Genesis of epicardial adipocytes and its association with progenitor markers, muscarinic receptor type 3 and b-blockers intake in patients with cardiovascular disease

Introduction

Epicardial fat thickness or volume was found to be associated with cardiovascular disease (CVD). Our aim was to study the epicardial adipocyte-progenitors' markers and its association with cholinergic or adrenergic activity in patients with cardiovascular disease.

Materials and methods

We have included epicardial adipose tissue (EAT) biopsies from 29 patients underwent open-heart surgery. From 10 patients (69±5 years old, 31±8 kg/ m2, 40% CAD, 40% HF, 60% AF, 0% T2DM) stromal cells from epicardial and subcutaneous fat were isolated after collagenase activity and cultured for 14 days and then submitted to adipogenesis for next 14 days. Samples from 19 patients (60±9 years old, 29±4 kg/m2, 42% CAD, 37% HF, 32% AF, 32% T2DM, 53% β-blockers) were used for “ex vivo assays”. Explants were split into equal pieces (100 mg), treated with or without acetylcholine (ACh) for 30 min. Afterwards RNA was isolated and cDNA was amplified by real time PCR. We selected adipocytes progenitors (CD36, PREF1, COL1A1), adipocytes markers (ADIPO, FABP4), muscarinic (muscarinic receptor type 2 (CHRM2) and 3 (CHRM2)) and β-adrenergic receptors (ABRD1, ABRD2 and ABRD3). Gene expression was represented regarding ACTB as 2HK/GEN.

Results

The stromal vascular cells (SVC) from subcutaneous fat (SAT) had higher expression levels of CD36, PREF1 and COL1A1 than SVC from epicardial fat (EAT). It explains the higher adipocytes markers after adipogenesis induction in SAT than EAT cells. However, an upregulation of fibroblasts markers was detected on EAT. The levels of CD36 and PREF1 in SVC were associated with higher adipogenesis. Although CHRM2 was higher in EAT than SAT SVC, the adipogenesis induction upregulated only CHRM3 (1.48±0.065 vs 1.42±0.036 a.u.) in EAT cells. Thus, this receptor was associated with adipocytes markers in epicardial fat (r=0.777 for CD36 and r=0.746 for FABP4) and incremented in epicardial fat biopsies from patients who were taken β-blockers (1.61±0.011 n=10 vs 1.54±0.097 a.u. n=9; p=0.05) and modulated by ACh treatment (p=0.05).

Conclusions

Our results showed that CD36 and PREF1 in epicardial SVC are adipocytes progenitors. The higher presence of adipocytes markers is associated with higher levels of muscarinic receptor (CHRM3), which are upregulated in epicardial fat from patients who were taken β-blockers and modulated by cholinergic activity. Because a metabolic and lipolytic dysfunction was associated with CHRM3, the sympathetic modulation might play a role in the epicardial adipocytes genesis. Further studies are needed to understand if this mechanism might improve or not future cardiovascular events.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIII (PFIS2020)

Cortico-muscular and cortico-cortical coherence changes resulting from Perampanel treatment in patients with cortical myoclonus

OBJECTIVE

To investigate the mechanisms by which Perampanel (PER) reduces the severity of action myoclonus, we studied on MEG signals the changes occurring in cortico-muscular coherence (CMC) and cortico-cortical connectivity in patients with progressive myoclonus epilepsies.

METHODS

The subjects performed an isometric extension of the hand; CMC and cortico-cortical connectivity were assessed using autoregressive models and generalized partial-directed coherence. The contralateral (Co) sensors showing average CMC values >0.7 of the maximum (set to 1) were grouped as central (C) regions of interest (ROI), while adjacent sensors showing CMC values >0.3 were grouped as Surrounding (Sr) ROIs.

RESULTS

Under PER treatment, CMC decreased on Co C and Sr ROIs, but also on homologous ipsilateral (Ip) ROIs; out-degrees and betweenness centrality increased in Co ROIs and decreased in Ip ROIs. The flow from Ip to Co ROIs and from activated muscles to Ip C ROI decreased.

