Stenotic Orifice Research Articles

Laparoscopic management of double moiety: A case report with review of literature

Duplication of the ureter is one of the most common anomalies of the urinary tract. Ureterocele is a developmental anomaly with cystic dilation of the distal aspect of the ureter and is often associated with some urological anomaly, such as a duplicated system or stenotic ureteric orifice. Early detection of these anomalies during the antenatal period has dramatically increased due to advances in imaging technology. However, a few undiagnosed adults also exist. It may remain asymptomatic but may cause repeated urinary tract infections or calculi. This is a case report of a 47-year-old female who had bilateral duplex collecting systems with right ureterocele. The patient had a recurrent urinary tract infection. She underwent cystoscopic deroofing and a laparoscopic right total nephrectomy. Congenital anomalies of the urogenital system should be considered in patients with chronic or recurrent infections. Multimodal imaging techniques such as ultrasonography, computed tomography, or magnetic resonance imaging should be used to confirm the diagnosis, especially before surgical management. The rationale for reporting this case is to highlight this rare condition and the feasibility of its minimally invasive therapy.

Impact of pressure recovery on the assessment of pulmonary homograft function using Doppler ultrasound.

Relevant pressure recovery (PR) has been shown to increase functional stenotic aortic valve orifice area and reduce left ventricular load. However, little is known about the relevance of PR in the pulmonary artery. The study examined the impact of PR using 2D-echocardiography in the pulmonary artery distal to the degenerated homograft in patients after Ross surgery. Ninety-two patients with pulmonary homograft were investigated by Doppler echocardiography (mean time interval after surgery 31 ± 26 months). PR was measured as a function of pulmonary artery diameter determined by computed tomography angiography. Homograft orifice area, valve resistance, and transvalvular stroke work were calculated with and without considering PR. PR decreased as the pulmonary artery diameter increased (r=-0.69, p < 0.001). Mean PR was 41.5 ± 7.1% of the Doppler-derived pressure gradient (Pmax ), which resulted in a markedly increased homograft orifice area (energy loss coefficient index [ELCOI] vs. effective orifice area index [EOAI], 1.3 ± 0.4 cm2 /m2 vs. 0.9 ± 0.4 cm2 /m2 , p < 0.001). PR significantly reduced homograft resistance and transvalvular stroke work (822 ± 433 vs. 349 ± 220 mmHg × ml, p < 0.0001). When PR was considered, the correlations of the parameters used were significantly better, and 11 of 18 patients (61%) in the group with severe homograft stenosis (EOAI <0.6 cm2 /m2 ) could be reclassified as moderate stenosis. Our results showed that the Doppler measurements overestimated the degree of homograft stenosis and thus the right ventricular load, when PR was neglected in the pulmonary artery. Therefore, Doppler measurements that ignore PR can misclassify homograft stenosis and may lead to premature surgery.

Hemodynamics of Mitral Stenosis

Hemodynamic is the intravascular pressure and flow that circulate blood throughout the body. In both the venous and arterial compartments, variations in pressure and flow will necessarily affect each other. Flow and pressure within and between the arterial and venous compartments are influenced by hemodynamic on a beat-to-beat basis. Hemodynamic values that are treated in one compartment are dependent on the state of the other compartments. There are several curved proximal isovelocity surface areas as the streamlines of flow approach the stenotic orifice. A stenotic valve's spatial flow velocity profile depends on its anatomy, inlet geometry, and degree of flow acceleration. A patient with Mitral Stenosis (MS) experiences a pressure gradient from the left atrium to the left ventricle that propels the flow abruptly across the stenotic orifice. An arc-shaped flow profile is created, and the atrioventricular valve will therefore have a hemi elliptical velocity profile. At the level of narrowed stenotic orifices, high-velocity jets form in laminar flow when it reaches the vena contracta, the narrowest cross-sectional area downstream from the anatomic orifice, the flow profile in cross-section is relatively flat at the jet's origin and remains flat until the jet reaches the anatomic orifice. Distally from the stenotic region, the blood flow becomes disorganized with multiple velocities and directions. Stenotic mitral valves exhibit thickened leaflets with a reduced excursion. In this review, we will discuss the challenges and changes which occur in hemodynamic of MS.

