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With advancements in the operative techniques, patient survival following liver transplantation (LTx) has increased substantially. This has led to the acceleration of pre-existing kidney disease because of immunosuppressive nephrotoxicity making additional kidney transplantation (KTx) inevitable. On the other hand, in a growing number of patients on the waiting list to receive liver, long waiting time has resulted in adverse effect of decompensated liver on the kidney function. During the last two decades, the transplant community has considered combined liver kidney transplantation (CLKTx) to overcome this problem. The aim of our study is to present an overview of our experience as well as a review of the literature in CLKTx and to discuss the controversy in this regard. All performed CLKTx (n = 22) at our institution as well as all available reported case series focusing on CLKTx are extracted. The references of the manuscripts were cross-checked to implement further articles into the review. The analyzed parameters include demographic data, indication for LTx and KTx, duration on the waiting list, Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, immunosuppressive regimen, post-transplant complications, graft and patient survival, and cause of death. From 1988 to 2009, a total of 22 CLKTx were performed at our institution. The median age of the patients at the time of CLKTx was 44.8 (range: 4.5-58.3 yr). The indications for LTx were liver cirrhosis, hyperoxaluria type 1, polycystic liver disease, primary or secondary sclerosing cholangitis, malignant hepatic epithelioid hemangioendothelioma, cystinosis, and congenital biliary fibrosis. The KTx indications were end-stage renal disease of various causes, hyperoxaluria type 1, polycystic kidney disease, and cystinosis. The mean follow-up duration for CLKTx patients were 4.6 +/- 3.5 yr (range: 0.5-12 yr). Overall, the most important encountered complications were sepsis (n = 8), liver failure leading to retransplantation (n = 4), liver rejection (n = 3), and kidney rejection (n = 1). The overall patient survival rate was 80%. Review of the literature showed that from 1984 to 2008, 3536 CLKTx cases were reported. The main indications for CLKTx were oxalosis of both organs, liver cirrhosis and chronic renal failure, polycystic liver and kidney disease, and liver cirrhosis along with hepatorenal syndrome (HRS). The most common encountered complications following CLKTx were infection, bleeding, biliary complications, retransplantation of the liver, acute hepatic artery thrombosis, and retransplantation of the kidney. From the available data regarding the need for post-operative dialysis (n = 673), a total of 175 recipients (26%) required hemodialysis. During the follow-up period, 154 episodes of liver rejection (4.3%) and 113 episodes of kidney rejection (3.2%) occurred. The cumulative 1, 2, 3, and 5 yr survival of both organs were 78.2%, 74.4%, 62.4%, and 60.9%, respectively. Additionally, the cumulative 1, 2, 3, and 5 yr patient survival were 84.9%, 52.8%, 45.4%, and 42.6%, respectively. The total number of reported deaths was 181 of 2808 cases (6.4%), from them the cause of death in 99 (55%) cases was sepsis. It can be concluded that there is still no definitive evidence of better graft and patient survival in CLKTx recipients when compared with LTx alone because of the complexity of the exact definition of irreversible kidney function in LTx candidates. Additionally, CLKTx is better to be performed earlier than isolated LTx and KTx leading to the avoidance of deterioration of clinical status, high rate of graft loss, and mortality. Shorter graft ischemia time and more effective immunosuppressive regimens can reduce the incidence of graft malfunctioning in CLKTx patients. Providing a model to reliably determine the need for CLKTx seems necessary. Such a model can be shaped based upon new and precise markers of renal function, and modification of MELD system.

Caring for a brain dead potential organ donor requires a shift in critical care from the extensive treatment of increased intracranial pressure towards strategies to maintain donor organ function. Suboptimal, unstandardized critical care management of organ donors, however, is one of the main reasons for insufficient organ procurement. The pathophysiological changes following brain death entail a high incidence of complications including hemodynamic instability, endocrine and metabolic disturbances, and disruption of internal homeostasis that jeopardize potentially transplantable organs. Strategies for the management of organ donors exist and consist of the normalization of donor physiology. This has resulted in standardized efforts to improve the critical care delivered to potential organ donors, increasing not only the number, but also the quality of suitable organs and aiming at an optimal outcome for the recipients. In this review, we discuss the pathophysiological changes associated with brain death and present the current guidelines at our department, which are optimized based on available literature.

