Nail gun injury to the median nerve: A barbed issue

Nail gun injuries to the hand are an increasingly common encounter amongst those in the construction injury and a frequent presentation to the emergency department. Despite their frequency, nail gun injuries rarely involve significant structural injury. We present a rare case of severe injury by a barbed nail to the median nerve requiring surgical exploration. At our latest follow up 14 months post-operatively, the patient had ongoing sensory and motor deficits, cold intolerance and reduced proprioception and range of motion at the index finger. Continued hand therapy resulted in improved range of motion and desensitization. A systematic literature search has revealed no other reported cases of median nerve injury by nail gun.

Outcomes following surgical fixation of Gustilo-Anderson IIIb open tibial fractures

There is no consensus as to the optimal skeletal fixation method for Gustilo-Anderson IIIb fractures. External fixation methods have previously shown higher rates of superficial infection, whilst internal fixation has shown higher risk of deep infection, but lower risk of other complications. This paper investigates outcomes in open tibial fractures based on fixation method. A retrospective review was performed for patients presenting to an ortho-plastic unit with GA IIIb tibial fractures between June 2013 and October 2021. 85 patients were identified. The most common implant was an intramedullary nail (IMN), used in 29 patients (34.1%); open reduction and internal fixation (ORIF) was performed in 16 patients (18.8%). 18 patients (21.2%) were definitively managed with a frame alone. Mean follow-up from was 18 months (2-77). Patients with ORIF needed a mean of 3.37 operations; it was 2.48 for IMN which was significantly different from frames at 5.00 (p=0.000). The mean time to bony union after definitive fixation was 11.4 months. This differed depending on the implant used for fixation, with ORIF at 7.1 months, 10.1 for IMN, and frames at 17.2 months; ORIF significantly differed from frames (p=0.009). Superficial infection was common, seen in 38.8% of patients, and only 3 patients (4%) developed deep infections involving metalwork, with no difference in rates of either based on fixation method This study supports that ORIF has faster healing times, with less time to union compared to frames. It also shows that no implant was superior to another in terms of outcomes.

Reducing the risk of criminal exploitation using multi-systemic therapy (the RESET Study): study protocol for a feasibility study and process evaluation

BACKGROUND

Child criminal exploitation is a form of child abuse that poses a serious risk to the welfare, safety, and wellbeing of young people. Multisystemic therapy (MST) is an intensive family and community-based intervention for young people with anti-social behavioral problems, many of whom will be at risk of criminal exploitation. This protocol describes a pilot feasibility study and process evaluation, designed to examine MST for children at risk of criminal exploitation.

METHODS

This pilot feasibility study and process evaluation involves two phases with associated subphases: phase 1.1 involved the collaborative refinement of the logic model adapting MST for children at risk of criminal exploitation; phase 1.2 involved pre-pilot interviews with MST therapists, families, and young people; phase 2.1 is a pilot modeling study of MST for children at risk of criminal exploitation, and; Phase 2.2 is a process evaluation that will involve interviewing stakeholders, MST therapists and employees, families, and young people. The dataset for the process evaluation will include questionnaires completed by parents and young people at baseline, mid-treatment, end of treatment, and 6 months after treatment. We will supplement these data with participant-level data linkage from MST sites and services.

RESULTS

Accrual to the pilot stage of this project opened on 6th August 2021 and is due to close on 31st May 2022. We aim to publish the results of this feasibility study and process evaluation in 2023.

CONCLUSIONS

The results of this feasibility study and process evaluation will inform the decision as to whether it is advisable to progress to a pilot clinical trial of MST for children at risk of criminal exploitation.

TRIAL REGISTRATION

Trial registration: ISRCTN registry, ISRCTN16164816 on 25th January 2021- https://doi.org/10.1186/ISRCTN16164816 .

Can Anti-Müllerian Hormone levels predict future pregnancy outcomes in recurrent pregnancy loss?

OBJECTIVE

Serum Anti-Müllerian Hormone (AMH) levels have been shown to be lower among women who have experienced recurrent pregnancy loss (RPL) compared with the general population. However, it is unclear whether it can predict livebirth. This study aims to determine whether AMH can predict the likelihood of a livebirth in women with RPL.

