Search

Coronary angiographic observations in 10 patients with coronary artery aneurysms (CAAs) are reported. Four patients had atherosclerotic (acquired) and six had congenital CAAs. The mean age of patients with acquired CAAs was higher (64.7 years) compared with the congenital group (53.2 years). Ipsilateral myocardial infarction (MI) occurred in three of four patients with acquired CAAs but MI was not located on the same side as the aneurysm-bearing coronary artery (contralateral) in two patients with the congenital variety. In the patients with congenital CAAs, an aneurysm predilection site was observed in the proximal portion of the aneurysm-bearing vessel. Dual and multiple aneurysms were more common in the acquired CAAs. Although congenital CAAs were sizeable, the small-sized atherosclerotic CAAs developed complications more frequently. During an average follow-up of 7.9 years, only one patient died of a noncardiac cause and another developed recurrent uncomplicated non-Q wave lateral MI. Both subjects had atherosclerotic CAAs. In our series, no rupture or sudden death occurred. Coronary artery bypass grafting (CABG) was performed in three patients with acquired and in one patient with congenital CAAs. In the latter patient, simultaneous ligation of the congenital aneurysm associated with a coronary arteriovenous fistula was performed. Regarding antiplatelet and anticoagulant policy for the whole group, three patients were on aspirin, four were on acenocoumarol, and in another three subjects with congenital CAAs, a medical regimen was followed. Larger series, however, are required in order to elucidate further angiographic characteristics of acquired vs congenital CAAs.

Item does not contain fulltext Elderly patients with heart failure are at risk of postprandial hypotension (PPH), orthostatic hypotension (OH), and concomitant cerebral oxygenation changes because of altered cardiovascular balance and the use of cardiovascular medications, such as furosemide and captopril. In 24 patients with heart failure (New York Heart Association class II to III, in stable condition, and receiving cardiovascular medication [aged 70 to 83 years]), blood pressure (BP) was measured by Finapres, and cortical concentrations of oxyhemoglobin and deoxyhemoglobin were measured using near-infrared spectroscopy during standing and after a 292-kcal carbohydrate meal. Tests were performed before and during therapy with furosemide 40 mg once daily (n = 11) or captopril 6.25 and 12.5 mg twice daily (n = 13) in a double-blind randomized trial. Before treatment, 13 of 24 patients had PPH, and 2 of 24 patients had OH. The first dose of furosemide significantly decreased postprandial systolic BP (p

For many years, paediatric cardiologists and paediatric cardiac surgeons have felt the need for a common diagnostic and therapeutic coding system with which to classify patients of all ages with congenital and acquired heart disease. This desire has been highlighted by the recent, and ongoing, enquiry into the outcome of paediatric cardiac surgery at the unit in Bristol, in the United Kingdom, and the resulting obligation to provide national and international comparisons of surgical results between centres caring for these patients. In order to incorporate effective clinical governance and best practice into our speciality, a method is required to gather accurate and validated data on the diagnosis, therapy and outcome of patients with heart disease from prenatal life through to adulthood. This would facilitate comparisons between individual units which fully take into account the mix of cases involved, and thus attempt to focus on the relevant and genuine factors underlying the differing outcomes in terms of both mortality and morbidity. For this to be achieved, it is essential to have a comprehensive system of coding and classification, using mutually exclusive and unambivalent terms. The system must be both easy to use, and fulfil the needs and expectations of widely different cultures of practice. Although many centres have developed their own system of internal audit, with their own coding system, and some co-operation has taken place between centres nationally and across international boundaries within Europe by the European Congenital Heart Surgeons Federation (see below), a cohesive, and comprehensive system suitable for setting standards has yet to emerge. Historically, this has partly been due to the lack of recognition by governments of the importance of such a process, with underfunding of initiatives aimed at addressing these issues, both technologically and in terms of human resources.

Background: Apple peel atresia is the rarest type of small bowel atresia. Because of its rare occurrence and high mortality rate, little is known about the long-term outcome of these children.Methods: The patient charts, operative reports, and office notes of 15 children with apple peel atresia from 6 pediatric surgical centers in the Netherlands were reviewed. Longterm follow-up was assessed through review of office notes and through questionnaires.Results: The median age at the time of operation was 1.5 days. Postoperatively, 53% suffered from cholestasis, and 40% were septic. Three patients died (20%). At follow-up at a median age of 24 months, 1 child showed growth retardation and 2 children suffered from short bowel syndrome. At the time of the questionnaire, all children showed normal growth and development.Conclusions: Even though children with apple peel atresia often suffer serious morbidity like short bowel syndrome and sepsis during the postoperative course, late morbidity turned out to be low. If the patients survive the operative and direct postoperative period, and survive the morbidity associated with malnutrition and the long-term use of total parenteral nutrition, they have a good chance of having normal bowel function with normal growth and development. J Pediatr Surg 37:61-65. Copyright (C) 2002 by W.B. Saunders Company.

