While cardiac involvement is not a common presentation in human echinococcosis, it may lead to life-threatening complications including cyst rupture; anaphylactic shock; tamponade; pulmonary, cerebral or peripheral arterial embolism; acute coronary syndrome; dysrhythmias; infection; ventricular or valvular dysfunction, as well as sudden death. Here we report a 9-year old girl who was diagnosed to have hydatid cyst of the interventricular septum four years after diagnosis and medical treatment of pulmonary hydatidosis. Presentation, management and follow-up of the patient is discussed.

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Increase in international normalized ratio associated with smoking cessationTO THE EDITOR: The clearance of warfarin and international normalized ratio (INR) assessments must take into account the effect of various factors including diet, concomitant drugs, and comorbidities. 1 We report a patient whose INR increased after smoking cessation.Case Report. An 80-year-old white man had received Coumadin for the past five years for secondary prevention following a cerebral vascular accident. His anticoagulation regimen was directed by a multidisciplinary anticoagulation management service, which included a clinical pharmacist. Concurrent medical history included chronic stable angina, hyperlipidemia, and mild but chronic psoriasis on his hands and knees. Other medications included simvastatin 20 mg/d, isosorbide mononitrate 60 mg/d, and topical mometasone furoate for psoriasis. His INR check was routinely performed (Figure 1), and the warfarin dosage had been stabilized over the previous 10 months at 5 mg/d (35 mg/wk), with INRs ranging between 2.0 and 2.8 (target range 2.0-3.0).Approximately three months after smoking cessation, his INR value was discovered to be slightly elevated (3.0) on routine INR check. The patient was instructed to take a modified dose of warfarin (2.5 mg/d) for the next two days, then resume his routine regimen and return for evaluation in two weeks. At the time of the recheck, his INR was 3.7. The patient had experienced no apparent clinical bleeding, and the rest of the assessment was unremarkable. He was instructed to omit a single dose of warfarin and modify the warfarin dose over the next two days by taking only 2.5 mg/d, then return to his usual regimen with follow-up in two weeks. The INR 15 days later revealed a value of 3.7, possibly suggesting a new but elevated steady-state concentration of warfarin. There was no clinically evident bleeding or ecchymoses. At this time, a single dose of warfarin was omitted, and the weekly maintenance dose of warfarin was decreased by 14% to 30 mg/wk. Other factors that may have been affecting warfarin pharmacokinetics and clearance could not be discerned.The patient was cordial and compliant, and the information gleaned from him was evaluated to be reliable. Diet, including consumption of two to three beers per day, had remained constant over at least the past six years, as did his activity, which included daily walking. The medication regimen was unchanged. He denied the use of any herbal or over-the-counter product. The patient reported no recent illnesses or febrile events and no changes in bowel movements or obvious absorption issues; there also were no changes in his cardiovascular status and hemodynamics per cardiologist evaluation during this time frame. Liver function studies included only as-

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A novel vascular staple (C-staple) was developed that does not enter the vasculature lumen during anastomoses. The objective of this study was to demonstrate C-staple safety when used with a bovine xenograft and compare efficacy of the C-staple procedure with Anastoclip surgical clips or suturing when used with a bovine xenograft. Eight sheep had an acute comparison between suturing and C-staples using both common carotid arteries. Sixteen sheep had xenograft placement in the left carotid artery, eight with C-staples and eight with Anastoclips in a chronic study. Over 6 months, Doppler ultrasound interrogation of the common carotid arteries was performed. After 6 months, arteries were evaluated histopathologically. Cross-clamp and surgical times were longer in the C-staple group than the suture group, and xenograft implantation times were statistically longer with C-staples than with Anastoclips. After 6 months, C-staple biocompatibility was similar to Anastoclips. Patency and hemodynamics of the bovine xenograft were not statistically different between the two groups. C-staples performed as well as the Anastoclips except for implant times, likely due to delivery system differences. Histological findings and clinical outcomes were no different with the two devices. Further refinements of the C-staple delivery system are necessary before proceeding to clinical trials.