STUDY DESIGN

Prospective analysis of a consecutive cohort of women undergoing investigation for RPL in a tertiary referral centre over a seven year period (August 2014 -December 2021). Analysis was performed using descriptive statistics, chi-square models and logistic regression models adjusting for maternal age and previous livebirth. Exclusion criteria for the regression analysis included abnormal parental karyotype and abnormal pelvic ultrasound scan. Pregnancy outcome was defined as livebirth or further pregnancy loss.

RESULTS

There were 488 women who underwent investigation of RPL during the study period. Of these, 65.2% (n = 318) conceived following attendance at the clinic. The majority of these women (69.4%, n = 221) proceeded to have a livebirth. There were no differences in median AMH levels between the livebirth group and the further pregnancy loss group (11 pmol/L vs 9 pmol/L respectively (p = 0.083). AMH did not affect clinical pregnancy rates (p = 0.77, 95% CI = 0.99 [0.98, 1.01]) or pregnancy outcome (p = 0.30, 95% CI = 1.01 [0.99, 1.04]). Abnormal pelvic ultrasonography (p = 0.04) and an abnormal parental karyotype (p = 0.04) were associated with an increased likelihood of a subsequent pregnancy loss.

CONCLUSION

Although AMH levels may have some utility in counselling of some couples with RPL, these contemporaneous data indicate that low AMH does not negatively influence subsequent pregnancy outcome in women with recurrent pregnancy loss.

344 LONG-TERM OUTCOMES FOR HIP FRACTURE PATIENTS WHO HAVE RECEIVED A PERIOD OF INPATIENT REHABILITATION

Background

Twenty-eight percent of the 3,666 hip fractures reported by the Irish Hip Fracture Database (IHFD) in 2020 received a period of rehabilitation in an off-site facility nationally. Longer term outcomes for hip fracture patients are not yet included in the IHFD. This study aimed to describe recovery after hip fracture in patients admitted to a single inpatient rehabilitation facility.

Methods

Patients who experienced hip fracture between January 2020 and July 2020 were followed up for one year after their fracture. Baseline data was collected in relation to age, pre-fracture residence and New Mobility Score (NMS) and clinical frailty score. Residence, NMS and quality of life (EQ-5D-5L) were collected by a clinical physiotherapist at 30 days, 120 days and 1 year after hip fracture. Data was inputted and analysed using Microsoft Excel.

Results

Of 122 hip fracture patients admitted to rehabilitation,103 were followed up. The average age of patients was 79, 66% were female. The mortality rate was 9% (n=9) at 1 year follow up. Pre-fracture, n= 98 lived at home. Of these patients, 67%, 82% and 83% had returned home by 30 days, 120 days and 1 year. Pre-fracture 53% had high mobility levels (NMS>6). Of these patient 4%, 27% and 34% had returned to this level by 30 days, 120 and 1 year. 70% of patients had a low mobility score (0-6 on NMS) and 30 % had a high mobility score (7-9) at 1 year follow-up. 56% and 4% of patients reported no pain and severe pain at 1 year post op, respectively. 45% of patients had no issues performing their usual activities and 4% had severe issues/an inability to perform their usual activities at 1 year.

Conclusion

Our results show that recovery after hip fracture is slow with many not achieving baseline mobility or return to pre-fracture function within the first year.

Dual-task gait speed assessments with an electronic walkway and a stopwatch in older adults. A reliability study

BACKGROUND/OBJECTIVES

Slow gait speed prospectively predicts elevated risk of adverse events such as falls, morbidity, and mortality. Additionally, gait speed under a cognitively demanding challenge (dual-task gait) predicts further cognitive decline and dementia incidence. This evidence has been mostly collected using electronic walkways; however, not all clinical set ups have an electronic walkway and comparability with simple manual dual-gait speed testing, like a stopwatch, has not yet been examined. Our main objective was to assess concurrent-validity and reliability of gait speed assessments during dual-tasking using a stopwatch and electronic walkway in older adults with mild and subjective cognitive impairment (MCI and SCI).

DESIGN

Cross-sectional, reliability study.

SETTING

Clinic based laboratory at an academic hospital in London, ON, Canada.

PARTICIPANTS

237 walk tests from 34 community-dwelling participants (mean age 71.84 SD 5.38; 21 female - 62%, 13 male - 38%) with SCI and MCI. were included from the Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) study.

INTERVENTION

Each participant performed seven walk tests: three single gait walks at their normal pace, three dual-task walks (walking and counting backwards by one, by sevens, and naming animals), and one fast walk.