A124 GASTRIC RETENTION IN CAPSULE STUDIES – IS AN ENDOSCOPY ALWAYS REQUIRED?

Abstract Background Capsule endoscopy (CE) is a non-invasive procedure for evaluating small bowel (SB) disorders but is limited by the completion rate. Gastric retention (GR), whereby the capsule remains in the stomach for the duration of the recording, can contribute to incomplete examinations given CE’s finite battery life. Although this may be mitigated by using real-time imaging and/or endoscopic placement of capsule into the SB, such strategies require additional resource allocation. While other risk factors associated with incomplete examinations are well known, GR is not often discussed in the literature. Aims To describe the management and outcomes of patients with GR. We hypothesize that most patients with previous gastric retention of the capsule, without known obstruction, will pass the capsule normally through the stomach with a second attempt without requiring endoscopic placement into the duodenum. Methods Case series of patients with GR at a tertiary care centre in Vancouver, Canada. Prior to CE, all patients had undergone appropriate investigations to exclude obstructive pathology. All patients ingested 2L of polyethylene glycol-based bowel preparation the evening prior to the procedure and were fasting after midnight. Ingestion of the capsule occurred at 0700h. In patients who required repeat CE due to previous GR, capsule progress was assessed via real-time imaging at 1–2 hrs. If the capsule had not entered the SB by three hours, an attempt at endoscopic advancement of the capsule into the duodenum was made and/or endoscopic placement of capsule was arranged for a later date. Results GR was found in 21 (2%) of 1024 patients between 09/2015 - 09/2020. The mean age of patients with GR was 58 ± 20.9 years (48% female). The most common indication for CE in this group was obscure gastrointestinal bleeding (n = 12, 57%). The mean Charlson Comorbidity Index was 2.9 ± 3.5. Thirteen patients (62%) had a history of abdominal/pelvic surgery. Fourteen patients (67%) had repeat CE, nine (64%) of which passed into the SB without endoscopic assistance. Of those requiring endoscopic assistance (n = 5), two had successful endoscopic placement, one required dilation of pyloric stenosis prior to successful placement, one failed endoscopic placement due to stenotic gastroplasty orifice, and another required upper endoscopy for further evaluation. None experienced delayed adverse events related to GR. Conclusions CE can be safely repeated in patients with previous GR; most capsules will pass through the stomach spontaneously when repeated and do not require endoscopic assistance. Funding Agencies None

Very rare Image for Rheumatoid tricuspid valve changes

Rheumatic tricuspid valve disease occurs in association with rheumatic involvement of the mitral aortic valves combined. The third world still have a significant prevalence of rheumatic tricuspid valvular disease. The preponderance of cases is in young women. Rheumatic tricuspid disease usually results in a regurgitant valve with variable amounts of stenosis, Borders of the stenotic tricuspid orifice are usually fibrous and thickened, although peripheral portions of the leaflets remain thin. The hallmark of organic tricuspid stenosis is commissural fusion. All commissures are usually equally fused, but occasionally fusion is limited to the anteroseptal commissure. Chordal thickening and fusion are usually mild, and calcification is usually absent. Case of 30 years old lady who underwent cardiac surgery for mitral, Aortic, tricuspid valve replacement. Keywords: Valvular disease; Rheumatismal changes; Tricuspid valve disease

Airway management in a patient with bullous pemphigoid.

Airway management in patients with pemphigoid lesions has anaesthetic implications. We report a case of a 23 years old female with bullous pemphigoid who presented with laryngeal stenosis and critical airway narrowing. The airway was initially managed with jet ventilation. Anaesthesia was maintained with propofol infusion and ventilation was performed by introducing a size 10 French gauge suction catheter through the stenotic laryngeal orifice. Thirty minutes into anaesthesia, she developed subcutaneous emphysema and decreased air entry on right side of the chest but remained hemodynamically stable. The airway was further managed by tracheostomy. This case report highlights complications that can occur during the anaesthetic management of such cases.

