948. Ventricular Assist Device Infection due to Non-tuberculous Mycobacteria Leading to Successful Heart Transplantation: A Case Report and Literature Review

Background A 59-year-old man with acute myelogenous leukemia and matched allogeneic hematopoietic stem-cell transplant and non-ischemic cardiomyopathy requiring a left ventricular assist device (LVAD; HeartMate II™) was admitted after the spontaneous rupture of an abdominal fistula in his lower abdomen, and cloudy discharge from the driveline (DL) exit site for months. Figure 1 Denied systemic symptoms but had leukocytosis. CT scan of the abdomen revealed soft tissue enhancement around the LVAD DL Figure 2. Cultures from DL discharge grew Mycobacterium chelonae. He underwent incision and drainage (I&D) of the abdominal fistula, with unroofing of the tissue over the DL. Antimicrobial course is summarized in Table. He was thought to be an appropriate heart transplant candidate one month later. Cultures from the LVAD sites were negative. He completed antimicrobials for 10 weeks after transplant. 32 months after heart transplant he has no signs of M. chelonae infection. Figure 1. Driveline exit site with scant cloudy discharge and a shallow 3 x 2-centimeter open lesion inferior to the umbilicus. Driveline track in dotted line. Figure 2. CT scan of the abdomen revealed soft tissue enhancement (red arrows) around the LVAD driveline in the lower abdomen. Methods We performed a literature review of all published cases involving Non-Tuberculous Mycobacteria (NTM) and LVADs. Collected: date, sex and age, onset, organism, type of LVAD, transplant, surgical debridement, antimicrobials, outcome. Results A total of 11 patients with LVAD infection due to NTM have been described in the literature. Four cases of NTM LVAD infection culminated in heart transplantation. Cases are summarized in Table 1. All transplanted cases had an indolent presentation and driveline discharge, without systemic symptoms. All underwent I&D and/or de-roofing of the driveline and were treated with at least two active antimicrobials for an extended course ranging from 4 months and up to 17 months after transplant. All cases did well from the infection standpoint. One died within 12 months from transplant rejection. Conclusion Treatment with a combination with at least two active agents is recommended and continued for many months. Effective surgical debridement of affected tissue and unroofing of the driveline beyond the affected velour, along with the removal of the infected device at the time of cardiac transplant, is key to success. Disclosures Susan J. Rehm, MD, Lilly (Individual(s) Involved: Self): Shareholder; Merck (Individual(s) Involved: Self): Shareholder; Pfizer (Individual(s) Involved: Self): Shareholder

The utility of dynamic MRI in differentiating the hormone-producing ability of pituitary adenomas

Purpose To investigate the relationship between dynamic magnetic resonance imaging (MRI) findings and hormonal activity in pituitary adenomas. Methods We retrospectively evaluated the dynamic MRI findings in 244 patients with pathologically confirmed pituitary adenomas and a diagnosis of clinically active prolactin (PRL)-producing adenomas. Among the 244 pituitary adenomas, 55, 16, 6, and 4 produced growth hormone (GH), PRL, adrenocorticotropic hormone, and thyroid-stimulating hormone, respectively, while 163 were non-functioning (NF) adenomas. For each adenoma, we calculated the washout rate (WR) and early (EER) and delayed (DER) tumour-to-normal-tissue enhancement ratios. Results The respective mean values of the WR, EER, and DER were 9.4%, 75.2%, and 64.5% for GH-producing adenomas; 6.2%, 117.1%, and 106.2% for PRL-producing adenomas; and 5.4%, 116.7%, and 108.7% for NF adenomas. GH-producing adenomas had significantly lower EER and DER values than PRL-producing (P < 0.001) and NF adenomas (P < 0.001). In ROC analysis of GH-producing and non-GH-producing adenomas, the areas under the curves of WR, EER, and DER were 0.593, 0.825, and 0.857, respectively. Conclusion There are differences in dynamic MRI features between GH-producing and non-GH-producing adenomas, which suggests that EER and DER may be useful for diagnosing GH-producing adenomas.

Bone Regeneration and Soft Tissue Enhancement Around Zygomatic Implants: Retrospective Case Series

