A Novel Technique to Reconstruct Tricuspid Valve Anterior Leaflet in Massive Endocarditis

Tricuspid valve (TV) endocarditis is a common complication in intravenous drug addicts. In case of TV replacement, the main issue is the high risk of new endocarditis on TV prosthesis. On November 2014, a 44 year-old male patient with a history of intravenous drug addiction was referred for TV endocarditis owing to Staphylococcus aureus and severe regurgitation complicated by pulmonary embolism and heart failure. Preoperative echocardiography showed a large vegetation of the anterior leaflet (1.95 × 0.92 cm) covering a huge hole in the leaflet itself. Herein, a novel technique for the treatment of massive endocarditis of the TV is described. Complete anterior leaflet reconstruction was achieved with a huge equine pericardium patch along with native chordae tendinae reimplantation onto the free edge of the patch. Finally, a ring annuloplasty was performed to stabilize the valve reconstruction. The postoperative course was uneventful with evidence of trivial tricuspid regurgitation and no signs of IE recurrence. Complete reconstruction of the anterior leaflet with a patch of xenopericardium and native chordae tendinae reimplantation might be an alternative technique to TV replacement.

PSEUDOANEURYSMS IN INTRAVENOUS DRUG ABUSERS

Background: Intravenous drug abuse can lead to vascular complications, most frequent of which is pseudoaneurysm. Thesepseudoaneurysms (false aneurysms) are prone to rupture, leading to profuse hemorrhage and death. Objective: To evaluatepseudoaneurysms in intravenous drug addicts for the site, mode of presentation, management and outcome. Design: Descriptive study.Place and duration of study: Surgical unit I, Combined Military Hospital, Rawalpindi. Surgical unit 2, Combined Military Hospital, Lahore.January 2006 to September 2010. Subjects and methods: All cases of pseudoaneurysms in intravenous drug addicts who presented to asingle vascular surgeon, between 1st January 2006 and 30th September 2010, were evaluated for site, mode of presentation, treatment andthe outcome. Surgical procedures included excision of pseudoaneurysm with interpositioning of graft, repair of vascular rent, ligation of vesseland debridement. All cases were referred to psychiatrist for management of drug addiction. Results: Total 12 cases of pseudoaneurysms dueto IV drug abuse were included in our study. Arteries affected included 9(75%) common femoral arteries (CFA). In 3(25%) cases, both commonfemoral artery and vein were involved with arteriovenous fistula between them. There was 1(8.3%) pseudoaneurysm each of external iliacartery, superficial femoral artery and brachial artery. Nine cases (75%) presented with recurrent hemorrhage from a swelling while in 3(25%)cases there was swelling with no history of hemorrhage. In 7(58.3%) cases, repair/grafting, while in 5(41.6%) cases ligation and debridementwas done. There was seroma formation in 1(8.3%) case after excision and grafting. In none of the cases, in which artery was ligated, critical limbischaemia occurred. Conclusions: Common femoral artery is the most frequent site of pseudoaneurysms in IV drug abuse. In those caseswhere vascular reconstruction is not possible due to extensive skin necrosis or infection, ligation of affected vessel is not only a life savingprocedure but a safe option also.

Farbduplexsonographische Befunde an den Leistengefäßen von Drogenabhängigen

Background: During recent years increasing numbers of intravenous drug addicts with severe damage to the groin vessels were examined in our angiological ultrasound laboratory. The value of color duplex sonography for the clinical evaluation of these findings is the subject of the present study. Patients and methods: Over the course of six years every drug addict admitted to our hospital who either complained of pain or discomfort in the inguinal region or showed conspicuous clinical findings in this area was examined in our ultrasound laboratory. First by B-mode, the diameter, wall structure and compressibility of the vessels were evaluated and the surrounding tissue was checked for abnormalities. Then the blood flow of the femoral vessels was examined by color coded duplex. If an abscess was suspected, a computed tomography of the groin was obtained before surgery in most cases. Results: A total number of 77 patients was examined with pathologic results in all cases. The most frequent finding was venous thrombosis: In 63 patients complete thrombotic occlusion of the femoral vein at the injection site was observed. We registered 14 partial thromboses. 30 patients showed vessel wall alterations to variable extents in which 23 cases referred to veins and 10 cases to arteries. 7 patients showed an occlusion of the femoral artery. In 4 patients we found a false aneurysm and 3 had an arteriovenous fistula. Chronic tissue alterations were present to a certain extent in all cases rendering evaluation frequently difficult. Especially problematic to evaluation were those 34 patients where one or more surgical interventions had been performed previously. The results of an additional computed tomography had little effect on the therapeutic decisions. In 11 patients an abscess incision had to be done during the course of their hospital stay. Conclusion: Extensive damage of the groin vessels is seen in i.v. drug addicts. There is no other patient group with such a diversity of different findings. In almost every case these findings involve veins and arteries as well as the surrounding tissues.

Neck Needle Foreign Bodies

The risk to pathologists of contracting diseases due to cuts or needles punctures while performing autopsies is well known. An additional risk is an accidental needle puncture due to retained needle fragments within the subcutaneous tissues or internal organs of intravenous drug addicts. We report 4 cases of drug addicted patients infected with human immunodeficiency virus who came to autopsy and had retained needle fragments within their cervical-clavicular soft tissues. The presence of retained needle fragments increases the risk to the autopsy pathologist of accidental needle puncture and exposure to disease. Because of this phenomenon, the pathologist should take precautions in addition to those currently prescribed when performing autopsies on possible drug abusers.