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Objectives To determine outcomes following balloon aortic valvuloplasty (BAV) in aortic stenosis (AS) patients with a left ventricular ejection fraction (LVEF)

Gait selection is a strategy used by quadrupeds to meet the demands of locomotion under variable environmental conditions. The movement of black-backed jackals Canis mesomelas within a desert area was investigated. The usage and distribution of gaits in three distinct desert environments in the Namib Desert, Namibia, were analysed. The areas were chosen based on topographical differences: a bare, a featureless sand plain in an interdune valley, a large sand dune and a narrow dune valley with clumped plant growth. Fresh jackal tracks were recorded by GPS once a week for 1 year. Gait types, gait segment lengths and the rate of switches between gaits were analysed. Trot was the most frequently used gait in all areas, followed by walk and the two types of gallop. Jackals used faster gaits, with the lowest number of gait switches in the interdune plain. Movements on the sand dune were characterized by shorter gait segment lengths and frequent gait changes. In the dune valley, movements were slower and the rate of gait changes was intermediate between the other two areas. The strongest influence on gait choice and on gait changes was found to be the terrain topography, mainly the grade. Gait and track choice can be seen as a dynamic adaptation to a demanding environment like the Namib Desert.

Objectives: The goals of this study were to determine the feasibility, safety, and early outcomes of balloon aortic valvuloplasty (BAV) for severe aortic stenosis in a nonagenarian population. Background: This very elderly population is expanding rapidly, has a high incidence of aortic stenosis, and uncommonly undergoes surgical aortic valve replacement. These patients may best be treated with a transcatheter approach due to comorbidities, surgical risk, and personal preference. Methods: We reviewed 31 consecutive patients ≥≥90 years of age who underwent BAV at our institution from July 2003 to August 2006 for data pertinent to patient characteristics, procedural techniques, and 30-day outcomes. Results: Our patients had a mean age of 93 ± 3.0 years (90–101). The society of thoracic surgery risk score was 18.5 (±10.2) and logistic Euroscore was 35.8 (±19.3). Twenty-five patients (81%) underwent retrograde BAV and 6 (19%) antegrade BAV. Five patients (16%) underwent combined BAV and coronary stenting. Overall mean aortic valve area increased from 0.52 cm2 (±0.17) to 0.92 cm2 (±0.22) and mean New York Heart Association (NYHA) functional class improved from 3.4 to 1.8. Intraprocedural mortality occurred in one patient (3.2%) and 30-day mortality in three patients (9.7%). Conclusions: BAV can be carried out in high risk nonagenarian patients with an acceptable complication rate, low perioperative mortality, and early improvement in NYHA functional class. © 2007 Wiley-Liss, Inc.

Objectives: We wished to determine the feasibility and early safety of external beam radiation therapy (EBRT) used following balloon aortic valvuloplasty (BAV) to prevent restenosis. Background: BAV for calcific aortic stenosis (AS) has been largely abandoned because of high restenosis rates, i.e., > 80% at 1 year. Radiation therapy is useful in preventing restenosis following vascular interventions and treating other benign noncardiovascular disorders. Methods: We conducted a 20-patient, pilot study evaluating EBRT to prevent restenosis following BAV in elderly patients with calcific AS. Total doses ranging from 12–18 Gy were delivered in fractions over a 3–5 day post-op period to the aortic valve. Echocardiography was performed pre and 2 days post-op, 1, 6, and 12 months following BAV. Results: One-year follow-up is completed (age 89 ± 4). There were no complications related to EBRT. Eight patients died prior to 1 year; 5 of 10 (50%) in the low-dose (12 Gy) group and 3 of 10 (30%) in the high-dose (15–18 Gy) group. None of these 8 patients had restenosis, i.e., > 50% loss of the initial AVA gain, and only three deaths were cardiac in origin. One patient underwent aortic valve replacement and none repeated BAV. By 1 year, 3 of the initial 10 (30%) in the low-dose group and 1 of 9 (11%) in the high-dose group demonstrated restenosis (21% overall). Conclusions: EBRT following BAV in elderly patients with AS is feasible, free of early complications, and holds promise in reducing the 1 year restenosis rate in a dose-dependent fashion. © 2006 Wiley-Liss, Inc.

The origins of excessive daytime sleepiness in Parkinson disease (PD) are unclear. The authors hypothesize that orexin neurons, a recently identified wake promoting system, could contribute to its pathophysiology. They measured orexin-A/hypocretin-1 concentration in ventricular CSF in 19 parkinsonian patients and compared it with neurologic controls. Orexin levels were lower in patients and decreased with the severity of the disease. The authors suggest that orexin neurons contribute to daytime sleepiness in late stage PD.