CONCLUSION

The improvement of myoclonus corresponded to decreased CMC and recovered leadership of the cortical regions directly involved in the motor task, with a reduced interference of ipsilateral areas.

SIGNIFICANCE

Our study highlights on mechanisms suitable to treating myoclonus and suggests the role of a reduced local synchronization together a better control of distant synaptic effects.

High intensity focused ultrasound ablation for atrial fibrillation: results from the National Spanish Registry

BACKGROUND

A National Spanish Registry to compile all patients treated with high intensity focused ultrasound (HIFU) energy for atrial fibrillation (AF) was created to evaluate the safety and efficacy of AF surgical ablation.

METHODS

A national Spanish registry was created, and ten hospitals using HIFU to ablate AF joined it. A total of 412 patients undergoing cardiac surgery between 2006 and February 2013 were included. AF was divided between paroxysmal AF (33%) and persistent AF (67%) with a mean AF duration of 29.3±108.2 months. Mean left atrial diameter was 51.2±6.5 mm. Mean underlying heart disease were aortic valve disease (49.3%), ischemic disease (25.2%) and mitral disease (33.2%) Clinical follow-up of patients and a 6 months postoperative echocardiogram were performed in all patients.

RESULTS

A pacemaker implantation was needed in 4.9% of patients with a perioperative stroke in 2.5%. Rhythm at discharge from hospital was sinus rhythm in 58%, AF in 35.9% and atrial flutter in 0.8% of patients. Sinus rhythm restoration at 6, 12, 24 and 36 months follow-up was achieved in 66.1%, 63.8%, 63.9% and 45.9% of patients respectively. Multivariate analysis showed paroxysmal AF and sinus rhythm restoration in the operating theatre as factors related to sinus rhythm long term restoration.

CONCLUSIONS

The Spanish national registry showed an efficacy of AF ablation with the HIFU Epicor system of 66.1%, 63.8%, 63.9% and 45.9% at 6, 12, 24 and 36 months follow-up. There were no device-related complications.

Amoxicillin prophylaxis in oral surgery

INTRODUCTION

Postoperative infection is the most common postsurgical oral complication but no double-blind, randomized, placebo-controlled trial has been made yet to assess amoxicillin prophylaxis for oral surgery. The aim of this pilot study was to assess the effectiveness of prophylactic amoxicillin 3g per os versus placebo in the prevention of postoperative oral infections.

METHODS AND MATERIALS

A 5-year, multicentric, randomized, double-blind clinical trial was made on healthy patients undergoing complex oral surgery. Final analysis was by intention to treat.

RESULTS

The 286 patients were randomly assigned to the amoxicillin or placebo group. After a mean follow-up of two weeks, 11 patients in the control group and three patients in the amoxicillin prophylaxis group developed a postoperative infection (P=0.001 in unilateral test). The hazard ratio was 0.27 [95% CI: 0.07-0.94].

CONCLUSION

Amoxicillin prophylaxis seems to be effective in preventing postoperative infection in complex oral surgery, especially when mandibular third molars and multiple avulsions are involved.

Dynamic mechanical properties of oral mucosa: Comparison with polymeric soft denture liners

The purpose of this work was to characterize the viscoelastic behaviour of oral mucosa and compare it with the dynamic mechanical properties of different soft liners. For this purpose, a sample of pig oral mucosa and six commercialized soft liner samples have been investigated. A comparison was also carried with the first suitable hard rubber for dental prosthetics: vulcanite. Creep recovery (CR) and dynamic mechanical analysis (DMA) have been used to determine the mechanical modulus of oral mucosa and soft liners respectively. The Poisson ratio is used to compare mucosa bulk modulus and soft liner shear modulus. The biomechanical concept of conventional complete dentures needs a good adjustment of dynamic mechanical impedance between the base and oral mucosa. The viscoelastic mechanical property of the oral mucosa as a referent biopolymer has been confirmed in vitro. The modulus value, adjusted for old patients in physiological conditions, is in the order of 3 MPa. This study underlines the plasticization effect of absorbed water on the mechanical properties of the underlying tissue. This study allows us to define some characteristics of the most adapted biomaterial according to the clinical exigency. The required biomaterial must display the following properties: compatibility and chemical resistance with biological environment perpetuated mechanical properties during physiological conditions and clinical use, good adjustment of dynamic mechanical impedance with supporting mucosa and easy sample processing.

