Search

Background: The relation between flecainide's plasma level and its influence on human atrial electrophysiology during acute and maintenance therapy of atrial fibrillation (AF) is unknown. Therefore, this study determined flecainide plasma levels and atrial fibrillatory rate obtained from the surface ECG during initiation and early maintenance of oral flecainide in patients with persistent lone AF and assessed their relationship.Methods and Results: In 10 patients (5 males, mean age 63 +/- 14 years, left atrial diameter 46 +/- 3 mm) with persistent lone AF, flecainide was administered as a single oral bolus (day 1) followed by 200-400 mg/day (days 2-5). The initial 300 mg flecainide bolus resulted in therapeutic plasma levels in all patients (range 288-629 ng/ml) with no side effects. Flecainide plasma levels increased on day 3 and remained stable thereafter. Day 5 plasma levels were lower (508 +/- 135 vs 974 +/- 276 ng/ml, P = 0.009) in patients with daily mean flecainide doses of 200 mg compared to patients with higher maintenance doses. Fibrillatory rate obtained from the surface electrocardiogram measuring 378 +/- 17 fpm at baseline was reduced to 270 +/- 18 fpm (P < 0.001) after the flecainide bolus but remained stable thereafter. Fibrillatory rate reduction was independent of flecainide plasma levels or clinical variables.Conclusion: A 300 mg oral flecainide bolus is associated with electrophysiologic effects that are not increased during early maintenance therapy in persistent human lone AF. In contrast to drug plasma levels, serial analysis of fibrillatory rate allows monitoring of individual drug effects on atrial electrophysiology. [ABSTRACT FROM AUTHOR]

Introduction: Identification of suitable candidates for cardioversion currently is not based on individual electrical and mechanical atrial remodeling. Therefore, this study analyzed the meaning of atrial fibrillatory rate obtained from the surface ECG (as a measure of electrical remodeling) and left atrial size (as measure of mechanical remodeling) for prediction of early atrial fibrillation (AF) recurrence following cardioversion.Methods and Results: Forty-four consecutive patients (26 men and 18 women, mean age 62 +/- 11 years, no antiarrhythmic medication at baseline) with persistent AF were studied. Fibrillatory rate was obtained from high-gain, high-resolution surface ECG using digital signal processing (filtering, QRST subtraction, Fourier analysis) before electrical cardioversion. Univariate and multivariate regression analysis revealed larger systolic left atrial area (Beta = 0.176, P = 0.031) obtained by precardioversion echocardiogram from the apical four-chamber view and higher atrial fibrillatory rate (Beta = 0.029, P = 0.021) to be independent predictors for AF recurrence (n = 13). Stratification based on the regression equation (electromechanical index [EMI] = 0.176 systolic left atrial area + 0.029 fibrillatory rate - 17.674) allowed identification of groups at low, intermediate, or high risk. No patient with an EMI < -1.85 had early AF recurrence, as opposed to 78% with an EMI > -0.25. Intermediate results (40% recurrence rate) were obtained when the calculated EMI ranged between -1.85 and -0.25 (P < 0.001).Conclusion: Fibrillatory rate obtained from the surface ECG and systolic left atrial area obtained by echocardiography may predict early AF recurrence in patients with persistent AE These parameters might be useful in identifying candidates with a high likelihood of remaining in sinus rhythm after cardioversion. [ABSTRACT FROM AUTHOR]