Arterial reconstructions for pediatric splanchnic artery occlusive disease

ObjectivePediatric splanchnic arterial occlusive disease is uncommon and a rare cause of clinically relevant intestinal ischemia. This study was undertaken to better define the clinical manifestations and appropriate treatment of celiac artery (CA) and superior mesenteric artery (SMA) occlusive disease in children. MethodsClinical courses of 30 consecutive children undergoing operations for splanchnic arterial occlusive disease at the University of Michigan from 1992 to 2017 were retrospectively analyzed. ResultsVascular reconstructions were performed for splanchnic arterial disease in 18 boys and 12 girls, 1.5 to 16 years of age (mean, 7.5 ± 4.1 years). Isolated splanchnic arterial disease was uncommon (2 children), being more often associated with abdominal aortic coarctations (19 children) or ostial renal artery stenoses (25 children). Primary splanchnic arterial reconstructions (30) included aortic reimplantation of SMAs (15) or celiacomesenteric arteries (2), aortoceliac and aortomesenteric bypasses (7), reimplantation of the CA as a patch over the stenotic SMA orifice (3), and patch angioplasty of the CA (2) or SMA (1). There was no perioperative mortality. Two groups (I and II) were identified for study. Group I children (14) experienced symptomatic intestinal ischemia, manifested by various combinations of chronic postprandial abdominal discomfort (14), ischemia-related intestinal bleeding (2), or failure to thrive (4). Four children in group I became symptomatic after known CA and SMA occlusive disease was left untreated at the time they underwent earlier interventions for renovascular hypertension. Seven secondary redo interventions were undertaken for recurrent symptoms in six group I children. Only one major periprocedural complication occurred: segmental colon infarction. The assisted patency rate of reconstructed arteries in group I children was 93%, and intestinal ischemic symptoms resolved in every child. Group I follow-up from the most recent splanchnic arterial reconstruction averaged 4.3 years. Group II children (16) without manifestations of intestinal ischemia underwent prophylactic splanchnic arterial reconstructions in concert with combined aortic and renal artery procedures (11), isolated abdominal aortic reconstructions (3), or renal artery reconstructions alone (2). Group II children experienced no major perioperative morbidity and remained asymptomatic postoperatively, and none required secondary splanchnic artery interventions. Group II follow-up averaged 7.4 years. ConclusionsPediatric splanchnic artery occlusive lesions are often associated with developmental aortic and renal artery occlusive disease. Carefully conducted therapeutic and prophylactic reconstructive procedures are appropriate in children having splanchnic arterial occlusive disease.

Anoplasty for low anorectal malformation

BackgroundThe presence of a slightly anterior, stenotic anus is a low anorectal malformation. It is a type of rectoperineal fistula. The cardinal symptoms are constipation and straining at stool. Hendren described a technically simple anoplasty for this condition in 1978. Controversy about terminology has led to a lack of clarity about this condition. MethodsClinical data were reviewed about the authors' patients, who had Hendren anoplasty, from 2009 to 2015. Followup data were obtained from office visits and telephone interviews with families and primary care doctors. ResultsSeven patients (4 boys) presented with intractable constipation. All had a stenotic anal orifice, located anterior to the center of the anal wink, within the pigmented perianal skin. In 4 of 7 cases, the lesion was not recognized at birth. Anoplasty was performed at a median age of 8months (range 6–28). Late followup information was obtained on six of the seven patients at a median of 32months (range 28–61). Four reported no or minimal laxative requirement and two reported daily laxative use but good symptom control. ConclusionsLow anorectal malformation/rectoperineal fistula may be overlooked in the newborn. When symptomatic, it may be corrected by a simple anoplasty with excellent results.