A comparison study of multiple measures of adherence to HIV protease inhibitors

BACKGROUND

Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome.

OBJECTIVE

To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response.

DESIGN

Longitudinal cohort study.

SETTING

Public HIV clinic.

PATIENTS

108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals.

MEASUREMENTS

Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load.

RESULTS

Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94]).

CONCLUSIONS

Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.

Pilot study on n-3 polyunsaturated fatty acids in the treatment of human experimental gingivitis

The anti-inflammatory effect of n-3 PUFA on the gingivae has already been demonstrated in animal models. The aim of this double-blind, randomized pilot study versus placebo is to evaluate this action in human experimentally-induced gingivitis. For 14 days (D0-D14), 37 healthy volunteers practised intensive oral hygiene, then abstained from brushing their teeth for 21 days (D14 to D35). On D28, the patients were randomized into 2 groups: 18 received the drug (fish oil: 30% n-3 PUFA) and 19 received the placebo (olive oil containing only 1% of n-3 PUFA) at a daily dosage of 6 g (i.e., 1.8 g of n-3 PUFA) 3x for 8 days (D28-D35). The plaque (PI), gingival (GI) and papillary bleeding (PBI) indices were measured on D14, D28 and D35. On D28 and D35, 10 volunteers underwent removal of an inter-dental vestibular papilla, between the 1st and the 2nd superior premolars, to measure out arachidonic acid (AA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA). A gingival biopsy was also taken in another 11 patients, to assay prostaglandin E2 (PGE2) and leukotriene B4 (LTB4). The clinical results of the trial demonstrated, in particular, a significant reduction of GI in the treated group (p < 0.05, Student t-test), but no significant difference between the groups. The biochemical results showed that EPA, DHA and DPA were found in the cells sampled, at higher levels in the subjects taking the drug, with a significant difference for EPA between the 2 groups (p < 0.05, Student t-test). The levels of AA, PGE2 and LTB4 are reduced in the experimental group and increased in the control group, with no significant difference. The LTB4 levels decreased but this difference just failed to reach significance (p = 0.09. Student t-test). This human experimental gingivitis study demonstrated that n-3 PUFA induced a tendency towards reduced inflammation but it was not possible to conclude significant efficacy.

Stereolithographic models derived from x-ray computed tomography. Reproduction accuracy

We investigate the accuracy of complex anatomical replicas derived from X-ray computed tomography data linked to the rapid prototyping technique of stereolithography. Data processing by specific softwares (segmentation, three-dimensional interpolation) allows direct interfacing with the stereolithography apparatus to build a resin replica with reproduction of internal cavities. Our preliminary results about surface and dimensional accuracies suggest that the reproduction of complex anatomical structures by stereolithography is reliable enough to be used for surgical planning, for custom-made implants and for surgical anatomy teaching.