Primary prevention of sudden arrhythmic death in patients with organic heart disease with poor left ventricular function and/or heart failure is currently a major challenge in cardiology. Amiodarone (with or without beta blockers) and the implantable cardioverter defibrillator (ICD) are considered the 2 major therapeutic tools to prevent sudden arrhythmic death in these patients. Two large trials have been launched to define the prophylactic benefit of the ICD or amiodarone on total mortality in patients that receive optimal heart failure and anti-ischemic treatment but remain at high risk of dying suddenly. The Sudden Cardiac Death in Heart Failure Trial (SCD-Heft) is designed to determine whether amiodarone or the ICD will decrease overall mortality in patients with coronary artery disease or nonischemic cardiomyopathy who are in heart failure New York Heart Association (NYHA) class II or III and have a left ventricular ejection fraction < 35%. The primary endpoint is total mortality; secondary objectives are comparison of arrhythmic and nonarrhythmic mortality and morbidity in the 3 arms as well as quality of life, cost-effectiveness, and incidence of episodes of ventricular tachyarrhythmias. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) II is a follow-up study to the MADIT trial. It examines the prophylactic benefit in coronary artery disease patients with a left ventricular ejection fraction of < 30%, who have had at least 1 myocardial infarction but require no further risk stratification. MADIT II is a sequential design trial that compares ICD versus no ICD therapy. Programmed electrical stimulation to test inducibility of ventricular tachycardia is performed during ICD implantation, and various noninvasive risk markers are tested after randomization. Primary endpoint is total mortality, and secondary objectives are quality-of-life issues as well as cost-effectiveness ratio. [ABSTRACT FROM AUTHOR]

The findings of our initial study demonstrate for the first time the ability to terminate induced VT/VF reliably (100% of all episodes) by a single, monophasic 230-J shock delivered by the Wearable Cardioverter-Defibrillator (WCD). Although limited by sample size, our data suggest the WCD could be used as a feasible bridge to definitive implantation of an implantable cardioverter-defibrillator in patients in whom risk stratification for sudden death is not completed. [ABSTRACT FROM AUTHOR]

Background: Improving health equity and access to the highest possible standard of health care is a key issue of social accountability. Centretown Community Health Centre in Ottawa, Canada has iteratively developed a program to target and serve marginalized and complex populations since 1999. The program implementation was evaluated using a validated implementation framework., Methods: Quantitative and qualitative data were collected through a health records extraction (n = 570), a client complexity assessment tool (n = 74), semi-structured interviews with clients and key stakeholders (n = 41), and a structured client satisfaction survey (n = 30). Data were analyzed using descriptive statistics and inductive thematic analysis., Results: Five hundred and seventy unique clients were seen between November 1-30, 2021. A third of clients (34%) did not have a provincial health card for access to universal health care services, and most (68%) were homeless or a resident of rooming houses. Most clients who reported their income (92%) were at or below Canada's official poverty line. The total mean complexity score for clients seen over a one-month period (n = 74) was 16.68 (SD 6.75) where a total score of at least 13 of 33 is perceived to be a threshold for client biopsychosocial complexity. Clients gained the majority of their total score from the Social support assessment component of the tool. Clients (n = 31) and key informants (n = 10) highlighted the importance of building relationships with this population, providing wrap-around care, and providing low-barrier care as major strength to the Urban Health program (UH). Key areas for improvement included the need to: i) increase staff diversity, ii) expand program hours and availability, and iii) improve access to harm reduction services. Clients appeared to be highly satisfied with the program, rating the program an average total score of 18.50 out of 20., Conclusions: The program appears to serve marginalized and complex clients and seems well-received by the community. Our findings have relevance for other health care organizations seeking to better serve marginalized and medically and socially complex individuals and families in their communities., (© 2024. The Author(s).)