Introduction: The aim of the present study was to evaluate the feasibility of a technique that uses solely the transhiatal approach to create a high intrathoracic esophagogastric anastomosis after laparoscopic transhiatal resection of the distal esophagus., Method: Using a laparoscopic approach, the esophagi of 10 midsized pigs were dissected and transected as high as possible in the thorax, and the anvil of a circular stapler was introduced perorally into the esophageal stump. Through a midline short laparotomy, the circular stapler was inserted into the gastric tube and advanced through the hiatus to be connected with the anvil and create the anastomosis., Results: Development of the technique was completed within the first 6 experiments. The last 4 operations were entirely successful, standardized, and easily reproducible., Conclusion: The technique is feasible in this experimental setting. Further studies are required to establish if there is a clinical role for this technique in esophageal surgery.

Background: Filamentous fibrin strands (FSs) attached to valve prostheses have been well described in patients undergoing transesophageal echocardiography, but the frequency and clinical significance of these strands remain poorly defined. The aims of this study were to determine the frequency of prosthetic valve strands and to assess their significance in relation to clinical cerebral ischemic events (CIEs) and anticoagulant status., Methods: Three hundred consecutive patients with 421 prosthetic heart valves were evaluated for the presence of FSs (highly mobile, filamentous masses<1 mm thick)., Results: FSs were found in 139 patients (49%) and 147 prostheses (38%) in patients with left-sided prostheses, with a significant association between FSs, CIEs, and anticoagulant status (P<.001). A lower international normalized ratio (<2.5) had a positive association with the occurrence of CIEs., Conclusions: There is a significant association between FSs, CIEs, and patient's anticoagulant status; therefore, aggressive anticoagulation and close follow-up are recommended for these patients.

Changes in liver microcirculation are considered essential in assessing ischemia-reperfusion injury, which in turn has an impact on liver graft function and outcome following liver transplantation (LTx). The aim of this study was to introduce dynamic magnetic resonance imaging (dMRI) as a new technique for overall quantification of hepatic microcirculation and compare it to perfusion measured by laser Doppler flowmetry (LDF; hepatic artery/portal vein) and thermal diffusion (TD). The study included 3 groups, measuring hepatic blood flow and microcirculation with the help of TD, LDF, and dMRI. In group I (9 landrace pigs; 26 +/- 5 kg), the native liver before and after partial portal occlusion was studied; in group II (6 landrace pigs; 25.5 +/- 4.4 kg), the liver 24 hours after LTx was studied; and in group III (14 patients), the liver on days 4 to 7 following LTx was studied. A close correlation was found between dMRI measurements and TD (r = 0.7-0.9, P < 0.01) in 4 defined regions of interest. Portal blood flow and partial occlusion of the portal vein were accurately detected by LDF flowmetry and correlated well with dMRI (r = 0.95, P < 0.01). In the clinical setting, representative TD measurements in segment 4b of the transplanted liver correlated well with dMRI analysis in other segments. Quantification of the portal blood flow and imaging of the whole liver could be performed simultaneously by dMRI. In conclusion, dMRI has been proved to be a sensitive modality for the quantification of liver microcirculation and hepatic blood flow in experimental and clinical LTx. It allows for a synchronous, noninvasive assessment of macrocirculation and microcirculation of the liver and could become a valuable diagnostic tool in advanced liver surgery and transplantation.