Item does not contain fulltext BACKGROUND: Identify risk factors associated with mortality following repeat coronary revascularization (redoCABG) within the first 6 months following surgery. METHODS: Five hundred forty-one redoCABG patients (1987 to 1998) were studied by univariant and multivariant analysis. Mortality was assessed at three different points: hospital mortality (A) (36/541, 6.7%); mortality at 6 months (C) (75/541, 13.9%); and outpatient perioperative mortality, which is a death occurring from the time of hospital discharge to 6 months postoperatively (B) (39/541, 7.2%). RESULTS: Diabetes, hypertension, peripheral vascular disease, renal insufficiency, lung disease, myocardial infarction (MI) before the first operation, MI between the first and redoCABG, lack of sinus rhythm, no IMA graft, acute/emergency operation, perfusion time, and perioperative MI were all identified as risk factors related to early mortality. MI before the first operation, antegrade cardioplegia, and the time period 1987 to 1992 all influenced hospital mortality (A). Diabetes, hypertension, renal insufficiency, lung disease, and valvular heart disease all influenced the outpatient mortality up to 6 months. Independent predictive factors for early mortality were: age more than 69 years; diabetes; vascular insufficiency; chronic lung disease; MI between first and redoCABG; no IMA-graft; acute preoperative MI; emergency operation; perfusion time; perioperative MI; and the time period 1987 to 1992. Risk factors for in-hospital death included MI between the first and redoCABG, cardiopulmonary bypass time, and the time period 1987 to 1992. Diabetes is an important risk factor during the outpatient perioperative phase. Emergency surgery and perioperative MI predict mortality regardless of the time period (A, B, or C). CONCLUSIONS: Early mortality after redoCABG is influenced by many variables during the first 6 months following surgery. Understanding these factors and their time course may better help to assess the true risk associated with reoperation for recurrent coronary insufficiency.

Item does not contain fulltext OBJECTIVES: The aim of this study was to investigate the influence of prehospital administration of aspirin and heparin on the initial patency of the infarct-related artery (IRA) in patients with acute myocardial infarction (MI). BACKGROUND: Prehospital diagnosis of acute MI facilitates early pharmacologic intervention on the way to the catheterization laboratory for primary angioplasty. METHODS: We studied the angiographic data and 30-day clinical outcome of 1,702 patients treated with primary angioplasty; 860 received aspirin and heparin before transportation to our hospital and 842 received aspirin and heparin in our hospital. RESULTS: The Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 flow in the IRA was higher in the prehospital treated group (31% vs. 20%, relative risk 0.65, 95% confidence interval 0.55 to 0.78, p < 0.001). Patients with TIMI 2 or 3 flow on the initial angiogram had a higher angioplasty success rate (94% vs. 89%, p < 0.001), a smaller enzymatic infarct size, a higher left ventricular ejection fraction and a lower 30-day mortality (1.6% vs. 3.4%, p = 0.04). CONCLUSIONS: Prehospital administration of aspirin and heparin results in a higher initial patency of the IRA in patients with acute MI.

Objective. A scoring system to predict early mortality and morbidity in CABG, distinguishing low and high risk patients. Methods. 563 patients (1998) served as development dataset, 969 patients as validation set. Univariate and logistic regression analysis was used to identify risk factors. Results. Gender, hypertension, pulmonary disease, reoperation, age. operative status and left-ventricular function were predictive variables for early mortality. The area under the ROC curve was 0.81. We identified a low risk, mortality of 1.8% and a high-risk group, mortality of 13.4%. Diabetes, hypertension, kidney and lung disease, reoperation, operative status and left ventricular function were predictive variables for morbidity. The area under the ROC curve was 0.73. We identified a low risk, morbidity of 17%, and a high-risk group, morbidity of 41%. Conclusion. This scoring system is a simple system identifying a low and high-risk group for morbidity and early mortality.

Item does not contain fulltext To obtain information on water and salt regulating hormones and volume homeostasis during neonatal extracorporeal membrane oxygenation (ECMO), serial determinations of atrial natriuretic peptide (ANP), plasma renin activity (PRA), aldosterone (Aldo), antidiuretic hormone (ADH), colloid-osmotic pressure (COP), osmolality (Osmol), and central venous pressure (CVP) before, during, and after neonatal ECMO in 10 neonates with meconium aspiration syndrome (MAS) were carried out. Mean gestational ages and birth weights were 41(+3) weeks (39(+6) - 42(+4)) and 4,063 gm (3,500-4700), respectively; mean age at start and duration of ECMO 29.3 (14-69) and 152.6 hr (92-267), respectively. Plasma ANP (mean +/- SD) was 67.8+/-69.1 pmol/L before, decreased to 33.3+/-22.1 (not significant) pmol/L during, and significantly increased to 274.6+/-131.8 pmol/L after ECMO (p < 0.05). ANP correlated positively with CVP (r = 0.63; p < 0.001). Pre-ECMO PRA, Aldo, and ADH were comparable to those described earlier in normal neonates, decreased during (p < 0.001 for Aldo; p < 0.05 for PRA and ADH) and either remained elevated (PRA, p < 0.001; Aldo, p < 0.05) or decreased (ADH) after ECMO. COP and Osmol remained unchanged. Neonatal ECMO for MAS is characterized by circulatory and osmotic equilibrium. It is suggested that circulating volume contracts during and expands after neonatal ECMO for MAS.