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y 12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y 12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Extracellular matrix (ECM) protein expression/deposition within and stiffening of the breast cancer microenvironment facilitates disease progression and correlates with poor patient survival. However, the mechanisms by which ECM components control tumorigenic behaviors and responses to therapeutic intervention remain poorly understood. Fibronectin (FN) is a major ECM protein controlling multiple processes. In this regard, we previously reported that DHPS-dependent hypusination of eIF5A1/2 is necessary for fibronectin-mediated breast cancer metastasis and epithelial to mesenchymal transition (EMT). Here, we explored the clinical significance of an interactome generated using hypusination pathway components and markers of intratumoral heterogeneity. Solute carrier 3A2 (SLC3A2 or CD98hc) stood out as an indicator of poor overall survival among patients with basal-like breast cancers that express elevated levels of DHPS. We subsequently discovered that blockade of DHPS or SLC3A2 reduced triple negative breast cancer (TNBC) spheroid growth. Interestingly, spheroids stimulated with exogenous fibronectin were less sensitive to inhibition of either DHPS or SLC3A2 - an effect that could be abrogated by dual DHPS/SLC3A2 blockade. We further discovered that a subset of TNBC cells responded to fibronectin by increasing cytoplasmic localization of eIF5A1/2. Notably, these fibronectin-induced subcellular localization phenotypes correlated with a G0/G1 cell cycle arrest. Fibronectin-treated TNBC cells responded to dual DHPS/SLC3A2 blockade by shifting eIF5A1/2 localization back to a nucleus-dominant state, suppressing proliferation and further arresting cells in the G2/M phase of the cell cycle. Finally, we observed that dual DHPS/SLC3A2 inhibition increased the sensitivity of both Rb-negative and -positive TNBC cells to the CDK4/6 inhibitor palbociclib. Taken together, these data identify a previously unrecognized mechanism through which extracellular fibronectin controls cancer cell tumorigenicity by modulating subcellular eIF5A1/2 localization and provides prognostic/therapeutic utility for targeting the cooperative DHPS/SLC3A2 signaling axis to improve breast cancer treatment responses.

Intravascular hemolysis is a known complication of prosthetic heart valves. Severe hemolysis is rare (<1%) with the use of newer generation prosthetic valves. This usually occurs due to paravalvular leaks (PVLs). We present a case of hyperbilirubinemia and hemolytic anemia occurring as a result of a PVL of a prosthetic mechanical mitral valve. The patient was a 49-year-old female with a past medical history of rheumatic heart disease status following two mitral valve replacements each with a mechanical prosthesis; she presented with a complaint of worsening fatigue, epigastric pain, nausea, and vomiting. On examination, she had scleral icterus. Heart auscultation revealed a crisp mechanical S1 click and a soft 2/6 systolic murmur in the left lower sternal border. Her abdomen was soft with mild epigastric and right upper quadrant tenderness, and no Murphy's sign. Her labs revealed a white blood cell count of 7.0 x 10 3 /microliter, hemoglobin 10.5 g/dL, hematocrit 29.7%, total bilirubin 6.9 mg/dL, direct bilirubin 0.8 mg/dL, alkaline phosphatase (ALP) 62 U/L, aspartate aminotransferase (AST) 79 U/L, and alanine aminotransferase (ALT) 56 U/L. An ultrasound of the abdomen revealed cholelithiasis without pericholecystic fluid collection and no ultrasonographic Murphy's sign. Magnetic resonance cholangiopancreatography ruled out acute cholecystitis or intra- or extra-hepatic biliary ductal dilatation. A transesophageal echocardiogram showed a well-seated mitral valve prosthesis with a significant PVL and likely moderate mitral regurgitation. The patient was evaluated for possible hemolysis. Lactate dehydrogenase was 1155 U/L, haptoglobin was <30 mg/dL, and reticulocyte count was 5.2%. She underwent a mitral valve re-replacement with a mechanical prosthesis. An echocardiogram after the surgery showed the mechanical prosthesis mitral valve with no residual PVL., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Rai et al.)

Caseous calcification of mitral annulus (CCMA) is a rare variant of mitral annular calcification. Previously thought to have been a benign condition, CCMA may be a potential source of cardioembolic stroke. We present a case of a 40-year-old man with end-stage renal disease on hemodialysis and hypertension who presented with acute onset of visual blurring and headache and was diagnosed with cardioembolic stroke secondary to CCMA. It is imperative for the echocardiographers to recognize the typical features of CCMA and to differentiate it from other common causes for appropriate intervention., Competing Interests: The authors have declared that no competing interests exist.