The mineralized tissue of intertubular dentin is a collagen-mineral composite with considerable local variations of mechanical properties. Area scans of human coronal dentin were made by complementary methods to investigate correlations between local mechanical properties and the density, size, and crystallinity of the mineral particles. Scanning images from the same specimen were collected with Fourier-transform infrared microspectroscopy in reflectance mode (FTIR-RM), small angle X-ray scattering (SAXS), quantitative backscattered electron imaging (qBEI), and Nanoindentation in an atomic force microscope. The mineral content of dentin was found to decrease and the thickness of mineral crystals to increase towards the dentin-enamel junction (DEJ). Hardness and elastic modulus both decreased towards the DEJ. In a correlation analysis, the mineral content and, even more, the thickness of mineral crystals were found as the best predictors of hardness. The dentin layer close to the DEJ corresponds to a local minimum in hardness and elastic modulus, a configuration known to be an effective obstacle for crack propagation. Hence, the observed variations of mechanical and structural properties in an area between 0 and 1.5 mm below the DEJ define crown dentin as a gradient material optimized for its mechanical function.

Balloon aortic valvuloplasty (BAV) is occasionally a bridge for optimizing transcatheter aortic valve replacement outcomes. This study examined whether BAV improves renal insufficiency in these high-risk patients. Our 320 pt BAV database was queried for pts with stage-4 chronic kidney disease (CKD4

To determine outcomes following balloon aortic valvuloplasty (BAV) in aortic stenosis (AS) patients with a left ventricular ejection fraction (LVEF)20%.Severe AS patients with a LVEF20% are excluded from United States (U.S.) transcatheter aortic valve replacement (TAVR) trials and often surgical aortic valve replacement (AVR). The role for BAV to enhance LVEF is unclear.Our BAV database of 270 consecutive patients extending from 2005 through 2010 was queried for a preoperative LVEF20%. Demographics, echocardiograms, procedural technique, and outcomes were analyzed. Pre- and postoperative echocardiograms were used to determine improvement in aortic valve area (AVA) and LVEF.Sixteen patients were identified with a median age of 82 years. The composite Society of Thoracic Surgeons' (STS) mortality risk was 16.4%. The median preoperative AVA and LVEF were 0.60 cm(2) and 16%, respectively, and postoperative AVA and LVEF were 0.77 cm(2) and LVEF 19%, respectively. About 15 of the 16 patients had postoperative echocardiograms available for comparison. And 7 of these 15 (47%) demonstrated improvement in LVEF to ≥20% (median LVEF 25%). The absence of coronary disease and improvement in AVA of ≥0.2 cm(2) was associated with postoperative LVEF of ≥20%. Procedural mortality was 0%. The 30-day, 6-month, and 1-year survival was 69%, 56%, and 29%. STS's mortality risk score ≥15% was associated with short-term mortality.With appropriate technique, BAV can be reasonably safe in patients with LVEF20%. Roughly half of these patients demonstrated improvement in LVEF to ≥20%.

Modafinil is a central putative alpha-1 postsynaptic agonist with vigilance-promoting properties. Fifty narcoleptics (33 male and 17 female) participated in a multicentric study aimed at assessing the effects of the compound on night sleep, feeling on awakening, excessive daytime sleepiness and cataplexy. Modafinil was administered in a double-blind cross-over design at a daily dosage of 300 mg versus placebo. The duration of the study was 12 weeks, including a 2-week "run in" period with placebo, a first 4-week treatment period with either modafinil or placebo, a 2-week wash-out period with placebo and a second 4-week treatment period with either placebo or modafinil. Daily evaluation was based on a sleep log, visual analog scales, a sleep questionnaire and a clinical global index. Sleep laboratory evaluation took place on nights 1, 28, 42 and 70. It included 1 night of polysomnography preceded by a questionnaire on therapeutic and side effects, and a maintenance of wakefulness test (MWT). Sleep logs did not show any modification of night sleep, but a reduction of daytime sleepiness and sleep. Feeling on awakening was not modified. An overall benefit was noted by physicians as well as by patients. MWT disclosed a positive effect of modafinil on excessive daytime sleepiness. Cataplexy was not modified.

458 insomniac patients participated in a multinational, randomised, double blind, parallel groups study of zopiclone 7.5 mg versus placebo. Patients received the drug or placebo nightly for 14 days and for a further six weeks on demand. Sleep characteristics and Quality of Life measures were assessed at 14, 28 and 56 days after admission. Both groups of patients improved on these measures, but the active treatment showed significantly greater improvement compared to placebo, both after 14 days and at the end of the trial.

In order to assess the quality of sleep in surgical patients the amount of self-rated postoperative insomnia and its predisposing factors, we conducted a three-fold questionnaire * survey in 176 consecutive patients undergoing elective orthopaedic, vascular or abdominal surgery. The first questionnaire was completed the day preceding surgery, the second at the day of discharge and the third two weeks later. This survey concerned the patient's general status, his usual sleep profile and factors which could interfere with sleep (hypnotics, pain, environmental factors) throughout the study period. It allowed quantification of these parameters and the assessment of their time-course. Perioperative insomnia appeared to be a long-lasting phenomenon which persisted after discharge. Factor analysis and multiple regression models showed that postoperative, self-rated insomnia was multifactorial and mainly explained by the amount of postoperative pain (p = 0.035).