Item does not contain fulltext The composition and morphology of the atherosclerotic lesion are currently considered more important determinants of acute coronary ischemic syndromes than the degree of stenosis. When a lesion is unstable, it may rupture and cause an acute thrombotic reaction. A rupture prone plaque contains a large lipid pool covered by a thin fibrous cap. The stress in the cap increased with decreasing thickness. Additionally, it may be weakened by macrophage infiltration. Intravascular ultrasound elastography might be an ideal technique to assess the presence of lipid pools and identify high stress regions. Elastography is a technique to assess local mechanical properties of tissue. The underlying principle is that the deformation of tissue by a mechanical excitation is a function of its mechanical properties. The deformation of the tissue is determined using ultrasound. For intravascular purposes, the intraluminal pressure is used as the excitation force. The radial strain in the tissue is obtained by cross-correlation techniques on the radio frequency (rf) signal. The strain is colour-coded and plotted as a complimentary image to the IVUS echogram. Elastography was validated in vitro using diseased human coronary and femoral arteries. After the ultrasound experiments, the specimens were processed for routine histology to counterstain collagen, smooth-muscle cells, and macrophage activity. Regions were segmented in the elastograms based on their strain values. Next, the dominant plaque type (fibrous, fibro-fatty or fatty) was defined by observers blinded to the elastographic result. These experiments demonstrate that the strain in the three plaque types is different (Kruskall-Wallis p < 0.001). Especially between fibrous and fatty tissue, a highly significant difference (Wilcoxon p < 0.001) was found. In vivo, the technique is validated in an atherosclerotic Yucatan mini-pig animal model. High-resolution echo frames (30 frames per second) were acquired near end-diastole. In this phase of the pressure cycle, catheter motion was minimal. Frames with a pressure difference of approx. 5 mm Hg were taken to determine the elastograms. This in vivo validation study in Yucatan mini-pigs revealed higher strain values in fatty material (ANOVA p < 0.001). All cross-sections with a fatty plaque were identified with the elastogram by the presence of high strain values. Additionally, data are acquired in patients referred for Percutaneous Transluminal Coronary Angioplasty with the same set-up as tested in the animal study. Ultrasound data of soft, fibrous, calcified and stented plaques are acquired near end-diastole. The elastogram of soft plaques. as identified from the deformation during the pressure cycle, reveals strain values of 1% with increased strain up to 2% at the shoulders of the plaque. Calcified material, as identified from the echogram, shows low strain values of 0-0.2%. The elastogram of stented plaques reveals very low strain values, except for two regions: these are between the stent struts and at the shoulders of the plaque. In conclusion, intravascular elastography appears to be a unique tool to determine local mechanical properties in atherosclerotic lesions to identify fibrous and fatty tissue. Experiments have demonstrated the feasibility of this technique to be applied in vivo.

Item does not contain fulltext

Item does not contain fulltext Assessment of the performance of medical ultrasound equipment is generally based on the image quality in fundamental mode. Recent development of the so-called tissue harmonic imaging (THI) mode induces the need for assessment of differences in the quality of imaging in THI vs. fundamental imaging mode. Quality features to be tested are sensitivity (penetration depth), spatial resolution, contrast resolution, lesion signal-to-noise ratio, and tissue-to-clutter ratio (TCR). These features are explained and examples are shown. The main conclusion from a comparison of the results for the two imaging modes might be that when using THI improvement of TCR, in particular in the near field, is obtained at the expense of a loss in axial resolution. Furthermore, lesion detection is not significantly improved.

Item does not contain fulltext BACKGROUND: Antiplatelet treatment with aspirin and oral anticoagulants reduces recurrence of ischaemic events after myocardial infarction. We aimed to investigate which of these drugs is more effective in the long term after acute coronary events, and whether the combination of aspirin and oral anticoagulants offers greater benefit than either of these agents alone, without excessive risk of bleeding. METHODS: In a randomised open-label trial in 53 sites, we randomly assigned 999 patients to low-dose aspirin, high-intensity oral anticoagulation, or combined low-dose aspirin and moderate intensity oral anticoagulation. Patients were followed up for a maximum of 26 months. The primary composite endpoint was first occurrence of myocardial infarction, stroke, or death. FINDINGS: The primary endpoint was reached in 31 (9%) of 336 patients on aspirin, in 17 (5%) of 325 on anticoagulants (hazard ratio 0.55 [95% CI 0.30-1.00], p=0.0479), and in 16 (5%) of 332 on combination therapy (0.50 [0.27-0.92], p=0.03). Major bleeding was recorded in three (1%) patients on aspirin, three (1%) on anticoagulants (1.03 [0.21-5.08], p=1.0), and seven (2%) on combination therapy (2.35 [0.61-9.10], p=0.2). Frequency of minor bleeding was 5%, 8% (1.68 [0.92-3.07], p=0.20), and 15% (3.13 [1.82-5.37], p=

Item does not contain fulltext Intravascular ultrasound elastography is a method for measuring the local elastic properties of coronary atherosclerotic plaques using intravascular ultrasound (IVUS). Mechanical properties of the different tissues within a plaque are measured through strain. In the last decade, several groups have applied elastography intravascularly with various levels of success. In this paper, the approaches of the different research groups will be discussed and the focus will be on our approach to the application of intravascular elastography.

Item does not contain fulltext Three children, two boys aged 9 and 6 and a 12-year-old girl, had diffuse abdominal complaints, diarrhoea and a (sub)febrile temperature for several days. On admission, they were found to have a perforated inflamed appendix and peritonitis. Following asystole, intra-abdominal abscesses and an enterocutaneous fistula, the oldest boy showed good recovery after a hospital stay of two months; the girl recovered after one month in hospital following a psoas muscle abscess and two episodes of constrictive pericarditis with threatened tamponade. The younger boy was dead on arrival at the hospital. Appendicitis is not always easy to diagnose. An atypical presentation, very often with diarrhoea, can result in diagnostic delay. Early surgical consultation is mandatory in a child with progressive abdominal pain.

De prevalentie van aangeboren hartafwijkingen bij meisjes geboren met het syndroom van Turner (ts) is hoog, volgens de literatuur ongeveer 20 tot 25%. Hierbij komen vooral de obstructieve afwijkingen van de linker harthelft voor. Ook dilatatie van de aortawand met kans op dissectie en ruptuur wordt vaker gerapporteerd, hoewel harde gegevens over de prevalentie ontbreken. Aangeraden wordt om meisjes met ts zo snel mogelijk cardiologisch te onderzoeken als de diagnose is gesteld. Is op jonge leeftijd geen aangeboren afwijking aanwezig, dan wordt geadviseerd het cardiologische onderzoek te herhalen tijdens de puberteit. Vervolgens moet het aortaonderzoek iedere 3 tot 5 jaar worden herhaald, maar zeker voor en tijdens een geplande zwangerschap. Hypertensie komt bij ongeveer 25% van de meisjes met ts voor. Geregelde bloeddrukcontrole is dus gewenst. Een nadelig effect van de groeihormoonbehandeling op de hartspier is tot op heden niet aangetoond, maar langetermijnonderzoek hiernaar is zeker noodzakelijk.