Austrian syndrome is a very rare manifestation of invasive Streptococcus pneumoniae infection comprising a triad of pneumonia, meningitis, and endocarditis, also known as Osler's triad. We herein report a rare case of Austrian syndrome further complicated by septic arthritis., Competing Interests: The authors have declared that no competing interests exist.

Background: Phrenic nerve stimulation (PNS) and high pacing thresholds (HPT) hinder biventricular stimulation in patients (pts) undergoing cardiac resynchronization therapy (CRT). A new quadripolar left ventricular (LV) lead (Quartet 1458Q, St. Jude Medical) with increased number of pacing configuration, might overcome this problem., Methods: All consecutive pts in whom a standard bipolar lead intraoperatively resulted in PNS and/or HPT (≥4.00V/1mV), received, during the same implant, a quadripolar LV lead. Aim of the study was to evaluate acute and short term outcome., Results: 26 pts [24 (92%) male, mean age 74±6 years)] with PNS (22 pts; 85%) and HPT (4 pts; 15%) were included. Permanent right ventricular pacing was the reason for broad QRS complex in 4 (15%) pts, whereas all other pts had a left bundle branch block. Severely symptomatic (NYHA Class ≥3) heart failure with reduced ejection fraction (EF 31±9%) was mostly caused by ischemic heart disease (14 pts; 54%). Idiopathic dilated cardiomyopathy and valvular heart disease were diagnosed in 6 (23%) pts each. In most (24/26, 92%) pts the use of the Quartet lead led to successful biventricular pacing due to a significant reduction in intraoperative pacing threshold (5.2V/1.0ms vs. 1.4V/0.8ms; p=0.03), which was maintained (1.2V/0.7ms) at follow-up. PNS never represented reason for failed LV pacing, neither acutely nor during follow-up., Conclusion: Excessively HPT and/or PNS are frequently encountered when conventional bipolar leads are used for CRT. A new quadripolar LV lead increases the rate of successful biventricular stimulation. Lower pacing threshold and freedom from PNS are maintained at follow-up.

The Coronaviridae family, an enveloped RNA virus family, and, more particularly, human coronaviruses (HCoV), were historically known to be responsible for a large portion of common colds and other upper respiratory tract infections. HCoV are now known to be involved in more serious respiratory diseases, i.e. bronchitis, bronchiolitis or pneumonia, especially in young children and neonates, elderly people and immunosuppressed patients. They have also been involved in nosocomial viral infections. In 2002-2003, the outbreak of severe acute respiratory syndrome (SARS), due to a newly discovered coronavirus, the SARS-associated coronavirus (SARS-CoV); led to a new awareness of the medical importance of the Coronaviridae family. This pathogen, responsible for an emerging disease in humans, with high risk of fatal outcome; underline the pressing need for new approaches to the management of the infection, and primarily to its prevention. Another interesting feature of coronaviruses is their potential environmental resistance, despite the accepted fragility of enveloped viruses. Indeed, several studies have described the ability of HCoVs (i.e. HCoV 229E, HCoV OC43 (also known as betacoronavirus 1), NL63, HKU1 or SARS-CoV) to survive in different environmental conditions (e.g. temperature and humidity), on different supports found in hospital settings such as aluminum, sterile sponges or latex surgical gloves or in biological fluids. Finally, taking into account the persisting lack of specific antiviral treatments (there is, in fact, no specific treatment available to fight coronaviruses infections), the Coronaviridae specificities (i.e. pathogenicity, potential environmental resistance) make them a challenging model for the development of efficient means of prevention, as an adapted antisepsis-disinfection, to prevent the environmental spread of such infective agents. This review will summarize current knowledge on the capacity of human coronaviruses to survive in the environment and the efficacy of well-known antiseptic-disinfectants against them, with particular focus on the development of new methodologies to evaluate the activity of new antiseptic-disinfectants on viruses.