Alcohol reduces sleep latency but notably alters sleep structure: sleep is fragmented, particularly at the end of the night. Slow wave sleep duration is enhanced in the first part of the night and REM sleep duration and density are diminished. Alcohol withdrawal provokes inverse effects in alcoholic patients: sleep onset is delayed, slow wave sleep durations diminished and REM sleep duration is enhanced. REM sleep is associated with motor inhibition failure. Sleep remains disturbed in long term evaluations. Alcohol promotes the occurrence of sleep apneas and hypopneas. This effect persists in alcoholics after alcohol withdrawal. Sleep disturbances in alcoholism can be partly understood as the expression of amplitude diminution and phase advance of biological rhythms. Thus, the chronobiologic characteristics of alcoholics resemble those of depressives or the elderly.

Sera from patients with dilated cardiomyopathy contain autoantibodies modifying cardiac beta-adrenergic pathways. The influence of the methodology used to determine the prevalence of these antibodies was examined by comparing in 51 patients with idiopathic dilated cardiomyopathy the results of three assays: (1) isoproterenol-sensitive adenylate cyclase; (2) ligand binding inhibition; (3) enzyme-linked immunoassay (ELISA) of beta-receptor peptides. In 20% of the patients, all three tests gave positive results, while the concordance of the adenylate cyclase assay with either of the other two tests was 65%. ELISA was positive for a beta 1-receptor peptide corresponding to the second extracellular loop, but negative for a beta 2-receptor peptide. The results suggest that autoantibodies in dilated cardiomyopathy sera interact with several components of the beta-receptor-adenylate cyclase, and therefore a combination of methodologic approaches is needed to evaluate the prevalence and consequences of beta-receptor autoimmunity.

From December 1985 through January 1991, 9 patients underwent bridging to transplantation using a Symbion J-7-70 total artificial heart. There were 4 female and 5 male patients aged 31 ± 14 years (range, 15 to 52 years). Five patients were supported on an intraaortic balloon pump before total artificial heart support, and 2 had biventricular assist devices as well. Total artificial heart support was maintained for 17 ± 12 days (range, 4 to 44 days); all patients underwent transplantation. Three patients died after transplantation on day 0 (primary donor organ failure), 25 (acute rejection), and 256 (multiorgan failure). The remainder were discharged at 41 ± 32 days (range, 13 to 101 days). One patient died 28 months after transplantation of late acute rejection. Actuarial 1-year and 3-year survival is 67% and 55%. There were no surgical wound infections. Problems encountered in the J-7-70 period and the period after transplantation were for the most part related to patient condition in the period before implantation. The Symbion J-7-70 total artificial heart is an effective device for total circulatory support in patients with end-stage cardiogenic shock when an organ donor is not available. Organ system failure and infection before implantation may persist into the transplantation period resulting in long-term complications, increased mortality, and prolonged hospital stay; therefore, early implantation of the device when indicated should be applied.

To determine whether transesophageal echocardiography (TEE) is useful in ruling out the presence of atrial thrombus, we performed TEE in 20 patients immediately before valve replacement or valve repair and within 3 days of an autopsy in one patient. Mitral stenosis was the predominant lesion in three patients, mitral regurgitation was seen in 11 patients, five patients had mitral prosthesis malfunction, one patient had a tricuspid prosthesis malfunction, and one patient had aortic stenosis. Eight patients were in atrial fibrillation. Four patients demonstrated spontaneous contrast in the associated atria. Nine patients were receiving oral anticoagulation. Mean left atrial diameter was 5.3 +/- 1.3 mm. TEE revealed no evidence for atrial thrombus in 18 of the 21 patients; this finding was confirmed by careful inspection of the atria including the appendages. TEE demonstrated a left atrial thrombus in two patients and a right atrial thrombus in another (confirmed at the time of surgery or at autopsy). In all cases transthoracic echocardiography was negative. Our data suggest that TEE is useful in ruling out atrial thrombus, and therefore may be a useful test preceding interventions associated with an increased risk of embolism from the atria such as cardioversion, mitral valvuloplasty, or valve replacement.

Transesophageal echocardiography was used to assess myocardial function and to detect complications after mechanical circulatory support for 8 patients with cardiogenic shock. In 3 of 8 patients, serial transesophageal echocardiography documented improvement of systolic ventricular function, and it was possible to wean these 3 patients from the ventricular assist device. In all patients, transesophageal echocardiography added clinically important information including the extent of left and right ventricular dysfunction (6 patients), presence of atrial or ventricular thrombus (5 patients), presence of pericardial effusion or clot (2 patients), and verification of the position of the intravascular device (1 patient). Thus, transesophageal echocardiography may provide clinically useful information regarding both the underlying cardiac disease and potential complications from the mechanical circulatory assistance.