Purpose: To present a case series of zygomatic implants combined with bone regeneration and soft tissue enhancement techniques to reduce the risk of biological delayed complications such as maxillary sinusitis and soft tissue recession. Materials and methods: Zygomatic implants placed simultaneously with different bone regeneration techniques (buccal, palatal and buccal-palatal bone regeneration) and soft tissue enhancement techniques (pediculate and free connective tissue graft) were followed for at least 12 months. The following information was collected: patient age and sex, number of zygomatic implants, zygomatic implant success rate, zygomatic implant position according to classification of the Zygomatic Anatomy Guide Approach (ZAGA), sinus membrane perforation, type and outcome of the bone regeneration or the soft tissue enhancement technique, bone gain (width and length along the zygomatic implant) and keratinized buccal mucosa width, duration of follow-up, loading protocol (immediate or delayed) and biological complications (maxillary sinusitis and soft tissue recession). Results: Thirty-one zygomatic implants placed in 19 patients were included. All implants were successful and none of the implants presented biological complications. The bone regeneration technique was successful in 30 of 31 cases with a mean palatal bone width of 3 mm, buccal bone width of 2.65 mm, palatal bone length of 6.5 mm and buccal bone length of 8.3 mm. The success rate of soft tissue enhancement was 100% and it established at least 2 mm of keratinized buccal mucosa width in all implants. Conclusions: Within the limitations of the present study, bone regeneration and soft tissue enhancement techniques were useful to establish more favorable conditions of the peri-implant tissues around zygomatic implants. This could prevent biological complications such as maxillary sinusitis and soft tissue recessions. Prospective and randomized controlled clinical trials with longer follow-up periods are advisable.

A Gradient-Based Approach for Breast DCE-MRI Analysis

Breast cancer is the main cause of female malignancy worldwide. Effective early detection by imaging studies remains critical to decrease mortality rates, particularly in women at high risk for developing breast cancer. Breast Magnetic Resonance Imaging (MRI) is a common diagnostic tool in the management of breast diseases, especially for high-risk women. However, during this examination, both normal and abnormal breast tissues enhance after contrast material administration. Specifically, the normal breast tissue enhancement is known as background parenchymal enhancement: it may represent breast activity and depends on several factors, varying in degree and distribution in different patients as well as in the same patient over time. While a light degree of normal breast tissue enhancement generally causes no interpretative difficulties, a higher degree may cause difficulty to detect and classify breast lesions at Magnetic Resonance Imaging even for experienced radiologists. In this work, we intend to investigate the exploitation of some statistical measurements to automatically characterize the enhancement trend of the whole breast area in both normal and abnormal tissues independently from the presence of a background parenchymal enhancement thus to provide a diagnostic support tool for radiologists in the MRI analysis.

Soft Tissue Enhancement and Implant Placement Following Partial Mandibulectomy Due to Squamous Cell Carcinoma

Many dental procedures allow for implant placement in partially or totally edentulous patients. Despite the availability of various implant and abutment types on the market, it often becomes quite challenging to achieve the biological and esthetic goals in a patient who has ridge deficiencies. Problems arise from the lack of adequate bone quality and quantity.1,2 Soft tissue form and maintenance is also a consideration to evaluate.3 Primary reconstructive techniques following segmental mandibulectomy is evolving and improves quality of life. A seldom encountered complication is the discovery and treatment of a malignant process (for example, squamous cell carcinoma). Oral squamous cell carcinoma (OSCC) is one of the most aggressive malignancies worldwide and accounts for more than 90% of all oral cancers.4 It is ranked as the sixth leading cause of cancer mortality worldwide. The most common sites of OSCC are the lateral ventral surface of the tongue, the floor of the mouth and buccal mucosa. For most oral cavity cancers, surgery is the initial treatment of choice (often involving the full or partial removal of bony jaw structure).5 Radiation or chemoradiation is added postoperatively if disease is more advanced or has high-risk features. Successful cancer therapy can affect the quantity and quality of soft tissue in areas where implants are planned, thus affecting the initial placement and the long-term success of the implants. Complications can be numerous; especially difficult is implant treatment in the mandibular anterior area where inadequate alveolar height results in the lingual floor and the vestibule becoming contiguous.6 Further complicating treatment is the presence of scar tissue (often found following cancer surgery and radiotherapy). The present case is a report of the combination of a soft tissue enhancement and implant placement following partial mandibulectomy resulting from the treatment of oral squamous cell carcinoma. A video abstract is available for viewing at https://youtu.be/dZ9t3j4ufOc?list=PLvRxNhB9EJqbqjcYMbwKbwi8Xpbb0YuHI.

Soft-Tissue Enhancement Combined With Biologically Oriented Preparation Technique to Correct Volumetric Bone Defects: A Clinical Case Report

The aim of the present case report was to illustrate how to obtain an ideal alveolar ridge contour by means of peri-implant soft-tissue management combined with the prosthetic approach of the biologically oriented preparation technique (BOPT). A patient presenting a moderate vertical and horizontal bone loss in the posterior maxilla was treated with sinus floor elevation and simultaneous implant placement. During the reentry procedure, the horizontal defect was corrected with an apically repositioned flap combined with a connective tissue graft. To increase the volume of the interimplant papillae, a pedunculated flap originating from the primary flap was turned within the interimplant space. BOPT one-time abutments have been employed to maximize the space available for the papilla-like tissues. A focused and combined surgical and prosthetic procedure has permitted enhancement of both peri-implant esthetics and function without the need for further invasive and costly bone regeneration techniques.