Antiviral antisepsis and disinfection are crucial for preventing the environmental spread of viral infections. Emerging viruses and associated diseases, as well as nosocomial viral infections, have become a real issue in medical fields, and there are very few efficient and specific treatments available to fight most of these infections. Another issue is the potential environmental resistance and spread of viral particles. Therefore, it is essential to properly evaluate the efficacy of antiseptics-disinfectants (ATS-D) on viruses. ATS-D antiviral activity is evaluated by (1) combining viruses and test product for an appropriately defined and precise contact time, (2) neutralizing product activity, and (3) estimating the loss of viral infectivity. A germicide can be considered to have an efficient ATS-D antiviral activity if it induces a >3 or >4 log(10) reduction (American and European regulatory agency requirements, respectively) in viral titers in a defined contact time. This unit describes a global methodology for evaluating chemical ATS-D antiviral activity., (© 2011 by John Wiley & Sons, Inc.)

The relative lack of efficient methods for evaluating antiseptic antiviral activity, together with weaknesses in the existing European Standard (i.e. NF EN 14476+A1), underlines the need to seek a new method which could allow a more precise evaluation of the antiseptic antiviral activity of chemical agents. This protocol is based on an original gel-based filtration method, using "in-house" G-25 and G-10 Sephadex columns. This method allows the neutralization of both the activity and the cytotoxicity of a large range of molecules, according to their molecular size, in only 1min. The viral model used was the human coronavirus (HCoV) 229E chosen for (i) its increasing medical interest, (ii) its potential resistance and (iii) its representing enveloped viruses mentioned in the European Standard. First, the protocol was validated and it was demonstrated that it was fully operational for evaluating antiviral antiseptic potentiality and useful to screen potentially antiseptic molecules. Second, chlorhexidine (CHX) and hexamidine (HXM) were assessed for their potential anti-HCoV 229E antiseptic activities. It was demonstrated clearly that (i) HXM had no activity on the HCoV 229E and (ii) CHX showed a moderate anti-HCoV 229E activity but insufficient to be antiseptic.

Background: Conventional activation mapping in the dilated human left ventricle (LV) with left bundle-branch block (LBBB) morphology is incomplete given the limited number of recording sites that may be collected in a reasonable time and given the lack of precision in marking specific anatomic locations., Methods and Results: We studied LV activation sequences in 24 patients with heart failure and LBBB QRS morphology with simultaneous application of 3D contact and noncontact mapping during intrinsic rhythm and asynchronous pacing. Approximately one third of the patients with typical LBBB QRS morphology had normal transseptal activation time and a slightly prolonged or near-normal LV endocardial activation time. A "U-shaped" activation wave front was present in 23 patients because of a line of block that was located anteriorly (n=12), laterally (n=8), and inferiorly (n=3). Patients with a lateral line of block had significantly shorter QRS (P<0.003) and transseptal durations (P<0.001) and a longer distance from the LV breakthrough site to line of block (P<0.03). Functional behavior of the line of block was demonstrated by a change in its location during asynchronous ventricular pacing at different sites and cycle lengths., Conclusions: A U-shaped conduction pattern is imposed on the LV activation sequence by a transmural functional line of block located between the LV septum and the lateral wall with a prolonged activation time. Assessment of functional block is facilitated by noncontact mapping, which may be useful for identifying and targeting specific locations that are optimal for successful cardiac resynchronization therapy.

The mode and duration of anticoagulation in the setting of cardioversion of atrial fibrillation-either with or without guidance by transesophageal echocardiography (TEE)-is still an unresolved issue. Oral anticoagulation with warfarin or phenprocoumon is frequently used but may be associated with an increased risk of bleeding complications or, conversely, episodes of undercoagulation. Moreover, it takes several days to reach full anticoagulation with oral compounds. This phase may be covered with intravenous heparin but this requires prolonged hospitalization. Low-molecular weight heparin is an attractive alternative as it not only provides a safe and predictable level of anticoagulation with few side effects but can also be administered safely on an outpatient basis. In addition, anticoagulation monitoring is usually unnecessary. The ACE study (Anticoagulation in Cardioversion using Enoxaparin) compared the safety and efficacy of subcutaneous enoxaparin with intravenous heparin/oral phenprocoumon before and after cardioversion (stratified to TEE guidance or no TEE guidance). This article summarizes the study rationale and design. The results will be published shortly.