Sleep in the elderly is characterized by a decrease in the ability to stay asleep resulting in a more fragmented sleep. Spindles are less frequent and less ample, shorter, without an increase during the night contrary young subjects. Delta activity in slow wave sleep is decreased in the 0.5-2 Hz frequency band only. REM sleep occurs earlier the first REM period duration increases. The REM sleep appearance is almost uniform during the night. REMs density does not increase toward the end of the sleeping period. The sleep-wake circadian rhythm is advanced (bedtime and morning awakening occur earlier). The temperature rhythm is also advanced. The rise in temperature after the nadir begins earlier for females and the initial ascent is more rapid. This explains why women wake up earlier and sleep for shorter durations than men. The nocturnal and diurnal mean plasmatic norepinephrine values increase. The rhythm of cortisol secretion is advanced. The GH and melatonin peaks of secretion are decreased. The acrophase of melatonin rhythm is occurring later in the elderly. These results suggest a weakening of circadian structure in the course of aging and an altered relationship between the pacemakers driving melatonin and cortisol circadian rhythms.

To determine if transesophageal echocardiography provides better visualization of valvular vegetations than transthoracic echocardiography, we used both methods to evaluate 24 consecutive patients (mean age, 54 years; 15 female patients and nine male patients) referred for symptoms suggestive of infectious endocarditis. Ten of the 24 patients had one or more valvular prostheses. Echocardiograms were classified as positive or negative based on visualization of valvular vegetations or abscesses. Of ten patients with a final diagnosis of infectious endocarditis on extended follow-up, transthoracic echocardiography was positive in five patients. Transesophageal echocardiography not only yielded abnormal findings in all ten of these patients, but also revealed additional information in four of the five patients with abnormal transthoracic echocardiographic examinations. Among the 14 patients who, on subsequent follow-up, were found not to have infectious endocarditis, transthoracic echocardiography was normal in 13 and falsely abnormal in one. Transesophageal echocardiography revealed no evidence of infectious endocarditis in any of these patients. The ten patients who were determined to have infectious endocarditis all had positive blood cultures and no alternative cause for their clinical presentation; in seven patients in this group who underwent operative or postmortem evaluation, infectious endocarditis was confirmed. All patients without infectious endocarditis were demonstrated to have other causes for their clinical presentation. We conclude that transesophageal echocardiography is a highly valuable test in the work-up of patients with suspected infectious endocarditis, especially those patients with inconclusive or normal transthoracic echocardiograms. In addition, transesophageal echocardiography may be of benefit to patients with previously documented infectious endocarditis and a complicated clinical course in whom additional cardiac lesions are suspected but not demonstrated by transthoracic echocardiography. (Chest 1991; 100:351-56)

Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.

Autoantibodies against the cardiac beta 1-adrenoceptor are present in the sera of patients with idiopathic dilated cardiomyopathy and may modulate the responsiveness of cardiac beta-adrenergic pathways to agonists. The regulation of cardiac adenylate cyclase activity by autoantibodies was examined in 50 patients with dilated cardiomyopathy. Inhibition of isoproterenol-sensitive adenylate cyclase activity could be demonstrated by serum dilutions or IgG in 52% (26 of 50) of the patients; basal and NaF-stimulated activities, in contrast, were unaffected. In 14 patients, both ligand binding to beta-receptor and isoproterenol-sensitive adenylate cyclase activity were inhibited by 100-fold serum dilutions. Pretreatment of cardiac membranes with pertussis toxin did not affect inhibition of adenylate cyclase indicating that the effect of sera does not depend on Gi. The immunogenetic control of antireceptor antibodies was examined by comparing the distribution of HLA antigens in antibody-positive and antibody-negative patients. HLA-DR4 and HLA-DR1 were strongly associated with antibodies inhibiting ligand binding and adenylate cyclase activity (71% of patients with such antibodies typed as either DR4 or DR1). Conversely 58% of patients with HLA-DR4 and 71% of patients with HLA-DR1 antibodies showed inhibition of adenylate cyclase activity compared to 46% of those who lacked both HLA-DR4 and HLA-DR1 antibodies. These results strongly suggest that cardiac beta-adrenergic receptors and adenylate cyclase activity in dilated cardiomyopathy can be modulated by circulating autoantibodies, the presence of which is under the control of the major histocompatibility complex.

This study examined the impact of transcatheter fulguration on creatine kinase-MB release in 21 patients (age range 17-71 years). Arrhythmia diagnoses were ventricular tachycardia 9, atrial fibrillation with a rapid ventricular response 7, atrioventricular nodal reentry 2, and reciprocating tachycardia utilizing a posteroseptal accessory pathway 3. Seven patients had apparently normal hearts while 8 had ischemic heart disease and 6 cardiomyopathy. Timing of initial elevated creatine kinase-MB activity (mean 1.34 +/- 0.69 SD hours) and peak creatine kinase-MB activity (mean 3.73 +/- 0.89 SD hours) was relatively uniform in all patients. Time to peak creatine kinase-MB activity was unrelated to either underlying cardiac disease (normal: 3.9 +/- 1.0 hours; ischemic heart disease: 3.5 +/- 0.9 hours; cardiomyopathy: 3.8 +/- 0.9 hours), or fulguration site (His bundle (n = 9): 4.2 +/- 0.9 hours, proximal coronary sinus (n = 3): 3.3 +/- 0.3 hours, ventricle (n = 9): 3.4 +/- 0.8 hours). The magnitude of peak serum creatine kinase-MB activity was independent of myocardial diagnosis or fulguration site, but was linearly related to total energy delivered (r = 0.5, P less than 0.022). The latter correlation was particularly strong within cardiac diagnosis subgroups (normal: r = 0.92, P less than 0.002; ischemic heart disease: 0.73, P less than 0.04; non-ischemic cardiomyopathy: r = 0.57, P = NS). Thus, serum creatine kinase-MB activity following transcatheter fulguration is linearly related to the magnitude of delivered energy, and is similar to that observed after transient coronary artery occlusion and reperfusion.