Item does not contain fulltext BACKGROUND: Activated platelets play a major role in acute vessel closure after coronary angioplasty. Although aspirin is the routine therapy during angioplasty, it only incompletely prevents acute closure. This might be due to suboptimal dosing. OBJECTIVE: First, to study the effect of additional high-dose aspirin on platelet activation during coronary angioplasty. Second, to assess the potential of the new PFA-100 analyzer to evaluate the effect of different doses of aspirin in patients undergoing angioplasty. METHODS: Fifty-one patients on 100 mg aspirin/day for at least 1 month were randomized to continuation of 100 mg aspirin/day only (Group A=24 patients), or to this regime plus a bolus of 1000 mg of aspirin given 1 day before angioplasty (Group B=27 patients). Results were compared with 15 controls. Platelet function was measured before angioplasty by the PFA-100 analyzer; platelet activation was measured by flow cytometry just before and 1 h after angioplasty. RESULTS: At baseline, Group A had significantly more activated platelets than the control group (P

Background: Hypertension is an established risk factor for cardiovascular disease. Risk factor patterns for various cardiovascular complications are different. We studied the relationship between increasing diastolic blood pressure and arterial wall dynamics of various peripheral arteries in hypertensives to increase insight in the variability of properties within the arterial tree. Methods: Eighty-six untreated hypertensives participated in this cross-sectional study. The study-population was divided into quartiles with increasing diastolic office blood pressure. Cross-sectional compliance and distensibility coefficients of the carotid and femoral arteries were determined, using a vessel wall movement detector system (Wall Track System®). Results: Diameters of both common carotid arteries enlarged (right: from 7.4 ± 0.2 to 7.9 ± 0.2 mm) while cross-sectional compliance (right: from 0.61 ± 0.04 to 0.42 ± 0.04 mm2/kPa) and distensibility coefficients (right: from 14.2 ± 1.0 to 9.0 ± 1.0 10−3/kPa) gradually dropped with increasing diastolic blood pressure. Cross-sectional compliance and diameter of the right common femoral artery remained unchanged while distensibility coefficient decreased although less gradually when compared with the carotid arteries. Conclusions: In untreated hypertensives gradual arterial wall stiffening of the carotid arteries occurred with increasing diastolic blood pressure. Gradual changes were less clear in the common femoral artery which points to the heterogeneity of the arterial tree.

We performed transesophageal echocardiography (TEE) with pediatric biplane probes throughout the procedure of transcatheter closure of the ductus arteriosus in 42 out of 46 patients who were scheduled for this intervention. Patient ages ranged from 15 months to 14 years and body weight from 9-53 kg. Both Rashkind double umbrella devices and coils were used. The described approach resulted in fewer contrast injections and was helpful in monitoring the procedure and in deciding when to release the device. To the best of our knowledge this is the first report describing a large series where continuous monitoring of transcatheter ductus closure was combined with x-ray fluoroscopy and TEE.

OBJECTIVESWe sought to identify the risk factors predicting the development of dilated cardiomyopathy (DCM) in patients with isolated congenital complete atrioventricular block (CCAVB).BACKGROUNDRecently evidence has emerged that a subset of patients with CCAVB develop DCM.METHODSThis was a retrospective study of 149 patients with CCAVB who had heart size and left ventricular (LV) function assessed by echocardiography and chest radiography over a follow-up period of 10 ± 7 years.RESULTSNine patients developed DCM at the age of 6.5 ± 5 years. No definite cause could be identified. In these nine patients, CCAVB was diagnosed in eight at 23 ± 2.3 weeks gestation and in one at birth. Maternal SSA/SSB antibodies were confirmed in seven of the nine patients. Pacemakers were implanted in eight patients in the first month and in one patient at five years of age. The initial left ventricular end-diastolic dimension (LVEDD) was in the 96th ± 2.6 percentile and the cardiothoracic (CT) ratio was 64 ± 3.8% in the nine patients who developed DCM, and differed significantly in patients with CCAVB (p < 0.005) who did not develop DCM. The LVEDD and CT ratio did not decrease in the patients with CCAVB and DCM, but decreased significantly in the patients with CCAVB without DCM (p < 0.001) once pacing was initiated. Two patients with DCM died within two months of diagnosis; one patient is neurologically compromised; two patients received a heart transplant; and four patients are listed for heart transplantation.CONCLUSIONSIsolated CCAVB is associated with a long-term risk for the development of DCM. Risk factors may be SSA/SSB antibodies, increased heart size at initial evaluation and the absence of pacemaker-associated improvement.

Milk, dairy products, grains, fish and meat can be preserved using living lactobacilli. For the prevention of vaginal infections after sexual intercourse, the use of lactobacilli is recommended. Vaginal infections are increasingly treated with lactobacilli. This kind of bacteria has been reported to prevent both antibiotic-associated diarrhoea (1) and travellers’ diarrhoea (2), and to promote recovery from acute diarrhoea in children (3). In addition, antibacterial, antitumour and antimutagenic effects of these bacteria have been reported. This makes people consume probiotic lactobacilli, mainly Lactobacillus acidophilus and/or Lactobacillus casei to ‘cleanse the body and to increase natural defence’. Another group of probiotic micro-organisms are the nonpathogenic yeasts, of which Saccharomyces boulardii is increasingly used in cases of diarrhoea. To date, all data concerning beneficial effects of lactobacilli and yeasts on health have been collected empirically rather than from a sound scientific basis. Our studies on the fundamental microbiological (4) and metabolic (5) aspects of short small bowel syndrome (SSBS; 6) allow us to create a simple immunity model that may explain both the lactobacilli- and the yeast-mediated effects. This will also reduce the number of effects which have previously been characterized as immunological. The model dismantles the rather mysterious mechanism of immuno-manipulation, and shows that the real immunological processes are limited to intestinal immuno-stimulation.