Carbon dioxide enhancement of peroxynitrite-mediated protein tyrosine nitration

Production of reactive species has been associated with tissue injury in diverse human disorders and experimental models of disease. Peroxynitrite is a strong oxidant with multiple pathways of reactivity. One protein modification reaction that may be specific to peroxynitrite is the nitration of the ortho position of tyrosine residues and nitrotyrosine has been used as a marker for peroxynitrite-mediated oxidative stress. Nitrotyrosine was formed when peroxynitrite was reacted at physiological pH with fatty acid-free bovine serum albumin or with human plasma proteins. Nitrotyrosine was not formed when proteins were incubated with nitric oxide, nitrogen dioxide, or nitric oxide plus hydrogen peroxide in the presence of ferrous iron or ferrihorseradish peroxidase. Low-molecular-weight molecules such as uric acid, ascorbate, and sulfhydryls inhibited protein tyrosine nitration in the absence of bicarbonate. Addition of bicarbonate catalytically enhanced the yield of nitration and overcame the inhibition of these antioxidants. Bicarbonate/CO2 enhanced the yield of protein nitrotyrosine in a concentration-dependent manner. Catalysis of nitration is achieved by the interaction of CO2 with the peroxynitrite anion. A mechanism is proposed involving an ONOO(O)CO- intermediate, which readily nitrates tyrosine residues in a non-radical-dependent manner. Thus, peroxynitrite nitrates tyrosine residues by a mechanism that is catalyzed by CO2 under normal physiological conditions.

Effects of peroxynitrite-induced protein modifications on tyrosine phosphorylation and degradation

The ability of protein tyrosine kinases to phosphorylate a synthetic peptide was inhibited 51% by peroxynitrite-mediated nitration of tyrosine. Exposure of endothelial cells to peroxynitrite decreased the intensity of tyrosine phosphorylated proteins and increased the intensity of nitrotyrosine-containing proteins. Peroxynitrite-modified BSA was degraded by human red blood cell lysates. However, human plasma in a concentration-, time-, and temperature-dependent manner, removed the protein nitrotyrosine epitope. These results suggest that tyrosine nitration interferes with phosphorylation and targets proteins for degradation. Specific enzymatic process(es) for removing nitrotyrosine may be present in vivo.

[Polyunsaturated omega-3 fatty acids in the treatment of experimental human gingivitis]

The anti-inflammatory effect of omega-3 polyunsaturated fatty acids (n-3 PUFA) has already been demonstrated in an animal model. The aim of this randomized, double-blind, versus placebo study is to assess this action on experimental gingivitis in humans. Over a 14-day period (day 0-day 14), 37 healthy volunteers undertook intensive oral hygiene, and then did not brush their teeth for 21 days (day 14-day 35) so that gingivitis could then develop. On day 28, the subjects were randomized in two groups: 18 in the treatment group (fish oil: 1.8 g of n-3 PUFA), 19 in the placebo group (olive oil), at a daily dose of 6 g over days (day 28-day 35). The Plaque Index (PI), the Gingival Index (GI) and the Papilla Bleeding Index (PBI), as inflammation markers, were measured on day 14, day 28 and day 35. On day 28 and day 35, five volunteers of each group underwent removal of an interdental papilla to carry out the n-3 PUFA composition of cell membranes: arachidonic acid (AA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), docosahexaenoic acid (DHA). The results show the integration of EPA, DHA and DPA in the membranes of the cells removed and particularly a significant increase of EPA in the treatment group (p = 0.04 S). GI in the treatment group decreased significantly (p = 0.008 S). The level of AA decrease, but no significantly. It would therefore seem that the n-3 PUFA have an effect on the reduction of gingival inflammation in this experimental gingival model in humans.

Reactions of nitric oxide and peroxynitrite with organic molecules and ferrihorseradish peroxidase: interference with the determination of hydrogen peroxide