The goal of this study was to compare outcomes of combined balloon aortic valvuloplasty (BAV) plus percutaneous coronary intervention (PCI) with BAV alone in a surgically high risk, older (>70 years) population with both aortic stenosis (AS) and coronary artery disease (CAD). The medical records, coronary angiograms, and procedural reports of 100 consecutive patients who underwent BAV and coronary angiography at our institution from July 2003 to November 2006 were reviewed. Seventeen patients (mean age 86.2 ± 6.4 years) underwent combined (nonstaged) BAV and PCI with a calculated Society of Thoracic Surgery risk score of 13.5% ± 6.7; 13 of these underwent coronary stenting before BAV and 4 after BAV. All 17 patients were successfully treated with this combined strategy. The incidence of periprocedural mortality, myocardial infarction, and stroke was zero. An additional 25 patients (mean age 85.9 ± 6.9) with CAD were identified who underwent BAV alone with a Society of Thoracic Surgery risk score of 12.6 ± 5.7%. PCI in these patients was avoided primarily because of greater lesion complexity or a perceived low probability of symptomatic benefit. There was 1 procedural death, no myocardial infarction, and 1 postprocedural stroke in these 25 patients. The procedural duration and hospital length of stay for the combined BAV and PCI group was 98.8 ± 17.6 minutes and 4.1 ± 2.8 days, respectively, and for the BAV only group was 86.2 ± 27.3 minutes and 3.3 ± 2.1 days, respectively. In conclusion, with appropriate selection, BAV plus PCI was safely performed in this retrospective series of elderly, high-risk patients with severe AS and CAD.

Increasing uncertainty regarding the reliability of Global Navigation Satellite Systems (GNSS) has led the navigation community to seek valuable alternatives. Aerospace navigation by integration of inertial systems with reference to maps of Geophysical Fields of the Earth (GFE) is a promising area which can be highly advanced utilizing tremendous achievements in embedded micro-processing, including the memory devices capability and miniature size. GFEs are the properties of the planet Earth. Most GFEs are already well mapped in geographical system coordinates. GFEs can’t be destroyed or changed in the foreseeable future. They don’t require special service, therefore, they can be considered as a solid source of navigation information. EMF maps, models and charts, which are currently used in a wide range of commercial and military applications, mostly for directional information, are periodically updated and can be used as a reliable navigation reference on at least 98% of the Earth’s surface including water covered areas. This paper presents a brief review of terrain navigation efforts (using land topography and geomagnetic maps) in the last 50 years. Information about the accuracy of existing EMF maps is discussed. The geomagnetic methods position and velocity determination, along with potential accuracy and major sources of error, are reviewed. EMF parameters dependency on altitude and mapping for different altitudes, including the effect of daily variation are addressed and discussed. The paper includes a description of an integrated navigation system utilizing the correlation principle of actual coordinate determination by finding the best fit between the geomagnetic profile measured onboard during the flight and the corresponding profile in a stored on board map. The precision fluxgate magnetometer can be employed for high accuracy measurement of EMF vector components and the anomaly part of EMF on board of aircraft is described. This paper also addresses the problems of precision measurement of EMF on the aircraft and gives recommendations to secure such measurements in the aircraft environment.

Women undergoing coronary artery bypass graft (CABG) surgery have a worse medical condition and fewer social and financial resources than men. Some studies have found that women recover less well than men after CABG, whereas others have found women's outcomes comparable to those of men. Past studies of health-related quality of life after CABG have too few women for adequate comparison with men and have not included patients whose data are not available at baseline (eg, emergency CABG), limiting generalizability.A longitudinal study of symptoms and health-related quality of life was conducted among patients from four clinical centers enrolling both men (n = 405) and women (n = 269) in the Post CABG Biobehavioral Study in the United States and Canada.After 6 weeks from CABG (average 81 days), both men and women had less anxiety and symptoms related to depression than before surgery (P.001). After 6 months (average 294 days), both men and women improved in physical and social functioning (P.001). Although changes in scale scores were similar for men and women at each time point, women scored lower than men on these domains (P.001, adjusted for baseline medical and sociodemographic differences) and had more symptoms related to depression through 1 year after CABG (P =.003).Both male and female patients improve in physical, social, and emotional functioning after CABG, and recovery over time is similar in men and women. However, women's health-related quality-of-life scale scores remained less favorable than men's through 1 year after surgery.