The purpose of the present study was to examine the effect of social isolation stress on the expression of messengers ribonucleic acid (mRNAs) for corticotropin-releasing factor receptor type 2 (CRF2 receptor), urocortin 1 (Ucn 1) and urocortin 2 (Ucn 2) in the cardiovascular system of female and male prairie voles (Microtus ochrogaster). Isolation for 1 h (single isolation) or 1 h of isolation every day for 4 weeks (repeated isolation) was followed by a marked increase in plasma corticosterone level. However, continuous isolation for 4 weeks (chronic isolation) did not significantly affect plasma corticosterone level in female or male animals. A single period of isolation did not influence the expression of the CRF2 receptor, however, both repeated and chronic isolation significantly decreased CRF2 receptor mRNA in the ventricle and aorta of both sexes. Neither single nor chronic isolation significantly affected Ucn 1 mRNAs expression; however, repeated isolation increased Ucn 1 mRNA expression in the ventricles of female and male animals. Although, a single isolation produced no effect on cardiac Ucn 2 mRNA expression, both repeated and chronic isolation were followed by increased heart Ucn 2 mRNA expression in both sexes. We speculate that during repeated isolation Ucn 1 along with Ucn 2 are increased, which in turn down-regulates CRF2 receptor mRNA expression, and that Ucn 2 also may be one of factors responsible for the down-regulation of CRF2 receptor mRNA expression in cardiovascular system that is associated with chronic isolation.

The most common fungal organism to cause endocarditis is Candida which is followed by Aspergillus. Aspergillus endocarditis can occur in either the native or prosthetic heart valves, usually occurs post-operative after cardiac valve surgery. This case is illustrative of a 49-year-old man with previous history of coronary artery bypass grafting presenting with aortic valve endocarditis which was diagnosed as Aspergillus endocarditis. Unfortunately, despite medical and surgical therapy, progressive fatal aortic invasion occurred.

Aims: Enhanced external counter pulsation (EECP) is a non-invasive and non-pharmacological therapy for patients with symptomatic coronary artery disease (CAD). There are, however, insufficient data to support the effectiveness of EECP in improving the myocardial mechanical properties of patients with refractory stable angina. We aimed to assess the effects of EECP on myocardial mechanical properties and cardiac functions in CAD patients not eligible for surgical or percutaneous revascularization procedures., Methods and Results: Twenty patients in New York Heart Association (NYHA) functional Class III and IV angina were evaluated. The mean age of the patients was 63 +/- 9 years, and 65% were male. A comprehensive echocardiographic study including an evaluation of the tissue Doppler-based parameters of systolic and diastolic functions was performed before and after the termination of the protocol. EECP was carried out 1 h per day, 5 days per week, for 7 weeks. EECP resulted in a significant increase in peak late diastolic transmitral inflow velocity (0.75+/-0.14 vs. 0.83+/-0.20 m/s, P<0.05), propagation velocity (42.35+/-6.25 vs. 46.00+/-5.68 cm/s, P<0.05), peak early diastolic velocity of mitral annulus (5.35+/-1.79 vs. 5.95+/-1.10 cm/s, P<0.05), peak systolic velocity (2.51+/-0.28 vs. 2.67+/-0.26, P<0.05), and early diastolic velocity (3.24+/-0.18 vs. 3.52+/-0.26 cm/s, P<0.01) of all middle segments, peak late diastolic velocity of all basal (4.48+/-0.58 vs. 4.75+/-0.70 cm/s, P<0.05) and middle segments (2.82+/-0.66 vs. 3.25+/-0.46 cm/s, P<0.01), peak systolic strain rate of all basal (0.76+/-0.07 vs. 0.99+/-0.08 1/s, P=0.001) and middle segments (0.75+/-0.09 vs. 0.94+/-0.09 1/s, P<0.001), peak systolic strain of basal (11.64+/-1.51 vs. 13.97+/-1.52%, P<0.01) and middle segments (11.81+/-1.15 vs.13.73+/-1.57%, P<0.001), and left ventricular (LV) ejection fraction (40.25+/-12.72 vs. 46.25+/-12.97%, P<0.001).There was also a significant decrease in the ratios of transmitral E/A (0.92+/-0.41 vs. 1.08+/-0.46, P<0.05) and E/Ea (12.61+/-4.22 vs. 15.44+/-6.96, P<0.05) after EECP therapy. A significant reduction in NYHA angina class (>or=1 angina class) was seen in the patients, who completed treatment., Conclusion: EECP therapy seemed to improve both regional and global LV systolic and diastolic functions in patients with chronic angina pectoris.