Endothelial, inflammatory, and other cell types, in addition to forming reactive oxygen species, under proper stimulation release free radicals such as nitric oxide (.NO) and strong oxidants such as peroxynitrite (ONOO-), which is the product of the reaction of nitric oxide with superoxide. Several methods for the detection of H2O2 are based on the ferrihorseradish peroxidase catalyzed oxidation of organic molecules. We investigated the reactions of nitric oxide and peroxynitrite with organic molecules as well as with ferrihorseradish peroxidase and examined the potential interference with the detection of H2O2. Peroxynitrite at low concentrations (0-10 microM) induced a concentration-dependent oxidation of 1,2 phenylenediamine, 3-3' dimethoxybenzidine (o-dianisidine) and para-hydroxyphenylacetic acid (pHPA). With the exception of pHPA, the oxidation of the above compounds by peroxynitrite was not affected by the presence of ferrihorseradish peroxidase. The yield of HPA-dimmer, the oxidation product of pHPA by peroxynitrite, was decreased because ferrihorseradish peroxidase catalyzed the formation of a different product, 3-nitro-HPA. Nitrogen oxides, formed by the reaction of nitric oxide with oxygen, oxidized the aromatic amines o-phenylenediamine and o-dianisidine. A 10-fold excess of nitric oxide over H2O2 decreased the yield of pHPA and dihydrorhodamine 123 (DHR123) by 58 and 72%, respectively, as compared to H2O2 plus ferrihorseradish peroxidase. The inhibition of pHPA oxidation by nitric oxide was in part to the reaction of nitric oxide with compound I and compound II and in part due to the reaction with the phenoxyl radical. These data suggest that the simultaneous generation of nitric oxide and peroxynitrite can interfere with the detection of H2O2. The overestimation or underestimation of the H2O2 detected is dependent upon the organic molecule utilized for detection and by the relative rate of nitric oxide, superoxide, and peroxynitrite generation.

Peroxynitrite-mediated inhibition of DOPA synthesis in PC12 cells

Experimental evidence has implicated oxidative stress in the development of Parkinson's disease, amyotrophic lateral sclerosis, and other degenerative neuronal disorders. Recently, peroxynitrite, which is formed by the nearly diffusion-limited reaction of nitric oxide with superoxide, has been suggested to be a mediator of oxidant-induced cellular injury. The potential role of peroxynitrite in the pathology associated with Parkinson's disease was evaluated by examining its effect on DOPA synthesis in PC12 pheochromocytoma cells. Peroxynitrite was generated from the compound 3-morpholinosydnonimine (SIN-1), which releases superoxide and nitric oxide simultaneously. Exposure of PC12 cells to peroxynitrite for 60 min greatly diminished their ability to synthesize DOPA without apparent cell death. The inhibition was due neither to the formation of free nitrotyrosine nor the oxidation of DOPA by peroxynitrite. The inhibition in DOPA synthesis by SIN-1 was abolished when superoxide was scavenged by the addition of superoxide dismutase. These data indicated that neither nitric oxide nor hydrogen peroxide generated by the dismutation of superoxide is responsible for the SIN-1-mediated inhibition of DOPA production. The inhibition of DOPA synthesis at high concentration of SIN-1 persisted even after removal of SIN-1. The inactivation of the tyrosine hydroxylase may be responsible for the significant decline in DOPA formation by peroxynitrite. Inactivation of tyrosine hydroxylase may be part of the initial insult in oxidative damage that eventually leads to cell death.

Echocardiographic features of the normofunctional Labcor-Santiago pericardial bioprosthesis

Echocardiography was performed in 94 patients with a total of 99 normally functioning Labcor-Santiago bioprostheses, 62 in the aortic and 37 in the mitral position. The following variables were measured: peak and mean transvalvular velocities, peak and mean instantaneous pressure gradients as calculated from the modified Bernoulli equation, pressure half-time, cardiac index, stroke volume and effective orifice area (using continuity and Hatle equations). Regurgitation patterns were sought by transthoracic echocardiography (all valves) and, for selected mitral bioprostheses, by transesophageal echocardiography. Calculated mean aortic pressure gradient ranged from six to 10 mmHg and calculated effective aortic orifice area increased with ring diameter, with means of 1.27 cm2 for the 19 mm valve and 2.58 cm2 for the 27 mm valve. For mitral bioprostheses, mean pressure gradient ranged from 3.0 to 4.5 mmHg and calculated effective orifice area from 2.27 to 2.73 cm2. Only central regurgitation was observed. The Labcor-Santiago pericardial bioprostheses created little resistance to forward flow. In the small aortic root their hemodynamic performance was as good or better than that of other currently available devices. It is hoped that this new design will contribute increased in vivo mechanical durability.