We describe a case of rotational atherectomy (RA) used in the setting of extensive coronary dissection. Unsuccessful predilitation of a heavily calcified proximal LAD stenosis resulted in balloon rupture, which produced occlusive dissection extending into the mid LAD. Limited options for this patient required that we perform RA to permit stent delivery and deployment and avoid anterior myocardial infarction. A brief discussion of reasons for balloon angioplasty failure and the potential role for subsequent RA is given. Predictors for coronary perforation when performing RA are reviewed. Our rationale and strategy to avoid the increased risk of perforation with RA in this contraindicated setting of extensive dissection is given.

Pharmacological treatment for insomnia is far from being restricted to prescribing hypnotics. Hypnotics are often ineffective in fact (tolerance effect), or even dangerous (in unsuspected cases of sleep apnoea) and may lead to problems of over-consumption and dependence. It must be remembered that since the international consensus conference in Bethesda [11], hypnotics can no longer be prescribed for more than three weeks. A number of other families of psychotropic medication can be used as treatment for insomnia: the foremost is the antidepressants, but others include the centrally active antihistamines, L tryptophan and plant extracts.

To compare the efficacy and patient tolerance, compliance, and preference between auto-continuous positive airway pressure (CPAP) and constant CPAP.Single-blinded, crossover, cohort study of consecutive patients with obstructive sleep apnea syndrome, with two treatment periods of 2 months each.Twenty-five patients (22 men, 3 women) with sleep apnea syndrome confirmed by ambulatory polysomnography.After baseline polysomnography, patients underwent in-laboratory polysomnography for titration of constant CPAP. The order of treatment was randomly allocated, either auto-CPAP and then constant CPAP, or vice versa. The auto-CPAP pressure range was 6 to 16 cm H(2)O. At the end of each 2-month period, patients underwent a control ambulatory polysomnography and received a questionnaire on subjective well-being and device evaluation. Duration of use was checked through CPAP device monitoring.No differences were found in apnea/hypopnea index (constant CPAP, 9.7+/-1.9 events/h vs auto-CPAP, 10.6+/-9.3 events/h), awakening/arousal index (constant CPAP, 13.7 +/- 8.0 events/h vs auto-CPAP, 15.5 +/- 8.9 events/h), slow-wave sleep duration, nocturnal saturation, or complaint of daytime sleepiness. The mean pressure required was significantly lower during auto-CPAP than during constant CPAP (8.8+/-1.8 cm H(2)O vs. 9.7+/-2.6 cm H(2)O, respectively). Patient tolerance, compliance, and duration of use were similar with both treatments.Auto-CPAP is as effective as constant CPAP. A wide pressure range for auto-CPAP can be used in all patients, suggesting that, in the future, use of a broad pressure range in the auto-CPAP mode could obviate the need for the titration night.

There is evidence that autoimmunity plays a role in the pathogenesis of dilated cardiomyopathy and that susceptibility to the disease is related to products of human leukocyte antigens (HLA) class II genes. We compared the distribution of HLA-DQA1 and -DQB1 alleles and haplotypes in 44 normal controls and 34 patients with idiopathic dilated cardiomyopathy patients. The distribution of two DQA1-DQB1 haplotypes (*0102-*0604 and *0102-*0501) were more frequent in the patients. Histidine at position 30 of the HLA-DQB1 gene was associated with disease (62% of patients compared to 36% of controls), whereas homozygosity for leucine at position 26 was more frequent in controls (36% vs 18% of patients). There was no correlation between HLA-DQA1-DQB1 haplotypes and the presence of anti-beta-receptor antibodies. These results suggest that the HLA-DQB1 gene is involved in the pathogenesis of human dilated cardiomyopathy.

Background There is evidence that autoimmunity plays an important role in the initiation and progression of myocardial injury in dilated cardiomyopathy. Abnormalities of both cellular and humoral immunity have been described in this disease. Soluble interleukin-2 receptor (sIL-2R) levels in the serum reflect activation of T lymphocytes in the periphery or in tissues. The present study explored the possibility that activation of cellular immunity is frequent in patients with idiopathic dilated cardiomyopathy and may have functional consequences. Methods and Results Serum sIL-2R levels were determined with an enzyme-linked immunosorbent assay in 50 dilated cardiomyopathy patients, 30 patients with ischemic heart disease, and 22 normal control subjects. In addition, the presence of anti–β-receptor and antimyosin antibodies was sought in the serum of cardiomyopathy patients. High sIL-2R levels (>1400 pg/mL) were found in 38% of the dilated cardiomyopathy patients but only 6% of the ischemic heart disease patients. The group of sIL-2R–positive patients was characterized by higher average age, a higher percentage of women, and more severe disease (lower ejection fraction, higher left ventricular filling pressures, and lower cardiac output). Although the prevalence of cardiac autoantibodies did not correlate with the presence of high sIL-2R levels, higher titers of autoantibodies were found predominantly in the sIL-2R–positive group. Conclusions T-lymphocyte activation, as reflected in elevated sIL-2R levels, is frequent in patients with dilated cardiomyopathy and is associated with more severe disease. Cellular and humoral immune activation may correlate with progression of the disease process.