Common bile duct stones (CBDSs) may occur in up to 3%-14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.

Objective: Few reports have been published on the Doppler-derived echocardiographic data for pulmonary valve prostheses (PVPs). The aim of this study was to provide a comprehensive Doppler echocardiographic assessment of PVPs., Methods: We studied 40 patients (mean age 24.2) with PVPs: 13 (32.5%) mechanical and 27 (67.5%) bioprosthetic valves. After clinical evaluation, all patients underwent complete, two-dimensional and Doppler studies., Results: In 30 patients with normally functioning PVPs, the mean (SD) peak velocity was 2.33 (0.36) m/s with an average peak pressure gradient of 22.69 (6.7) mm Hg and an average mean pressure gradient of 12.5 (4.1) mm Hg. The mean PVPs velocity time integral (VTI) was 47.49 (12.78) cm with mean right ventricle outflow tract/peak velocity (PV) VTI ratio 0.43 (0.14), mean PVPs effective orifice area was 1.63 (0.36) cm(2). Metallic PVPs had significantly better hemodynamic Doppler study compared with biologic PVPs. In 9 patients with PVP malfunction, average peak PVPs velocity, average peak pressure gradient, mean pressure gradient, PV VTI, PV/left ventricle outflow tract VTI ratio was significantly increased (P < 0.05)., Conclusion: This study contributes to establishing the normal range for Doppler hemodynamics in various PVPs.

Objectives: We sought to evaluate the geometric changes of the mitral leaflets, local and global LV remodeling in patients with left ventricular dysfunction and varying degrees of Functional mitral regurgitation (FMR)., Background: Functional mitral regurgitation (FMR) occurs as a consequence of systolic left ventricular (LV) dysfunction caused by ischemic or nonischemic cardiomyopathy. Mitral valve repair in ischemic MR is one of the most controversial topic in surgery and proper repairing requires an understanding of its mechanisms, as the exact mechanism of FMR are not well defined., Methods: 136 consecutive patients mean age of 55 with systolic LV dysfunction and FMR underwent complete echocardiography and after assessing MR severity, LV volumes, Ejection Fraction, LV sphericity index, C-Septal distance, Mitral valve annulus, Interpapillary distance, Tenting distance and Tenting area were obtained., Results: There was significant association between MR severity and echocardiogarphic indices (all p values < 0.001). Severe MR occurred more frequently in dilated cardiomyopathy (DCM) patients compared to ischemic patients, (p < 0.001). Based on the model, only Mitral valve tenting distance (TnD) (OR = 22.11, CI 95%: 14.18 - 36.86, p < 0.001) and Interpapillary muscle distance (IPMD), (OR = 6.53, CI 95%: 2.10 - 10.23, p = 0.001) had significant associations with MR severity.Mitral annular dimensions and area, C-septal distance and sphericity index, although greater in patients with severe regurgitation, did not significantly contribute to FMR severity., Conclusion: Degree of LV enlargement and dysfunction were not primary determinants of FMR severity, therefore local LV remodeling and mitral valve apparatus deformation are the strongest predictors of functional MR severity.

Among primary cardiac tumors, hemangiomas are relatively rare with a reported incidence of 2.8%. To date, less than 100 cases are reported in literature. We present a 40-year-old woman with atypical chest discomfort of 1 month duration, previous history of glomus tumor of hand and a large cavernous hemangioma of right atrium.

