily-available phosphates and forming insoluble molecules. In patients who receive large doses of Gd-chelates and who do not undergo rapid and effective dialysis, there is a risk that larger amounts of these gadolinium compounds could develop and remain in the body in a form that is not readily removable. Whether there is an independent risk associated with endothelial damage or hypercoagulation remains an open question, although circulating fibrocyte migration from the blood is facilitated in both scenarios. In summary, the pathophysiological trigger and disease mechanism is still under investigation and our knowledge continues to evolve. Our community has and is evolving guidance on how to most appropriately manage this risk assessment. The issue of multiple imaging studies in short time periods is evolving as a safety concern in that potential cumulative effects are difficult to study and are frequently superimposed on other underlying medical ailments. How to most appropriately handle the medical indications to use Gd-chelates in patients with renal impairment requires a patient-specific assessment and continues to rapidly evolve. The paramagnetic gadolinium chelates can be classified according to their degree of protein interaction. The ultra-small iron oxide particles are "blood pool agents" that demonstrate long intravascular enhancement. In addition to the already identified medical conditions, special considerations need to include a review of frequency of imaging studies and potential drug to drug interactions, patient compliance, and appropriate follow-up capabilities. Although this time window is influenced by the injection/infusion protocol used, the dosage, and cardiac output, it is most importantly dependent on the kind of contrast agent used-a first pass agent or a blood-pool agent. The availability and market introduction of gadofosveset trisodium has for the first time enabled a combined clinical first pass and steady-state imaging of the vasculature. The challenges and opportunities of steady-state imaging will be discussed in other chapters of this book. Multi-vial dosing combined with patient-specific dosing can be accommodated if appropriately approved injection/infusion systems are being used. The broadest use for cardiovascular imaging is based on gadolinium chelates which can be subclassified into agents revealing no interaction with proteins, those that have weak temporary interaction with proteins leading to increased relaxivity and/or having an 256 P A R T T W O G Cardiac Imaging Techniques additional extrarenal elimination pathway, and those that have strong protein binding. Seven of those have been developed as multipurpose imaging contrast agents and all have at least neuroimaging as a labeled indication. Both agents are ionic, linear chelates and have a dual elimination pathway with partially hepatobiliary elimination, gadobenate is weaker than gadoxetate. The higher T1 relaxivity manifests as a significantly greater intravascular signal intensity enhancement compared to that achieved with conventional gadolinium chelates at equivalent doses with the benefits of a more pronounced effect in smaller vessels as well as in the margins of the tumors. To objectively assess if differences in intravascular image contrast exist between the first group of standard gadolinium chelates and the new group, an intraindividual cross-over study was performed that revealed that gadobenate dimeglumine presented a significantly more intense contrast enhancement with a higher, longer peak duration and larger area under the vascular contrast enhancement curve. The practical impact is that for the same dose and administration approach, a more intense and longer duration intravascular signal intensity benefit was noted. The clinical advantages of the increased relaxivity also have been demonstrated for many vascular territories that range from the carotid vasculature16 to the distal run-off vessels. The fact that more signal/ enhancement can be obtained for the same dosing more readily enables full diagnostic quality at lower doses, thereby reducing dose and accumulation-dependent potential effects. Gadoxetate disodium has only recently been developed and is being marketed in many countries for liver imaging and is packaged in a 0. Although differences exist between these agents in terms of the molecular structure and chemical and physical properties (Tables 18-1 and 18-2), all agents are nonspecific and are eliminated unchanged via the renal pathway by glomerular filtration. The T1 relaxation rates of these agents are comparable and fall in the range between 4. These similarities lead to equivalent imaging characteristics at the same dose and injection rate. From the molecular structure, the agents can be subclassified into ionic or nonionic, linear, or macrocyclic. The concept of the nonionic agents was that they would have an even better safety profile with fewer adverse events comparable to the impact of reducing ionicity in iodinated contrast agents. This idea could not be realized with the agents and the stability of the binding of the gadolinium central atom has become much more critical. From this perspective, the nonionic linear molecules are the least stable and the ionic macrocyclic agents are the most stable. Therefore, the binding strength of the gadolinium by its surrounding chelating complex has become a differentiating factor. The elimination pathway is primarily renal but it also has some hepatobiliary elimination.