Clinical events prompting angiography occur in patients post bypass surgery, and often necessitate repeat revascularization procedures. In these patients the culprit lesion may occur in either the native vessel or the graft. The Post CABG study, a 5 year trial aimed at reducing SVG closure in minimally symptomatic patients 1–11 years Post-CABG, offers a unique view into this problem, since this study requires an initial angiogram to document baseline graft patency. In a subgroup of Post-CABG patients in whom symptoms prompted an interim “clinically driven” angiogram, we compared the baseline and interim angiograms for the presence or absence of a culprit lesion defined as total occlusion, angiographic clot, lesion change ≥ 50% or lesion g 75% diameter stenosis. Of 1253 enrolled patients with at least one SVG patent, 127 patients with clinical events and analyzable interim angiograms were evaluated. Results Culprit Lesion None Graft Native Vessel n (pts.) 15 (11.8%) 66 (52.0%) 46 (36.2%) Age [baseline angio] (yrs) 65.5 (53-76) * 59.8 (45-73) † 60.4 (36-74) Male gender (%) 80 90.9 86.9 Time CABG-interim angio (mo) 77.1 ± 10 102.6 ± 3.2 † 90.3±5.1 ** Resultant PTCA/CABG (1%) 0/0 33.3/31.8 30.4/4.3 * none vs native vessel † none vs graft ** graft vs native vessel, p l 0.05 Clinical indications for angiography differed depending on the anatomic site of the culprit lesio R. Patients with graft culprit lesions more frequently had MI (30.8%) than patients with culprit native vessel lesions (11.1%) P l 0.05, or with no lesions (0%) Conclusions In Post-CABG patients with clinical events that necessitated repeat angiography, only one-half had graft disease as the identifiable cause. No responsible lesion was found in 12%. Treatment for symptomatic patients following coronary artery bypass surgery may differ substantially depending on the anatomic cause of symptoms.

Ten patients with isolated right atrial tamponade complicating open heart surgery were identified over a 3.5-year period at three institutions. Clinical manifestations varied but were typically those of decreased perfusion with elevated central venous pressure. Hemodynamically these patients had systemic hypotension and tachycardia with elevated central venous pressure but without elevation of pulmonary artery or pulmonary artery wedge pressures. The correct diagnosis in each case was established by echocardiography; 7 via the transthoracic and 3 via the transesophageal approach. The typical echocardiographic feature was an extrinsic extracardiac mass compressing the atrium. Doppler findings included high flow velocities through the right atria, and color flow demonstrated narrow color jets through compressed, slit-like right atria. Surgical exploration confirmed these findings in each case. We conclude that the combination of clinical awareness and appropriate hemodynamic evaluation can alert the physician to the possibility of isolated right atrial hematoma causing decreased perfusion and/or shock following open heart surgery. Echocardiography using either the transthoracic or transesophageal approach can establish the diagnosis and lead to timely surgical intervention.

The objective of this multicenter, randomized, double-blind, placebo-controlled study was to determine the safety and efficacy of intravenous diltiazem in the treatment of 37 patients with rapid (ventricular rate, mean +/- SD 142 +/- 17 beats/min) atrial fibrillation or flutter and moderate to severe congestive heart failure (ejection fraction, mean +/- SD 36 +/- 14%; New York Heart Association class III [23 patients], class IV [14 patients]). During the double-blind portion of the study, patients received either intravenous diltiazem, 0.25 mg/kg over 2 minutes, or placebo followed 15 minutes later by diltiazem or placebo, 0.35 mg/kg over 2 minutes, if the first dose was tolerated but ineffective. Placebo nonresponders were given open-label intravenous diltiazem in a similar fashion as in the double-blind portion of the study. In the double-blind part of the study, 21 (18 with 0.25 mg/kg, 3 with an additional 0.35 mg/kg) of the 22 patients (95%) responded to diltiazem, and 0 of 15 patients (0%) responded to placebo (p0.001). All 15 patients (13 with 0.25 mg/kg and 2 with an additional 0.35 mg/kg) who received placebo during the double-blind period had a therapeutic response to diltiazem during open-label therapy. Overall, 36 of 37 patients (97%) had a therapeutic response to intravenous diltiazem. Heart rate response to diltiazem after the 2-minute bolus infusions consisted of aor = 20% decrease in heart rate from baseline in 36 patients; in addition, 17 patients also had heart rates decreased to100 beats/min, whereas no patient had conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

We present a case of cardiac tamponade masked by bilateral internal jugular vein thrombosis occurring in a patient 1 month after orthotopic heart transplantation. Because patients who undergo heart transplantation undergo both heart surgery and multiple endomyocardial biopsies, they are at risk for both of these complications. Therefore when evaluating hypotensive patients who are at risk for both pericardial effusion and bilateral internal jugular vein thrombosis, cardiac tamponade should not be excluded, even in the absence of jugular vein distention.