Endocarditis with pericardial bioprostheses: clinico-pathologic characteristics, immediate and long term prognosis

Between 1977 and 1992, 30 consecutive episodes of infective endocarditis in 28 patients involving pericardial bioprostheses were diagnosed and treated in our hospital. Eleven (37%) were early pericardial valve endocarditis occurring in the first 60 days following valve surgery, and 19 (63%) were late endocarditis. In both the early and late groups, more aortic that mitral valves were affected (19/30). The most frequent pathogen in the early cases was staphylococcus, (S. epidermidis in five cases, S. aureus in one). The most frequent pathogen among late cases was streptococcus: (St. viridans in four, St. faecalis in two, St. bovis in one). In four cases (13%) no pathogen was isolated. Twelve patients received antibiotic treatment alone, six specific for the pathogen and other six only arbitrarily chosen regimen. All patients were cured in the former and all patients died in the latter group (four with negative blood cultures and two in whom identification of the pathogen was delayed-Proteus mirabillis in one case and Brucella mellitensis in the other). Valve replacement during the infective endocarditis episode was necessary in 18 cases, either because of failure of the antibiotic treatment or because of heart failure secondary to prosthetic malfunction. Peri-annular abscess was present in five cases. Surgical mortality was 22.2% (4/18). In all, 11 patients (39%) died during the active stage of infective endocarditis. The most frequent cause of death was heart failure (45.5%). All four patients with negative blood cultures died. The most advisable strategy for treating bacterial endocarditis of pericardial bioprostheses is a combination of antibiotic therapy and early surgery, especially in cases of staphylococcus endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

A tridimensional study using cuts at a low temperature of the infratemporal region

Although the infratemporal region is well defined anatomically, its complex topography has been the subject of numerous, and sometimes, opposite works. That is the reason why it appeared necessary for the authors to re-evaluate this topic using the original method of Combelles and Boyer, allowing to define three referential planes, and thereby, a tridimensional shape and the volume of this region. This study allows to conclude that the infratemporal region is a triangular prism with an horizontal main axis 47 mm long. Its anterior base has a mean area of 733 mm2. The posterior top consists of the Juvara slot and has a mean area of 490 mm2. This infratemporal prism contains another one, the pterygomandibular space, prismatic too. It widens out from coronoïd plane (93 mm2) to mandibular foramen plane (169 mm2) before ending as a narrow groove between the neck of the mandibular condyle and the interpterygoïd fascia. The volume of the pterygomandibular space is quite superior to the value usually reported in the dental literature. It is of 4.8 ml to 5.8 ml according to denture. These results point out the opportunity to accomodate more important volumes of anesthesic solutions, than the 1.8 ml usually performed, without any leak out of the infratemporal region.

Doppler echocardiographic evaluation of the Bioflo pericardial bioprosthesis

The Bioflo pericardial bioprosthesis was introduced to improve the durability of previous pericardial bioprostheses by means of a protective sheath of bovine pericardium around the stent. It has since been withdrawn from the market. Before its withdrawal, we studied 19 patients with mitral Bioflo valves (three of 25 mm, seven of 27 mm, eight of 29 mm, one of 31 mm) and 21 patients with aortic Bioflo valves (eight of 19 mm, nine of 21 mm, four of 23 mm) between two weeks and six months postoperatively, at which time all were in NYHA functional classes I or II. Standard Doppler echocardiographic measurements were taken to determine the effective orifice area of all valves, the peak and mean diastolic gradients across the mitral valves, and the peak and mean systolic gradients across the aortic valves. The smaller Bioflo valves performed poorly both in absolute terms and in comparison with other valves, presumably due to a reduction in the effective orifice area by the protective sheath. This finding should be borne in mind by the designers of future pericardial bioprostheses.