Abstract 9923: Feasibility of New Real-Time 3-Dimensional Echocardiographic Imaging in a Mitral Valve Stenosis Model: A Comparison With 2D Imaging

Introduction: This study investigated the feasibility and accuracy of real-time three-dimensional echocardiography (RT3DE) in assessing the severity of simulated mitral stenosis in a pumped porcine heart model. Hypothesis: RT3DE is accurate for assessing mitral stenosis. Methods: Eight porcine hearts were used to simulate mitral stenosis. Four different sized inner-diameter tubes (9,11,13 and 15mm) were used to create stenotic mitral valve orifice areas. These tubes were inserted into vinyl tubing which was then connected to a pulsatile pump. A balloon was secured to the end of the tubing entering the left ventricle, and the model was sutured at the mitral annulus. The heart was submerged in a water tank and the pump set at 60 bpm with stroke volumes ranging from 30-70 mL in 10 mL increments. At each increment, images were acquired in 2D echo and RT3DE using a GE Vivid 7 ultrasound system. Data were analyzed using GE EchoPAC PC. Results: A comparison of true area and measured orifice areas were analyzed for both 2D echo and RT3DE. Linear regression analysis showed excellent correlation 2D and RT3DE acquired areas and true areas (2D: r 2 =0.9; RT3DE: r 2 =0.9). It was found that while RT3DE presented significantly similar mean values for all areas tested (P&lt;0.05), 2D-measured areas were consistently larger than expected values (P&lt;0.05). Conclusions: RT3DE has the potential to be an accurate, noninvasive diagnostic tool in clinical cardiology that overcomes imaging limitations present in 2D echo.

Diarrhea With Severe Weight Loss Secondary to Gastrocolic Fistula (GCF)

Introduction: Gastric resection for peptic ulcer disease has decreased over the past 2 decades and hence complications of surgery for peptic ulcer disease are seen less frequently in clinical practice. We report a case of a large GCF in a patient with a history of gastrectomy. Case Report: 54 year-old-female with a 30 pack year history of smoking, Billroth 11 gastrectomy for peptic ulcer disease and revision with a Roux-en-Y gastrojejunostomy for delayed gastric emptying presented with a 3-month history of severe weight loss and diarrhea. Her weight dropped from 130 lbs to 73 lbs. with passages of 10 to 20 watery pale stools a day, occurring 15 to 30 minutes after meals. She reported no melena or hematochezia nor vomiting. On examination, the patient was disheveled and emaciated (BMI 11.5). Vital signs were within normal limits. Mild periorbital edema was present. There was only mild abdominal tenderness and no organomegaly or ascites. There was 2+ pitting bilateral peripheral edema. Significant laboratory results: Complete blood count was normal. Basic metabolic profile was normal except for BUN 2 mg/dl, creatinine 0.2 mg/dl, albumin 1.5 g/dl, prealbumin 10 mg/dl, phosphorus 1.1 mg/dl. Stool specimen was negative. Gastroscopy revealed a large cleaned based gastric ulcer on the jejunal side of the gastrojelunal anastomosis with a severely stenotic jejunal orifice (1-2 mm opening); a large gastrocolic fistula (15 mm) which the scope easily traversed. Colonoscopy and ileoscopy were unremarkable except for the fistula which was identified in the transverse colon.The patient was placed on TPN and after 4 weeks underwent surgery with en bloc resection and primary anastomosis. Discussion: Gastrointestinal malignancies were reported previously as the most common causes of GCF. Recently, benign etiologies appear to be more common. These include complications of peptic ulcer disease and enteral feeding tubes. The most common presenting symptoms are diarrhea, weight loss and abdominal pain. Diagnosis is made by barium enema. Endoscopy are useful but may miss small fistulae. Treatment in most cases is surgical.Figure 1: Gastroscopy revealing a large cleaned base gastric ulcer with a 2-mm stenotic jejunal orifice and a 15-mm gastrocolic fistula.

Congenital Right Intermediate Bronchial Stenosis With Carina Trifurcation: Successful Management With Slide Tracheobronchial Plasty

Congenital bronchial stenosis is rarely described and is difficult to manage. Here we report two cases of right intermediate bronchial stenosis (stenotic orifice with complete cartilage rings). Both cases were associated with ventricular septal defects, and a "trifurcation" pattern was found in both carinas. Both patients underwent surgical repair of the ventricular septal defects but could not be separated from ventilator support despite successful cardiac operations. Slide tracheobronchial plasty was applied to the right intermediate bronchus and lower trachea. After correction of the bronchial stenosis, both patients could be extubated and live without supplementary ventilation support.