Introduction: Identification of suitable candidates for cardioversion currently is not based on individual electrical and mechanical atrial remodeling. Therefore, this study analyzed the meaning of atrial fibrillatory rate obtained from the surface ECG (as a measure of electrical remodeling) and left atrial size (as measure of mechanical remodeling) for prediction of early atrial fibrillation (AF) recurrence following cardioversion., Methods and Results: Forty-four consecutive patients (26 men and 18 women, mean age 62 +/- 11 years, no antiarrhythmic medication at baseline) with persistent AF were studied. Fibrillatory rate was obtained from high-gain, high-resolution surface ECG using digital signal processing (filtering, QRST subtraction, Fourier analysis) before electrical cardioversion. Univariate and multivariate regression analysis revealed larger systolic left atrial area (Beta = 0.176, P = 0.031) obtained by precardioversion echocardiogram from the apical four-chamber view and higher atrial fibrillatory rate (Beta = 0.029, P = 0.021) to be independent predictors for AF recurrence (n = 13). Stratification based on the regression equation (electromechanical index [EMI] = 0.176 systolic left atrial area + 0.029 fibrillatory rate - 17.674) allowed identification of groups at low, intermediate, or high risk. No patient with an EMI < -1.85 had early AF recurrence, as opposed to 78% with an EMI > -0.25. Intermediate results (40% recurrence rate) were obtained when the calculated EMI ranged between -1.85 and -0.25 (P < 0.001)., Conclusion: Fibrillatory rate obtained from the surface ECG and systolic left atrial area obtained by echocardiography may predict early AF recurrence in patients with persistent AF. These parameters might be useful in identifying candidates with a high likelihood of remaining in sinus rhythm after cardioversion.

The technologically important prediction of Auger recombination lifetimes in semiconductors is addressed by means of a fully first-principles formalism, based on precise energy bands and wave functions provided by the full-potential linearized augmented plane wave code. The minority carrier Auger lifetime is determined by two related approaches: (i) a direct evaluation within Fermi's golden rule, and (ii) an indirect evaluation, based on a detailed balance formulation combining Auger recombination and its inverse process, impact ionization, in a unified framework. Lifetimes determined with the direct and indirect methods show excellent consistency between them (i) for n-doped GaAs and (ii) with measured values for GaAs and InGaAs. This indicates the computational formalism as a new sensitive tool for use in materials performance optimization.

An increase in sinus rate has been previously described in patients with AV node reentry (AVNRT) following successful AV node modification. This increase could either be a specific sign of elimination of slow pathway conduction or it could be a consequence of energy application in the posteroseptal area. Thus, we compared the changes in sinus cycle length following successful slow pathway ablation (defined as complete elimination of dual AV node physiology) in patients having AVNRT with those in patients undergoing successful ablation of a posteroseptal atrioventricular accessory connection. Twenty five patients (16 women and 9 men, mean age 41 +/- 4 years) with typical AVNRT (cycle length 378 +/- 12 ms) and 29 patients (16 women and 13 men, age 34 +/- 5 years) with an accessory connection (17 manifest and 12 concealed) were studied. The electrophysiology study was performed during sedation with Fentanyl and Midazolam. The mean number of energy applications was 3 +/- 1 for successful slow pathway ablation and 4 +/- 1 for successful ablation of the accessory connection (p:NS). Following the successful energy application, the sinus cycle length decreased significantly 776 ms at baseline to 691 ms in patients with AVNRT. Following successful ablation of the posteroseptal AC, sinus cycle length decreased from 755 ms at baseline to 664 ms (p < 0.05 in both groups [difference between groups not significant]). The decrease in sinus cycle length did not correlate with the number of RF energy applications required for successful ablation or the total energy delivered. In conclusion, ablation of the AV node slow pathway and a posteroseptal accessory connection results in similar increases in the sinus rate. Thus, the increase in sinus rate is probably due to energy application in the posteroseptal space, possibly due to concomitant destruction of vagal inputs, and it is not specific for elimination of slow pathway conduction.

