Dynamic right ventricular outflow tract obstruction (RVOTO) has been reported following lung transplantation for pulmonary hypertension, usually in association with the use of inotropic agents. This report describes delayed severe right-sided heart failure associated with right ventricular outflow tract obstruction following sequential bilateral lung transplantation and closure of a ventricular septal defect. The patient had no evidence of outflow tract obstruction in the early posttransplant period but developed progressive right heart failure more than 2 months later. Catheterization revealed dynamic RVOTO and an elevated right ventricular end-diastolic pressure. The patient was treated with metoprolol tartrate and diltiazem hydrochloride with resolution of the outflow tract obstruction and heart failure. This case demonstrates that RVOTO can occur in the late posttransplant period and must be included in the differential diagnosis for patients who develop right-sided heart failure.

A review of the literature on reduction pneumoplasty for giant bullous emphysema was undertaken to identify current criteria for this surgical treatment and in the hope of obtaining insights into evaluating reduction pneumoplasty for nonbullous emphysema. Twenty-two retrospective case series, published since 1950, were retrieved by a computer search of the literature and a search of the Index Medicus prior to 1966. Reduction pneumoplasty is most effective when bullae are larger than one third of a hemithorax with evidence of compression of adjacent lung tissue and an FEV1 of less than 50% predicted; the presence of emphysema in nonbullous lung and the amount of compression are best judged by CT. The rationale for reduction pneumoplasty for nonbullous emphysema is supported by the similar early functional changes after reduction pneumoplasty for bullous and nonbullous-improvement of blood gas values and lung mechanics. A single study showing that decline of lung function after surgery for bullous emphysema was less in those who stopped smoking than in those who continued to smoke supports the need for preoperative and maintained smoking cessation in patients receiving reduction pneumoplasty. After 4 decades, the duration of improvement in lung function, whether worsening of emphysema occurs in remaining lung, and late morbidity and mortality after reduction pneumoplasty for bullous emphysema are not well defined. A registry with an unoperated-on comparison group could more rapidly accumulate such data after reduction pneumoplasty for nonbullous emphysema.

Hypercalcemia occurs in about 10% of the patients with sarcoidosis; hypercalciuria is about three times more frequent. These abnormalities of calcium metabolism are due to dysregulated production of 1,25-(OH)2-D3 (calcitriol) by activated macrophages trapped in pulmonary alveoli and granulomatous inflammation. Undetected hypercalcemia and hypercalciuria can cause nephrocalcinosis, renal stones, and renal failure. Corticosteroids cause prompt reversal of the metabolic defect. Chloroquine, hydroxychloroqune, and ketoconazole are the drugs that should be used if the patient fails to respond or develops dangerous side effects to corticosteroid therapy.

Native valve endocarditis normally presents with fever and only later in its course demonstrates dysfunction of the affected valve. We describe a case of endocarditis due to Neisseria subflava, a Gram-negative diplococcal saprophyte of the oral cavity, which was unsuspected clinically and found unexpectedly during a mitral valve operation performed for symptomatic prolapse with regurgitation.

Dissemination of lung cancer beyond the intrathoracic lymph nodes (stage IV disease) implies surgical unresectability. However, solitary brain metastases (SBMs) from non-small cell lung cancer (NSCLC) have often been treated by combined resection of the primary tumor and its metastasis. Such an aggressive approach appears to substantively improve patient outcome and provide better quality of life in selected cases. A search of the literature reveals extended survival (10 years or longer) in 16 patients following combined surgical excision. We report three patients with NSCLC and isolated central nervous system involvement who achieved exceptionally long survival. The existing literature on SBMs from NSCLC is reviewed.

Cardiac complications can occur long after chest radiotherapy. We describe a patient who developed both valve disease and complete heart block at different intervals following radiotherapy for Hodgkin's disease. The combined presentation of these two very rare cardiac complications and surgery for radiation-induced tricuspid valve disease have not been described before.

Thrombosis of left-sided prosthetic valves is an uncommon yet potentially serious complication. Thrombolytic therapy has been proposed as an alternative to surgical methods in treating this condition. We sought to determine from a review of the literature what outcomes may be expected subsequent to thrombolytic administration and what groups may be at risk or benefit from this approach. We searched for studies including two or more patients treated with thrombolytic agents. Ten studies were reviewed. We describe and include two patients with valve thrombosis treated at our institution. A total of 182 episodes of prosthetic valve thrombosis in 162 patients were examined. Clinical success was achieved in 72.0% of cases and there was a mortality risk of 9.9%. Clinical success from thrombolysis was significantly related to the degree of heart failure at presentation and aortic valve position. Clinical success was not related to the duration of symptoms, time from valve replacement to obstruction, or valve type. Rethrombosis of successfully treated valve occurred subsequently in 19.5% of cases. Repeated thrombolytic administration in these patients was associated with similar rates of success as those treated for their initial episode of prosthetic valve thrombosis. Candidates for thrombolytic therapy include patients with obstructive valve thrombosis with or without congestive heart failure who are hemodynamically stable. Duration of time since valve replacement or symptom onset does not limit successful outcome. Close observation and aggressive maintenance of anticoagulation after therapy is suggested.