Item does not contain fulltext Oral anticoagulation is one of the oldest ways for preventing secondary ischemic heart disease. With the introduction of aspirin, and low-dose aspirin in particular, the interest in oral anticoagulants has diminished, given the inherent bleeding risk. This short review deals with the efficacy and safety of oral anticoagulation in treating ischemic heart disease compared to placebo and to low-dose aspirin. Also, the comparison of the combination of oral anticoagulants and aspirin to aspirin alone is made. After myocardial infarction, oral anticoagulation is far superior to placebo in preventing recurrent ischemic events, with a risk of major bleeding of 1 per 100 patient-years. Oral anticoagulation seems equivalent to aspirin after myocardial infarction, but shows the same excess bleeding. Clearly, aspirin is, therefore, preferable for this indication. Combination therapy with oral anticoagulants and aspirin seems superior to aspirin alone provided the international normalized ratio is kept over 2.0. Also, here bleeding occurs in 1 out of 100 patient-years and the risk must be weighed against the risk of recurrent ischemic events. In coronary angioplasty, warfarin given before intervention looks promising in one large trial, but when given after intervention it is not beneficial and leads to more bleeding. Long-term oral anticoagulation does not lead to better graft patency after coronary surgery, but in one large trial it did lead to a better rate of survival.

Gerrits HL, de Haan A, Sargeant AJ, van Langen H, Hopman MT. Peripheral vascular changes after electrically stimulated cycle training in people with spinal cord injury. Arch Phys Med Rehabil 2001;82:832-9. Objective: To test whether a short period of training leads to adaptations in the cross-sectional area of large conduit arteries and improved blood flow to the paralyzed legs of individuals with spinal cord injury (SCI). Design: Before-after trial. Setting: Rehabilitation center, academic medical center. Participants: Nine men with spinal cord lesions. Intervention: Six weeks of cycling using a functional elec- trically stimulated leg cycle ergometer (FES-LCE). Main Outcome Measures: Longitudinal images and simul- taneous velocity spectra were measured in the common carotid (CA) and femoral (FA) arteries using quantitative duplex Doppler ultrasound examination. Arterial diameters, peak sys- tolic inflow volumes (PSIVs), mean inflow volumes (MIVs), and a velocity index (VI), representing the peripheral resis- tance, were obtained at rest. PSIVs and VI were obtained during 3 minutes of hyperemia following 20 minutes of FA occlusion. Results: Training resulted in significant increases in diam- eter ( p .01), PSIVs ( p .01), and MIVs ( p .05), and reduced VI ( p .01) of the FA, whereas values in the CA remained unchanged. Postocclusive hyperemic responses were augmented, indicated by significantly higher PSIVs ( p .01) and a trend toward lower VI. Conclusion: Six weeks of FES-LCE training increased the cross-sectional area of large conduit arteries and improved blood flow to the paralyzed legs of individuals with SCI.

Item does not contain fulltext Glycoprotein IIB/IIIA receptor blockers given early to patients with ST segment elevation acute coronary syndrome improves early coronary patency, both in the absence and presence of thrombolytic therapy. Glycoprotein IIB/IIIA receptor antagonists can be given prehospitally to patients eligible for primary angioplasty and may enhance the efficacy in improving the outcome of patients undergoing primary angioplasty for acute myocardial infarction. Glycoprotein IIB/IIIA receptor blockers used as adjunct to fibrinolytic therapy have promising angiographic results. Large trials evaluating the efficacy and safety of these combinations compared to fibrinolytic therapy alone are underway.

Item does not contain fulltext 5 p.

Hirschsprung disease (HSCR) is a congenital disorder characterised by intestinal obstruction due to an absence of intramural ganglia along variable lengths of the intestine. RET is the major gene involved in HSCR. Mutations in the GDNF gene, and encoding one of the RET ligands, either alone or in combination with RET mutations, can also cause HSCR, as can mutations in four other genes (EDN3, EDNRB, ECE1, and SOX10). The rare mutations in the latter four genes, however, are more or less restricted to HSCR associated with specific phenotypes. We have developed a novel comprehensive mutation detection system to analyse all but three amplicons of the RET and GDNF genes, based on denaturing gradient gel electrophoresis. We make use of two urea-formamide gradients on top of each other, allowing mutation detection over a broad range of melting temperatures. For the three remaining (GC-rich) PCR fragments we use a combination of DGGE and constant denaturing gel electrophoresis (CDGE). These two dual gel systems substantially facilitate mutation scanning of RET and GDNF, and may also serve as a model to develop mutation detection systems for other disease genes. In a screening of 95 HSCR patients, RET mutations were found in nine out of 17 familial cases (53%), all containing long segment HSCR. In 11 of 78 sporadic cases (14%), none had long segment HSCR. Only one GDNF mutation was found, in a sporadic case.

Item does not contain fulltext

Item does not contain fulltext

Item does not contain fulltext

Item does not contain fulltext

Objective: A direct communication between the pulmonary artery and the left atrium is a rare anomaly. On the basis of two cases of our own and a literature review of 49 cases, we focus on clinical presentation, anatomy, diagnosis, and the role of surgery. Methods: Two cases of a fistula between the right pulmonary artery and the left atrium are described in a girl of 4 years and a boy of 15 years. Both presented with unexplained cyanosis. Diagnosis was made on echocardiography and angiography. The fistula was ligated using extracorporeal circulation in the first case and not in the second case. Results: The surgical results were successful with resolution of the cyanosis. Conclusions: In newborns, urgent surgery may be necessary. In other patients, early elective surgical correction should be performed to prevent complications, especially systemic and cerebral emboli, cerebral abscesses, and rupture of aneurysmal fistulas. Complete cure can be achieved by ligation and possible division or by intracardiac repair. © 1997 Elsevier Science B.V.