The repair may involve anastomosis to or reconstruction of the branch vessels erectile dysfunction song discount 50/30mg viagra with dapoxetine with visa, or may require excision and replacement of the aortic root erectile dysfunction non organic order genuine viagra with dapoxetine on line, with composite valve-conduit graft and reimplantation of the coronary arteries onto the graft erectile dysfunction doctors in orange county generic 100/60mg viagra with dapoxetine fast delivery. The goal of surgery is to excise and replace the entire pathologic area of the ascending aorta erectile dysfunction in 60 year old order viagra with dapoxetine 100/60mg with mastercard. Elective surgical repair of thoracic aortic aneurysm is generally indicated if the ascending aorta diameter reaches 5 to 5. These criteria are based on extensive analysis of the natural history of thoracic aortic aneurysms by Coady and associates,29 which showed a fourfold increase in risk of rupture or dissection after the ascending aorta reaches a diameter of 6 cm. In patients with Marfan syndrome or other familial aneurysms, earlier intervention is recommended. Bicuspid or unicuspid aortic valve has been associated with an abnormality of elastin formation in the aortic wall, and earlier intervention is indicated in these patients. Based on several studies, including one by Prenger and colleagues,30 it is recommended that an aorta with a diameter of 4 to 5 cm be repaired concomitantly because of a 27% risk of future dissection without repair. Contraindications Contraindications for surgical repair of the aorta include comorbid conditions that would make the mortality risk of the surgery outweigh the risk of nonoperative management. Relative contraindications include patients older than 80 years and patients presenting with stroke with dense neurologic deficit. For elective aneurysm repair, patients with recent significant stroke or recent myocardial infarction with reduced ejection fraction may be at inordinate risk not to survive the operation, and may not be considered reasonable surgical candidates. Three-dimensional reconstruction provides increased accuracy regarding the size of the aneurysm in patients whose aorta is tortuous. Conventional x-ray aortography is another modality used to evaluate suspected aortic dissection or traumatic transection. This study can accurately show the anatomy of the tear, including intimal flap and true lumen/false channel; depict the relationship of the arch vessels; and assess the aortic valve for incompetence. For patients undergoing elective repair of ascending aneurysm, this study provides accurate information regarding the size, location, and relationship to the branch vessels of the aorta and can depict the presence of aortic valve regurgita- Outcomes and Complications Operative mortality for elective repair of thoracic aortic aneurysm is very low, in most series 2% to 4%. The overall hospital mortality for repair of acute aortic dissection is higher, approximately 10% to 20%. Mortality is increased for patients presenting with hemodynamic instability, and is higher for patients requiring repair of the aortic arch, as shown in several series. Published 5-year survival for patients undergoing repair of acute type A aortic dissection is roughly 80%, and 60% at 10 years, whereas 5-year and 10-year postoperative survival for type B dissections is lower, 50% and 30%, respectively. If the patient is older than 40 years, coronary angiography may be performed concomitantly. A significant contrast bolus is required for this study, which may be problematic in patients with preexisting renal insufficiency. This is also an important tool for intraoperative assessment during operations on the ascending aorta, providing information on atherosclerotic disease, and cardiac valvular and ventricular function. Advantages are that this study may be done quickly at the bedside, and it requires no intravenous contrast agent. The serous portion is bordered by the visceral pericardium (a layer on the epicardium) and parietal pericardium. The serous pericardium contains fluid that provides lubrication during cardiac motion, reducing friction with the pericardial sac. Two natural recesses called sinuses provide a pathway around the heart within the pericardium. Common disorders of the pericardium include conditions of excessive fluid accumulation within the serous pericardium and involvement of the pericardium with disease (pericarditis). Postoperative Surveillance All patients who have had surgery of the thoracic aorta should undergo periodic, long-term surveillance. This risk is elevated in patients who have undergone surgical repair of aortic dissection, and they should have a more vigilant follow-up program. Table 30-15 shows an acceptable surveillance schedule as reported by Borst and associates. Constrictive Pericarditis Constrictive pericarditis can occur with any condition that causes inflammation of the pericardium with subsequent fibrosis. Constrictive pericarditis is seen in 4% to 5% of patients who have undergone previous cardiac surgery. Patients may present with worsening symptoms of congestive heart failure with a normal left ventricular ejection fraction and in the absence of other cardiac pathology. Constrictive pericarditis can also be caused by radiation therapy to the mediastinum, malignancy, and infection. The basic physiologic derangement in constrictive pericarditis is the inability of the heart to fill normally because the constricting membrane prevents chamber distention. The diagnosis of constrictive pericarditis is made using hemodynamic measurements as listed in Table 30-17. The most specific of these findings, ventricular interdependence, is seen as a decrease in left ventricular systolic pressure with an increase in right ventricular systolic pressure during inspiration, measured in the cardiac catheterization laboratory. A common finding on physical examination is pulsus paradoxus, which is a dissociation of cardiac and intrathoracic pressures, causing a decrease in systolic pressure of greater than 10 mm Hg with inspiration. Chronic effusive pericarditis is related to numerous diseases, including renal disease, hemodialysis, malignancy, medications, and (rarely) infection, and is more common in young women. Acute pericarditis with effusion may be seen after cardiac surgery and after myocardial infarction (Dressler syndrome). Description and Special Anatomic Considerations the surgical treatment for constrictive pericarditis is complete pericardiectomy. This may be performed through a median sternotomy or a left thoracotomy, and requires meticulous dissection of the visceral (off the epicardium) and parietal layers of the pericardium. The pericardiectomy includes removal of all encasing pericardial tissue (visceral, parietal, and fibrous).
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