Double giant thrombi in the left atrium in a patient with rheumatic mitral valve stenosis and atrial fibrillation

After a presyncopal attack, echocardiography of a 79-year old man with atrial fibrillation and rheumatic mitral valve stenosis revealed a giant mobile ball thrombus transiently obstructing the mitral valve orifice, with another giant immobile thrombus filling the left atrial appendage (Supplementary Videos 1 and 2). Both thrombi, with dimensions of 40 × 30 and 60 × 30 mm, were removed successfully with the implantation of a prosthetic mitral valve (Figs 1 and 2). Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Echocardiographic apical four-chamber view of the free-floating giant ball thrombus transiently obstructing stenotic mitral valve orifice during diastole. Video 2: Echocardiographic parasternal short-axis view of the two thrombi in the left atrium.

Treatment of pyloric stenosis in a cat via pylorectomy and gastroduodenostomy (Billroth I procedure)

A 5-month-old 1.9-kg (4.2-lb) spayed female Siamese cat was evaluated because of a history of decreased appetite, regurgitation, vomiting, and lack of weight gain. Radiographic findings included a fluid- and gas-distended stomach with a small accumulation of mineral opacities. Ultrasonographic examination confirmed severe fluid distention of the stomach with multiple hyperechoic structures present and revealed protrusion of the thickened pylorus into the gastric lumen, with normal pylorogastric serosal continuity. Endoscopy of the upper gastrointestinal tract revealed an abnormally shortened pyloric antrum and stenotic pyloric outflow orifice. Pyloric stenosis resulting in pyloric outflow obstruction was diagnosed. A pylorectomy with end-to-end gastroduodenostomy (Billroth I procedure) was successfully performed, and a temporary gastrostomy tube was placed. Six days after surgery, the cat was eating and drinking normally, with the tube only used for administration of medications. The gastrostomy tube was removed 12 days after surgery. Results of follow-up examination by the referring veterinarian 3 weeks after surgery were normal. Occasional vomiting approximately 2 months after surgery was managed medically. Fifteen months after surgery, the owners reported that the cat seemed completely normal in appearance and behavior. Pyloric stenosis should be considered a differential diagnosis for young cats with pyloric outflow obstruction. The cat of this report was treated successfully with a Billroth I procedure. Histologic examination and immunohistochemical analysis of the excised tissue showed the stenosis to be associated with hypertrophy of the tunica muscularis.

Bronchial cast hiding a lung cancer

A 70-year-old man was admitted for severe hypoxia, haemoptysis and cough. Chest-X-ray and CT-scan indicated a right-lower-lobe collapse. Bronchoscopy showed its occlusion by whitish dense mucus. Aspiration revealed a Bronchial Cast (BC) and a stenotic and inflamed orifice of the right-lower-lobe-bronchus which was biopsied. Histopathologic examination of BC showed fibrin with lymphocytes and neutrophils, and, surprisingly, also the presence of lung cancer. Although the association between BC and benign, myxoid-soft-tissue, tracheobronchial tumors has been described, the association with lung cancer has not previously been reported, and it remains unclear whether it is causal or casual.

Bronchial cast hiding a lung cancer

A 70-year-old man was admitted for severe hypoxia, haemoptysis and cough. Chest-X-ray and CT-scan indicated a right-lower-lobe collapse. Bronchoscopy showed its occlusion by whitish dense mucus. Aspiration revealed a Bronchial Cast (BC) and a stenotic and inflamed orifice of the right-lower-lobe-bronchus which was biopsied.Histopathologic examination of BC showed fibrin with lymphocytes and neutrophils, and, surprisingly, also the presence of lung cancer. Although the association between BC and benign, myxoid-soft-tissue, tracheobronchial tumors has been described, the association with lung cancer has not previously been reported, and it remains unclear whether it is causal or casual.