Aims: Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure patients with prolongation of QRS duration. Despite careful patient selection, some do not respond to CRT based on QRS complex duration. We sought to evaluate the presence of left ventricular dyssynchrony using tissue Doppler imaging (TDI) according to QRS duration in heart failure patients., Methods and Results: Ninety-nine patients (mean age 52.6 +/- 15.3 years) with severe heart failure [left ventricular (LV) ejection fraction, <35%] were prospectively evaluated. On the basis of QRS width, the patients were divided into two groups. Forty-eight patients (48.5%) had a normal QRS duration (<120 ms), Group I, and 51 (51.5%) had a prolonged QRS duration, Group II. All patients underwent echocardiography coupled with TDI. Spectral displays of six basal and six middle LV segments with pulsed-wave TDI were obtained to assess the time to peak systolic point from R-wave on electrocardiogram (Ts). The standard deviation of Ts (Ts-SD) and the maximal temporal difference of Ts (Ts-diff) were measured. Interventricular dyssynchrony [defined as the presence of an interventricular mechanical delay (IVMD) >40 ms] and intra-LV mechanical delays (defined as Ts-SD >33.4 ms and Ts-diff >100 ms) were correlated with the QRS width and morphology. We found a greater IVMD in Group II patients, compared with patients in Group I (42.5 +/- 22.3 vs. 26.8 +/- 21, respectively, P < 0.001). Intraventricular dyssynchrony defined as Ts-SD > or =33.4 ms was found in 45.1% of patients in Group II compared with 23% of patients in Group I (P = 0.03). Similarly, the Ts-diff was prolonged in Group II patients compared with Group I (P = 0.02). By linear regression analysis, a weak relation was found between Ts-SD and QRS duration (P = 0.055). A substantial portion of patients with prolonged QRS did not exhibit ventricular dyssynchrony defined either as total asynchrony index > or =33.4 ms or as IVMD >40 ms., Conclusion: A substantial proportion of patients with prolonged QRS (32.1%) did not exhibit inter- or intraventricular dyssynchrony, which may represent a limitation in identifying the ideal QRS interval for the selection of patients for CRT.

An intravenous leiomyoma, a histologically benign smooth muscle tumour, arises from either a uterine myoma or the walls of a uterine vessel, with extension into veins. The present report describes echocardiographic features of an intravenous leiomyoma that spread into the right-sided cardiac chambers in a middle-aged woman who had undergone a hysterectomy two years earlier. Echocardiographic features included an elongated mobile mass extending from the inferior vena cava and multiple masses in the right atrium and right ventricle. Intracardiac leiomyomatosis should be considered in women who present with a cardiac mass in the right-sided chambers.

This study assessed the effects of a course of enhanced external counterpulsation (EECP) therapy on systolic and diastolic cardiac function using echocardiography to measure left ventricular ejection fraction (LVEF), end-systolic volume (ESV), end-diastolic volume (EDV), systolic wave (Sm), early diastolic wave (Ea), Vp, E/Ea, E/Vp, and diastolic function grade in 25 patients before and after 35 hours of EECP. EECP reduced ESV and EDV and increased ejection fraction significantly in patients with baseline LVEF < or = 50% (P=.018, .013, .002), baseline E/Ea > or = 14 (P=.032, .038, .007), baseline grade II or III diastolic dysfunction (decreased compliance) (P=.014, .032, .027), baseline Ea <7 cm/s (P=.015, .024, .001), and baseline Sm <7 cm/s (P=.017, .016, .006), but not in patients with baseline LVEF >50%, baseline E/Ea <14, baseline normal diastolic function or grade I diastolic dysfunction (impaired relaxation), baseline Ea > or = 7 cm/s, and Sm > or = 7 cm/s. These results demonstrate improved systolic and diastolic function in selected patients and provide new insight into potential clinical applications of EECP.

The theory of ion-channel guiding in a helical wiggler is presented. Electron motion in the combined ion electrostatic and wiggler magnetostatic fields is analyzed in the absence of the radiation field. The Phi function that determines the rate of change of axial velocity with energy is derived and studied numerically. A detailed analysis of the pendulum equation and the gain equation in the low-gain-per-pass limit are presented. It is shown that the gain for stable group I orbits is positive, while for group II orbits the gain is negative in the negative mass regime and positive in the positive mass regime.