Background: Interest in minimally invasive coronary artery bypass grafting has been increasing., Methods: From April 1994 through December 1996, 199 patients (age, 36 to 93 years) underwent minimally invasive coronary artery bypass grafting through minithoracotomy, subxiphoid, and lateral thoracotomy incisions, with internal mammary artery, gastroepiploic artery, and composite grafts placed using local coronary artery occlusion., Results: The conversion rate to sternotomy was 7% (14/199). Preoperative risk factors included unstable angina (n = 83), reoperative coronary artery bypass grafting (n = 54), low ejection fraction (n = 53), congestive heart failure (n = 44), renal insufficiency (n = 25), chronic obstructive pulmonary disease (n = 36), cerebrovascular accident (n = 22), and diffuse vascular disease (n = 47). Morbidity included wound infections (n = 5), reoperation for management of bleeding (n = 6) and acute graft occlusion (n = 2), perioperative stroke (n = 1), atrial fibrillation (n = 14), and perioperative myocardial infarction (n = 7). The operative mortality was 3.8% (7/185). The number of grafts placed in 185 patients was as follows: single, 156; double, 28; and triple, 1. Early (less than 36 hours) angiography and Doppler flow assessment of the coronary anastomoses in 85% of the patients showed that 92% were patent. Routine use of mechanical stabilization of the coronary artery since April 1996 was found to be associated with an increase in the patency rate of the left internal mammary artery-left anterior descending coronary artery anastomosis to 97%, versus 89% (p = 0.055) associated with conventional immobilization techniques. Of the 148 patients followed up beyond 1 month (range, 1 to 32 months; mean, 9.2 +/- 7.4 months) postoperatively, 3 have died (3 to 7 months), and of the 145 survivors the cardiac-related event (percutaneous transluminal coronary angioplasty, reoperation, readmission for recurrent angina, and congestive heart failure)-free interval was 93%., Conclusions: The minimally invasive coronary artery bypass grafting operation is safe and effective. Regional cardiac wall mechanical immobilization enhances the early graft patency and must be considered an essential part of this operation.

A major problem in patients with cardioverter-defibrillators is to determine reliably the mechanism for spontaneous implantable cardioverter-defibrillator (ICD) discharges. Electrogram storage in ICD devices is comparable to that in permanent Holter monitors. Stored bipolar electrograms obtained from the sensing or shocking lead system contain a wide variety of different information. Intracardiac electrograms (EGMs) recorded from pace/sense electrodes (or "near-field" EGMs) show bipolar signals that have a distinct absence of any atrial activity during ventricular tachycardia or sinus rhythm. In contrast, the EGMs recording from the shocking electrodes, integrating a much larger area of myocardium, provide a more global visualization of electrical activity, which includes both atrial and ventricular deflections. Improved diagnostic capabilities available in the new generation ICD devices, in particular the stored intracardiac EGMs, facilitate sensing error diagnosis, permit a better evaluation of device function and ICD detection algorithms, and are helpful for reprogramming in order to overcome or prevent errors. In addition, EGMs give us a unique opportunity to gather information about the arrhythmic mechanism of the sudden cardiac death syndrome. Information such as the day and time of the episode, the preceding heart rate, the influence of the coupling interval of preceding premature beats, and their morphology can be gained from the analysis of stored EGM recordings. Although the availability of stored intracardiac EGMs are of enormous value in troubleshooting of ICD problems, they are occasionally not conclusive and must be complemented by additional techniques in order to complete the diagnosis. The information obtained by the analysis of stored intracardiac EGMs together with a database of EGMs can be of great importance for further improvements in future devices and may provide insights as to which patients are likely to benefit most from ICD therapy.