Ebstein anomaly and double orifice mitral valve–An unusual association

We report an unusual association between Ebstein anomaly of the tricuspid valve and a stenotic double orifice mitral valve diagnosed later in life.

Triple-Cavity Left Ventricle With an Abnormal Mitral Valve Apparatus

The patient is a 17-year-old boy who was referred to our center with complaints of easy fatigability and exertional dyspnea. In echocardiography, the left ventricle was identified to be composed of a small functional cavity, and 2 sequestrated apical cavities that communicated with the functional cavity only through few stenotic orifices. The mitral valve apparatus was also abnormal: there was no definite papillary muscle, and chordae tendineae arose from the aberrant fibromuscular ridge that partitioned the left ventricular cavity. Imaging findings and management of this patient with a triple-cavity left ventricle are discussed.

Focal Stenosis in Right Upper Lobe Bronchus in a Recurrently Wheezing Child Sequentially Studied by Multidetector-row Spiral Computed Tomography and Scintigraphy

Lower respiratory tract infections associated with wheezing are not uncommon in infants and young children. Among the wheezing-associated disorders, allergic etiologies are more commonly encountered than anatomic anomalies. We present a 3-year-old girl with a sudden attack of asthmatic symptoms including dyspnea, cyanosis and diffuse wheezing Based on a history of choking, and atelectasis in the right upper lobe detected by chest films, flexible tracheobronchoscopy was arranged and incidentally detected a stenotic orifice in the right upper lobe bronchus. Multidetector-row spiral computed tomography and pulmonary scintigraphy subsequently also disclosed the focal stenosis. She suffered from recurrent wheezing, pneumonia and lung atelectasis during 1 year of follow-up. We emphasize the diagnosis, clinical course and management of focal stenosis in the right upper lobe bronchus.

Imaging modalities in valvular heart disease

Evaluating valvular heart disease requires a multi-parametric analysis of valvular pathology, hemodynamic derangements, and impact on ventricular size and function. The capability to perform real-time three-dimensional (3-D) imaging has vastly strengthened the already established role of echocardiography. CT and MRI advances have led to their use as daily clinical tools. Two-dimensional and 3-D echocardiography and Doppler modalities allow for accurate assessment of valvular lesions, pressure gradients, stenotic valve orifice areas, pulmonary artery pressures, intracardiac pressures, and regurgitant volumes. Quantitation of chamber volumes has become more accurate and reproducible with 3-D echocardiography, CT, and cardiac MRI. Although ultrasound imaging is the primary tool, the other techniques provide adjuvant or alternate options to examine valvular heart disease. This array of imaging modalities is likely to provide greater insights into the pathophysiology of valvular heart disease, new pointers to prognosis, and also guide innovative treatment strategies.

Procoagulant Properties of Flow Fields in Stenotic and Expansive Orifices

In the United States, over 125,000 mechanical heart valves (MHVs) are implanted each year. Flow through the MHV hinge can cause thromboemboli formation. The purpose of this study was to examine various orifice geometries representing the MHV hinge region and how these geometries may contribute to platelet activation and thrombin generation. We also characterized these flow fields with digital particle image velocimetry (DPIV). Citrated human blood at room temperature was forced through the orifices (400 and 800 microm ID) with a centrifugal bypass pump, continuously infusing calcium chloride to partially reverse the citrate anticoagulant. Blood samples were tested for the presence of thrombin-antithrombin complex (TAT) and platelet factor 4 (PF4). Velocity and shear stress were measured with DPIV using a blood analog fluid seeded with fluorescent microbeads. The results indicate that small changes in geometry, although they do not affect the bulk flow, change the coagulation propensity as blood flows through the orifices. A more abrupt geometry allows more stagnation to occur resulting in more thrombin generation. PF4 measurements indicated similar levels of platelet activation for all orifices. DPIV showed differences in the jets with respect to entrainment of stagnant fluid. These results help to pinpoint the important parameters that lead to flow stasis and subsequent thrombus formation.