Item does not contain fulltext 4 p.

BACKGROUND AND AIM OF THE STUDY As increasing impedance of the pacing impulse decreases pacing current, high pacing impedance lowers pacing current and subsequently prolongs pacemaker longevity. The present assumption of a standard 500 ohms impedance disregards interindividual differences. In the present study, the interindividual range of pacing impedance was assessed at implantation. Additionally clinical parameters of patients with low pacing impedance were compared to those of patients with high values. PATIENTS AND METHODS The same lead and the same pacemaker (CapSure VDD; Thera VDD; Medtronic) were implanted in 126 patients (79 men, 47 women, mean age 65 +/- 16 years). Patients with an impedance below or similar to the median were compared to patients with an impedance above the median in respect to clinical (age, gender, arterial hypertension, cardiac diseases such as coronary heart disease, valvular heart disease, cardiomyopathy) and electrical parameters (pacing threshold at 0.5 ms pulse duration, R-wave amplitude). RESULTS Mean impedance was 687 +/- 121 ohms with a range from 333 to 1040 ohms and a median of 670 ohms. 64 patients had an impedance 670 ohms. Mean age, gender and the occurrence of arterial hypertension were similar in the two groups. Cardiac diseases occurred significantly (P < 0.01) more often in patients with lower (n = 23) than with higher impedance (n = 9). Intraoperative pacing thresholds and R-wave amplitudes were not different between the two groups. CONCLUSIONS The range of pacing impedance was 707 ohms for the studied lead. Under consideration of permanent pacing with 2.5 V pulse amplitude and 0.5 ms pulse duration this would vary expected longevity of the implanted pacemaker from 7.8 to 9.3 years. Patients with lower impedance more often had cardiac diseases than patients with higher impedance.

Between 1970 and 1993, 446 patients underwent pneumonectomy. Completion pneumonectomy was performed in 37 patients (8.3%): 34 men and 3 women, with a mean age of 61 years (range 20-78 years). Indications were benign disease in 4 patients and carcinoma in 33. Of the latter, 21 patients underwent resection for metachronous lung cancer, 6 for recurrent lung cancer, 4 for previous incomplete resection, I for primary lung cancer after previous resection for benign disease and 1 patient after previous segmentectomy for metastasis. The mean interval between first operation and completion pneumonectomy was 41 months (range 1-187 months) for the whole group, 30 months for benign disease and 42 months for carcinoma. The overall operative mortality was 6/37 (16.2%); 1/4 patients with benign disease and 5/33 (15.2%) patients with carcinoma. Nine patients (29%) had one or more major non-fatal complication. Actuarial 3- and 5-year survival rates were 41.0% and 24.5% for the entire group, 75% at both times for patients with benign disease, 36.4% and 18.3% for all patients with carcinoma at the time of completion pneumonectomy and 24.3% and 14.5% for patients with metachronous or recurrent lung cancer. For 15 patients with stage I or II metachronous lung cancer, the 3- and 5-year survival rates were 33.9% and 16.9%. All six patients with stage III metachronous cancer died within 18 months. In conclusion, completion pneumonectomy carries a high operative mortality and morbidity. Long-term survival is negatively influenced by stage III lung cancer.

Item does not contain fulltext

After epidural administration of 15 mg 3, 6-dinicotinoylmorphine (nicomorphine) in 10 patients undergoing pulmonary surgery, the parent compound was quickly metabolized into the metabolites 6-mononicotinoylmorphine and morphine. The mean apparent half-lives (+/- SD) of elimination were 10 min (0.165 h +/- 0.053 h) for 3,6-dinicotinoylmorphine and 1.77 h +/- 1.23 h for 6-mononicotinoylmorphine. Morphine is subsequently metabolized into morphine-3-glucuronide and morphine-6-glucuronide. The apparent half-lives of morphine, morphine-3-glucuronide, and morphine-6-glucuronide are similar: 3.63 h +/- 1.63 h, 4.10 h +/- 0.57 h, and 4.20 h +/- 1.64 h respectively. The possible glucuronide conjugate of 6-mononicotinoylmorphine was not detected. The prodrug 3,6-dinicotinoylmorphine was biotransformed into three active compounds: 6-mononicotinoylmorphine, morphine, and morphine-6-glucuronide.

Item does not contain fulltext

Item does not contain fulltext This report investigated the origin of H(2)S in a newborn boy with sulfhaemoglobin induced cyanosis, who died because of multiple organ failure. Frozen material was collected and studied after death. The results suggest that enzymes had been released from deteriorating organs into the blood and abdominal fluid, and that the reaction of one of these enzymes with sulfur containing amino acids might have resulted in increased H(2)S concentrations. It is hypothesised that this release of enzymes resulted from a haemolysin produced by an invasive haemolytic Escherichia coli that was found in the blood and organs of this patient.

Item does not contain fulltext

Unstable coronary artery disease continues to pose a major challenge to clinicians. The advent of new therapies, such as percutaneous transluminal coronary angioplasty, low-molecular-weight heparins, and glycoprotein IIb/IIIa inhibitors, provides new management options for this indication but also raises new questions with regard to optimal management. Prospective randomized trials with well-defined, long-term outcome measures and a means of identifying which patients will derive most benefit from each treatment, together with a means of rapid and clear dissemination of study results and implications, are required in order to advance the management of unstable coronary artery disease.

Item does not contain fulltext 3 p.