Records of 144 patients who received size 19 or 21 mm (Group A) aortic Standard St. Jude Medical (SSJM) prostheses were retrospectively reviewed and compared to 219 patients who received size 25 mm SSJM valves (Group B). Group A patients were older (70 +/- 9 years vs. 62 +/- 13 years) and had smaller body surface area (BSA) (1.65 m2 vs. 1.9 m2 p0.05). Operative mortality (5% vs. 2%) and postoperative unadjusted Doppler mean gradient (31 mmHg vs. 22 mmHg) were higher in Group A (p0.05). Total follow up was 1255 patient-years (450.6 Group A/804.4 Group B). There were no perivalvular leaks, valve thrombosis, or endocarditis in either group. Freedom from thromboembolism and anticoagulant-related hemorrhage was 89% and 95% in Group A and 93% and 98% in Group B, respectively. The major causes of late death were older age and progressive cardiac disease. The five-year actuarial analysis revealed a survival rate of 74% in Group A and 83% in Group B (p0.05). Of those who were alive, more than 70% were in functional class I and II. These patients not only enjoy a complication-free living but are able to perform daily routine activity despite being older. 19 mm and 21 mm SSJM aortic valve prostheses had higher transprosthetic gradient, but provided satisfactory performance in adult patients with a BSA of less than 1.7 m2. This valve can be used in the small aortic annulus with a valve size index of at least 12 mm/m2 as an alternative to an annular enlargement procedure.

This report describes the acute and intermediate-term results of percutaneous transluminal coronary angioplasty (PTCA) performed on all patients aged ≥90 years at the time of PTCA over a 6.5-year time frame at 7 high-volume academic institutions.

In order to assess the quality of sleep in surgical patients the amount of self-rated postoperative insomnia and its predisposing factors, we conducted a three-fold questionnaire * survey in 176 consecutive patients undergoing elective orthopaedic, vascular or abdominal surgery. The first questionnaire was completed the day preceding surgery, the second at the day of discharge and the third two weeks later. This survey concerned the patient's general status, his usual sleep profile and factors which could interfere with sleep (hypnotics, pain, environmental factors) throughout the study period. It allowed quantification of these parameters and the assessment of their time-course. Perioperative insomnia appeared to be a long-lasting phenomenon which persisted after discharge. Factor analysis and multiple regression models showed that postoperative, self-rated insomnia was multifactorial and mainly explained by the amount of postoperative pain (p = 0.035).

This paper describes the structure and contents of EC301, a standardized testing battery for the evaluation of brain-damaged adults in the area of calculation and number processing. The battery was administered to 180 normal subjects stratified by education (3 levels), age (3) and gender. EC301 is composed of a large variety of tasks dealing with basic arithmetic skills, and their linguistic, spatial, and mnesic dimensions. The three main notational systems for numbers - Arabic digits, written verbal, and spoken verbal number forms - are explored. Analysis of error rates indicated the effect of some demographic factors (principally, education; incidentally, gender) on normal performance in some tasks. © 1994, Taylor & Francis Group, LLC. All rights reserved.

A North American population's predictors of early clopidogrel discontinuation after drug-eluting stent implantation Ana Laynez, Michael A. Gaglia, Jr., Kohei Wakabayashi, Rafael Romaguera, Gabriel Maluenda, Gabriel Sardi, Itsik Ben-Dor, Manuel A. Gonzalez, Michael Mahmoudi, Camille Hauville, Rebecca Torguson, Zhenyi Xue, William O. Suddath, Lowell F. Satler, Kenneth M. Kent, Joseph Lindsay, Augusto D. Pichard, Ron Waksman Washington Hospital Center, Washington, DC

Sleep in depression is characterized by an increase in the number and duration of awakenings, sleep instability, and SWS decrease. REM sleep occurs earlier. REMs density during the 1st REM period is higher than in normal controls matched in age. Accordingly, sleep in depression is similar to sleep in normal aging. Endogenous depression cannot be distinguished from other types of depression by means of polygraphic criteria. Sleep recordings at the beginning of tricyclic compound treatment could be predictive of clinical response to treatment. Sleep modifications induced by antidepressive drugs are reviewed. Sleep recordings enabled us to formulate several physiopathological hypotheses of depression mechanisms: cholinergic-aminergic hypothesis, phase advance, deficiency of process S. Other hypotheses are reviewed: flattening of a hypothetical circadian rhythm of arousal, depressogenic property of sleep in itself (or only of SWS) or timing delay for the start of sleep. A significant phase advance of biological rhythms (temperature, cortisol) is rarely found. A reduction in the amplitude of rhythms (temperature, TSH, melatonine) is more frequent.

Alcohol reduces sleep latency but notably alters sleep structure: sleep is fragmented, particularly at the end of the night. Slow wave sleep duration is enhanced in the first part of the night and REM sleep duration and density are diminished. Alcohol withdrawal provokes inverse effects in alcoholic patients: sleep onset is delayed, slow wave sleep durations diminished and REM sleep duration is enhanced. REM sleep is associated with motor inhibition failure. Sleep remains disturbed in long term evaluations. Alcohol promotes the occurrence of sleep apneas and hypopneas. This effect persists in alcoholics after alcohol withdrawal. Sleep disturbances in alcoholism can be partly understood as the expression of amplitude diminution and phase advance of biological rhythms. Thus, the chronobiologic characteristics of alcoholics resemble those of depressives or the elderly.