Differences in blood pressure between direct intra-arterial and indirect cuff measurements have been reported, especially in elderly patients. We investigated the incidence of pseudohypertension among hypertensives with a poor response to drug therapy. We studied 24 patients, aged between 18 and 65 years, whose blood pressure could not be normalized with a combination of at least two antihypertensive drugs. We found no difference in systolic blood pressure but diastolic blood pressure was significantly (P less than 0.001) lower when measured intra-arterially. The mean difference between the direct and the indirect blood pressure determination was 16.2 +/- 1.5 mmHg (s.e.m.), and the range was 2.3-39.6 mmHg. Age, duration of hypertension and left ventricular hypertrophy was not correlated with the incidence and extent of pseudohypertension. We conclude that in hypertensives with a poor response to drug therapy, blood pressure measurements should be taken intra-arterially in order to avoid the hazards of overtreatment.

In the present study the effects of 1 h intravenous infusion of alpha-human atrial natriuretic peptide (24 ng/min/kg) on systemic and renal hemodynamics and on renal excretory function were studied in six insulin-treated and metabolically well-controlled patients with diabetes mellitus (DM) type I and in six healthy control subjects (C). Basal plasma atrial natriuretic peptide (ANP) concentration was 14.6 +/- 2.0 in DM patients and 14.9 +/- 1.3 pmol/L in C and rose similarly in both groups to 87.1 +/- 22.1 and to 86.9 +/- 11.1 pmol/L, respectively, during alpha-hANP infusion (P less than .05). Maximal effects of alpha-hANP occurred between 30 and 60 min after the start of the infusion. Mean arterial pressure (MAP) (83 +/- 5 v 81 +/- 3 mm Hg), heart rate (HR) (63 +/- 2 v 64 +/- 4/min) and total peripheral resistance (TPR) (11 +/- 1 v 10 +/- 1 mm Hg.min/L) remained unaltered in patients with DM. In contrast, in C MAP and TPR decreased from 83 +/- 3 to 77 +/- 2 mm Hg and from 12 +/- 1 to 10 +/- 1 1 mm Hg.min/L, respectively (P less than .05), whereas HR increased from 53 +/- 2 to 59 +/- 3 beats/min (P less than .05). Cardiac output (CO) rose initially by 11% and by 9% in DM and C, respectively. Urine flow increased from 4.1 +/- 0.9 to 11.3 +/- 1.5 mL/min in DM patients and from 3.9 +/- 1.0 to 8.4 +/- 0.8 mL/min in C (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Perceptions of secondary LD program supervisors were identified and compared with views of secondary LD teachers regarding the presence of specific program features, field-related issues, and suggestions for program improvement. Responses indicated that the supervisors were more positive and, in many cases, held significantly different views than LD teachers.

The results obtained in the cytologic study of sputa from 630 patients are presented. There were 251 cases of bronchogenic carcinoma; diagnosis through sputum examination was possible in 57.4 per cent of the patients. Abnormal cells were detected in an additional 24.3 per cent. Sputum examination has proven to be a valuable complement by establishing the correct diagnosis when other methods failed. Cancer cells were unequivocally identified in 45.8 per cent of the cases with normal bronchoscopic examination and in 52.4 per cent of the cases in which bronchial biopsy did not include malignant tissue. The same proportion of cases with the various tumor types was obtained by cytologic and by histologic study. However, one of the methods often showed a higher degree of cellular differentiation than the other. The number of cases with undifferentiated cancer or unclassified tumors was markedly reduced when the information concerning cell differentiation available through both methods was used. In this manner, excluding the oat cell carcinomas, only 7.6 per cent of the cases of bronchogenic carcinoma did not show any cellular differentiation. The authors recommend wider use of the information provided by simultaneous evaluation of both cytologic smears and tissue sections in order to achieve a more accurate appraisal of tumor type.