Contains fulltext : 25438___.PDF (Publisher’s version ) (Open Access)

An intravascular stent was successfully implanted in a 15-year-old gid with stenosis of the left pulmonary artery subsequent to a modified Fontan correction. Complaints of tiredness, edema, ascites and enlargement of the left breast disappeared. Unfortunately, she died of a rhythm disturbance unrelated to the stent. Autopsy revealed excellent endothelialization of the stent without any thrombosis and with patency of the orifice of the branch to the upper lobe of the lung.

Item does not contain fulltext We studied the association between plasma total homocysteine concentrations and the occurrence of stroke in newborn infants (n = 24). Newborn infants with stroke had significantly higher mean total homocysteine concentrations compared with 94 healthy newborn infants (9.3 vs 7.4 micromol/L). The odds ratio for neonatal stroke was 3.95 (95" CI 1.53-10.16) at the 80" cutoff level.

Item does not contain fulltext

Objective: Hyperhomocysteinemia has been identified as a risk factor for (cardio)vascular disease. Whether hyperhomocysteinemia contributes to graft failure after peripheral bypass surgery remains unclear. The present study evaluated the influence of hyperhomocysteinemia on graft patency after infrainguinal bypass surgery. Design: The present study was designed as a nested case-control study. Method: In this study (nested in the Dutch Bypass Oral anticoagulants or Aspirin Study), 150 patients with graft occlusion were each matched with two randomly selected controls with patent grafts (N = 299) from the same trial. Venous blood samples were drawn from cases and controls, and total plasma homocysteine (tHcy) was determined. Mean serum homocysteine levels and the presence of hyperhomocysteinemia (>95th percentile in healthy individuals) were compared between cases and controls. Results: No significant differences were found between serum levels of homocysteine in patients with and without graft occlusion. The mean plasma homocysteine levels were 14.4 μmol/L and 14.9 μmol/L in the case and control groups, respectively. The resulting mean difference was −0.4 (95% confidence interval [CI], −1.8-0.9). The odds ratio of hyperhomocysteinemia was 0.81 (95% CI, 0.49-1.33). Adjustment for risk factors of graft occlusion did not change these results. Conclusions: Postoperative raised serum levels of homocysteine proved not to be a risk factor for graft occlusion after infrainguinal bypass grafting. (J Vasc Surg 2002;36:336-40.)

T has been a growing awareness of the crucial role of the cascade of platelet-related events in the formation of an arterial thrombus. Platelet activation, adhesion, and aggregation result in the release of products causing vasoconstriction, thrombin generation, further platelet aggregation, and the initiation of the coagulation cascade. Given the pathophysiologic substrate of plaque rupture, thrombosis, and the platelet-rich milieu of acute coronary syndromes, plus the role played by platelets in the development of atherosclerosis, the benefit of platelet inhibition in both the acute and chronic phases of coronary artery disease is easily understood. Aspirin, which has been known as an antipyretic and analgesic for 100 years, has undergone a resurgence of popularity since it became appreciated in the 1980s as the most cost-effective agent for the secondary prevention of coronary artery disease. Following myocardial infarction, aspirin reduces death and recurrent myocardial infarction by 30%, and in patients with unstable angina, subsequent infarction is reduced by approximately 30%. Other subsets of patients with coronary artery disease that have been shown to benefit from aspirin include patients with previous coronary bypass surgery, previous coronary intervention, those with chronic stable angina, and those with a history of stroke and transient ischemic attacks. Aspirin’s undoubted clinical success is perhaps somewhat surprising, because it is a relatively weak antiplatelet agent that affects only 1 of the many pathways involved in platelet aggregation. Aspirin inhibits the cyclooxygenase pathway, but leaves the others intact, including several pathways activated in response to thrombin and collagen, both of which are abundant in acute coronary syndromes and after percutaneous coronary intervention. Inhibitors of the adensosine diphosphate-mediated pathway for platelet aggregation, such as ticlopidine and the more recently introduced clopidogrel, which lack the neutropenic side effects of ticlopidine, may be superior to aspirin for several indications, including transient ischemic attacks and peripheral vascular disease. In contrast, one of the strongest and most frequent indications for aspirin is in patients who have survived an acute myocardial infarction, a subgroup in which clopidogrel did not demonstrate an advantage over aspirin in the Clopidogrel versus Aspirin in the Prevention of Recurrent Ischemic Events (CAPRIE) trial. Furthermore, the safety of clopidogrel has been questioned because sporadic cases of thrombotic thrombocytopenic purpura with use of clopidogrel have been identified, although the incidence is probably only about 1 of 300,000 patients treated. Nonetheless, among acute infarct survivors, who remain intolerant of aspirin, clopidogrel may be a good but costly alternative. The only serious candidate that may add to the efficacy of aspirin is also clopidogrel. Recently, the Clopidogrel in Unstable Angina to prevent Recurrent Events (CURE) trial, in which clopidogrel plus aspirin was compared with aspirin alone in 12,500 patients with non–ST elevation acute coronary syndromes, showed a significant acute and long-term benefit, both in patients who did and did not undergo intervention, albeit with a 40% increase in major bleeding. These results have led to extensive use of clopidogrel in non–ST-segment elevation acute coronary syndromes, where clearly more efficacy and safety data are necessary, especially in patients who require urgent coronary surgery. Currently, short-term clopidogrel is being tested in 40,000 patients with ST-elevation myocardial infarction in China (Chinese Cardiac Study-2 [CCS-2]), and long-term clopidogrel has been evaluated in 2,000 patients after coronary intervention in the Clopidogrel for the Reduction of Events During Observation (CREDO) study, the results of which will be available shortly. These trials may confirm the shortand long-term protection as suggested in the CURE study. During the past 5 years, the intravenous platelet membrane glycoprotein IIb/IIIa inhibitors, particularly abciximab, have been shown to be effective in patients undergoing percutaneous coronary intervention. Among patients with acute coronary syndromes in whom percutaneous coronary intervention is not performed, the magnitude of benefit is less impressive, with an overall risk reduction in 30-day death or myocardial infarction of approximately 12%, which is substantially less than the benefits reported in patients in the coronary intervention trials. In particular, the disappointing results of the large Global Utilisation of Streptokinase and TPA in Occluded arteries-IV (GUSTO)-IV trial, using abciximab in the absence of early coronary intervention, have placed into question the routine use of the glycoprotein receptor blockers in patients not undergoing coronary intervention. Although the glycoprotein IIb/IIIa blockers have an acceptable safety profile with respect to bleeding in acute coronary syndromes, they are expensive. Several lines of evidence from clinical trials, plus an increased understanding of both the pharmacokinetics of the IIb/IIIa inhibitors and the prolonged time course of platelet activation in acute coronary synFrom the Heartcenter, Department of Cardiology, University Medical Center St. Radboud, Nijmegen, The Netherlands; and Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Manuscript received January 23, 2002; revised manuscript received and accepted February 26, 2002. Address for reprints: Freek W.A. Verheugt, MD, Heartcenter, Department of Cardiology, University Medical Center St. Radboud, P.O. Box 9101, Nijmegen, The Netherlands 6500 HB. E-mail: f.verheugt@cardio.umcn.nl.