The new Labcor-Santiago pericardial bioprosthesis

The Labcor-Santiago pericardial valve has been designed to minimize mechanical stress and to avoid abrasion wear, at the same time preserving the concept of mounting the pericardium outside the posts for full orifice opening. The new design has preserved the traditional superior hemodynamic performance of pericardial valves, avoiding abrasion by careful padding of the stents and introducing a new concept of cusp attachment in order to increase mechanical durability. Since June 1990, 40 patients received 46 Labcor-Santiago valves: 29 in the aortic position and 17 in the mitral position. Mean age was 65.6 years. Eighty percent of the patients were women. New York Heart Association Functional Class III-IV was present in 76% of patients. Hospital mortality has been 12.5%, with 31% undergoing concomitant procedures. No anticoagulation was administered and there has been one thromboembolic event. Echo-Doppler assessment yielded the following in the aortic position: effective orifice area for 19-mm size = 1 cm2; for 21-mm size = 1.2 cm2. Mean systolic gradient for 19-mm size = 14.7 mmHg; for 21-mm size = 11.2 mmHg. In the mitral position: effective orifice area for 27-mm size = 2 cm2; for 29-mm size = 2.3 cm2. Mean diastolic gradients for 27-mm size = 4.6 mmHg; for 29-mm size = 3.3 mmHg. The low-profile flexible stent, the streamlined shape without outside prosthetic material, and the anatomical sewing rim allow a comfortable implantation of the Labcor-Santiago valve, particularly in the small aortic annulus. It is hoped that this new design will contribute to an increase in in vivo mechanical durability.

[Ophthalmic accidents during local-regional anesthesia in dentistry: clinical aspects, anatomic routes]

Ophthalmic complications of intra-oral loco-regional anesthesia are rare. Three personal cases have incited the authors to review the world literature on this topic and emphasize a few epidemiological data as well as the broad outline of the characteristic clinical picture. Various etio-pathogenic hypotheses are discussed: arterial, venous or sympathetic routes. It seems that, with our current knowledge, no univocal explanation is perfectly satisfactory.

The Ionescu-Shiley pericardial bioprostheses in the aortic position. A 5-year perspective

From August 1977 to August 1982, aortic valve replacement (AVR) with the Ionescu-Shiley pericardial valve was carried out on 172 patients. Hospital mortality was 4.3% for solitary AVR and 15% for patients with additional surgery. The expected 5 year survival rate was 96.7% for patients with isolated AVR and 81.8% for associated AVR. Cumulative duration of follow-up was 3,892 patient-months (mean 26.8 months per patient). The actuarial projection of freedom from thromboembolic episodes was 98.6% for isolated AVR and 91.6% for associated AVR. Seven patients underwent reoperation: 4 for infective endocarditis, 1 for massive perivalvular leak, 2 for primary tissue failure. Although the actuarial rate of freedom from valve failure for isolated AVR with Ionescu-Shiley valve was 93.7% at 5 years after surgery, the next few years of follow-up will be critical in determining the superiority of this valve over the porcine bioprostheses.

Suppression of complex ventricular arrhythmias by oral flecainide

The effectiveness and safety of oral flecainide for suppression of complex ventricular arrhythmias was tested in nine patients in a short-term (4 wk), single-blind, placebo-controlled experiment. The prevalence of multiform premature ventricular complexes (PVCs), couplets and nonsustained ventricular tachycardia (VT) (less than 3 PVCs at rate less than 100/min) was determined by 48-hr Holter monitoring on placebo and flecainide (200 to 300 mg b.i.d.) therapy. Multiform PVCs/hr were reduced by 96% in eight of nine patients (P less than 0.001). Couplets per 24-hr period were suppressed entirely in six patients (P less than 0.001). Couplets per 24-hr period were suppressed entirely in six patients (P less than 0.001) and reduced by 92% in the remaining two patients. VT runs per 24 hr were abolished in six patients (P less than 0.02) and reduced by 91% in one. As a group the frequency of PVCs per hour, couplets per 24 hr and VT per 24 hr was reduced by 96% (P less than 0.01) over than in the preceding placebo period. Flecainide (P less than 0.02) slowed heart rate by 10% and prolonged PR, QRS, and QTc intervals by 31%, 47% and 6%. No hematologic, hepatic, or renal abnormalities were found. Side effects were mild, transient, and central nervous system related; blurring of vision was the most frequent effect and was reported in four patients.