Item does not contain fulltext In recent years, a new method to measure transverse blood flow, based on the decorrelation of the radio frequency (RF) signals has been developed. In this paper, we investigated the influence of nonuniform flow on the velocity estimation. The decorrelation characteristics of transverse blood flow using an intravascular ultrasound (IVUS) array catheter are studied by means of computer modeling. Blood was simulated as a collection of randomly located point scatterers; moving this scattering medium transversally across the acoustical beam represented flow. First-order statistics were evaluated, and the signal-to-noise ratio from the signals were measured. The correlation coefficient method was used to present the results. Three velocity profiles were simulated: random spread of blood-flow velocity, linear blood-flow velocity gradient, and parabolic blood-flow. Radio frequency and envelope signals were used to calculate the decorrelation pattern. The results were compared to the mean decorrelation pattern for plug blood-flow. The RF signals decorrelation patterns were in good agreement with those obtained for plug blood flow. Envelope decorrelation patterns show a close agreement with the one for plug blood flow. For axial blood flow, there is a discrepancy between decorrelation patterns. The results presented here suggest that the decorrelation properties of an IVUS array catheter for measuring quantitative transverse blood flow probably will not be affected by different transverse blood-flow conditions.

Objectives: Construct a predictive model for early mortality in coronary reoperations (RECABG). Methods: Five hundred and forty one RECABG (1987–1998) were studied by univariate and multivariate analysis. Stepwise selective procedure ðp , 0:05Þ was used to identify a subset of variables with prognostic value for early mortality. This subset was used to calculate a prognostic score ‘S’ and a predicted probability ‘P’ for early mortality, P ¼ 1=1 1 e 2S . Sensitivity analysis was used for evaluation. Results: The best predictive variables for early mortality were diabetes, vascular-, lung-disease, a myocardial infarction between the primary and the RECABG, acute- and emergency operation and the operative period. The prognostic accuracy (receiver operating characteristics curve (ROC) area) was 80%. Observed probabilities compare well with the predicted probabilities, and patients were classified in low risk (5%), intermediate risk (15%), high risk (30%) and very high risk (40%). A predicted probability of $0.40 was used as cut-off point for the prognostic test. The specificity of this test was 97%, sensitivity 33%, predictive value of a positive test 63% and 90% for a negative test. Conclusions: The results show that individual patients presented for RECABG, can be stratified according to their early mortality risk. This information can be used to inform the patient, and also to discus the opportunity of the RECABG. q 2002 Elsevier Science B.V. All rights reserved.

Aim: The aim of this study was to analyse the nephrological morbidity after myocardial revascularization. Methods and results: We analysed the pre- per and postoperative data of 3815 patients who underwent a primary isolated coronary bypass grafting between January 1987 and December 1995. Nephrological complications were divided into renal dysfunction and requiring dialysis. The increase in nephrological complications (1.2–4%) is the result of an increase of patients with renal dysfunction. Unifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, aortic cross-clamp time, emergency operation and perioperative myocardial infarction as risk factors. Multifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, perioperative myocardial infarction and the cohorts operated upon in 1990–92, 1993–95 as independent risk factors for renal dysfunction, and age, nephrological pathology and perioperative myocardial infarction for those needing dialysis. Conclusion: Several variables have been identified as risk factors for nephrological complications; especially important are pre-existing nephrological pathology and perioperative myocardial infarction.

Objective: To study the effects of long-term growth hormone (GH) treatment on left ventricular (LV) dimensions in children with Noonan’s syndrome (NS). Methods: Echocardiographic measurements of LV dimensions were performed before and during GH treatment in 27 participants (21 boys, 6 girls) in a partly controlled 3-year trial of high-dose GH treatment (0.15 IU/kg/day). Nineteen children had a congenital heart defect, 1 of them had hypertrophic obstructive cardiomyopathy. In the first 3 years, the children were assigned to 1 of 2 groups: group A with discontinuation of GH treatment in the 3rd year, or group B without GH treatment in the 1st year. After the 3rd year, 12 of the 27 children were followed up for 2 additional years to evaluate the long-term effects of GH treatment on the heart. Results: At baseline, LV internal diameters were smaller, while posterior wall thickness were thicker than normal. Over the 1st year, changes in LV dimensions were comparable between the 2 groups. No significant differences were found in LV dimensions between the situation at baseline and after 4 years of GH treatment. Conclusion: Long-term high-dose GH treatment does not have clinically significant adverse effects on LV dimensions in children with NS.