MEASUREMENTS

Gait speed (cm/s) for each walk was measured simultaneously with an electronic walkway (Zeno Mat®) and a handheld stopwatch (Ultrak chronometer®). Dual-task cost (DTC) was calculated for the three individual dual-task walks as [((single gait speed - dual-task gait speed) / single gait speed) ∗ 100]. Level of agreement between the two measurement methods was analyzed using Pearson correlations, paired t-tests, and Bland-Altman plots.

RESULTS

Gait speed was consistently lower when measured with the stopwatch than with the electronic walkway (mean speed difference: 10.6 cm/s ± 5.1, p < 0.001). Calculating DTC, however, yielded very similar results with both methods (mean DTC difference: 0.19 ± 1.18, p = 0.872). The higher the DTC, the closer the measurement between methods.

CONCLUSION

Assessing and calculating DTC with a stopwatch is simple, accessible and reliable. Its validity and reliability were high in this clinical sample of community older adults with SCI and MCI.

Outcome of ACHD patients with non-inducible versus inducible IART undergoing cavo-tricuspid isthmus ablation: the role of empiric ablation

PURPOSE

Catheter ablation for supraventricular tachycardia (SVT) in adults with congenital heart disease (ACHD) is an important therapeutic option. Cavo-tricuspid isthmus (CTI)-dependent intraatrial re-entrant tachycardia (IART) is common. However, induction of sustained tachycardia at the time of ablation is not always possible. We hypothesised that performing an empiric CTI line in case of non-inducibility leads to good outcomes. Long-term outcomes of empiric versus entrained CTI ablation in ACHD patients were examined.

METHODS

Retrospective, single-centre, case-control study over 7 years. Arrhythmia-free survival after empiric versus entrained CTI ablation was compared.

RESULTS

Eighty-seven CTI ablations were performed in 85 ACHD patients between 2010 and 2017. The mean age of the cohort was 43 years and 48% were male. Underlying aetiology included ASD (31%), VSD (11.4%), AVSD (9.1%), AVR (4.8%), Fallot's (18.4%), Ebstein's (2.3%), Fontan's palliation (9.2%) and atrial switch (13.8%). CTI-dependent IART was entrained in 59 patients whereas it was non-inducible in 28. The latter had an empiric CTI ablation. Forty-three percent of procedures were performed under general anaesthesia. There were no reported procedural complications. There was no significant difference in the mean procedure or fluoroscopy times between the groups (empiric vs entrained CTI; 169.1 vs 183.3 and 28.1 vs 19.9 min). Arrhythmia-free survival was 64.3% versus 72.8% (p value 0.44) in the empiric and entrained groups at 21 months follow-up.

CONCLUSIONS

Long-term outcomes after empiric and entrained CTI ablation for IART in ACHD patients are comparable. This is a safe and effective therapeutic option. In the case of non-inducibility of IART, an empiric CTI line should be considered in this cohort.

Application of a mixture DOE for the prediction of formulation critical temperatures during lyophilisation process optimisation

During lyophilisation cycle design, primary drying parameters (chamber pressure and shelf temperature) are adjusted to maximize the sublimation rate and prevent cake collapse, by maintaining the product continuously below its critical temperatures. The objective of this study was to employ mixture design of experiments to generate empirical models capable of predicting glass transition of the maximally freeze concentrated solution (Tg') and collapse temperature (Tc) of amorphous protein (BSA and IgG1) formulations. Additionally, the models developed aid the design of high concentration protein formulations with maximised critical temperatures to obtain shorter and more cost-effective lyophilisation cycles. Formulations contain sucrose as cryo/lyo-protectant and arginine/arginine-HCl as multifunctional excipient (e.g. solubility enhancer, viscosity and aggregation suppressor). The impact of formulation components at varied ratios on critical temperatures was evaluated; the amorphous excipients decrease critical temperatures, on the contrary, the protein increases critical temperatures. The robustness of the empirical models generated with BSA formulations was verified with BSA and IgG1 formulations. The models showed greater accuracy in predicting Tg' than the Fox-Flory equation. For the first time, empirical models are reported to predict both critical temperatures. Finally, unconventional collapse events observed for formulations with and without arginine/arginine-HCl at different protein concentrations are also discussed.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Parenteral protein formulations: An overview of approved products within the European Union

The study presented is a comprehensive overview of commercial parenteral protein formulations, approved by the European Medicines Agency (EMA), 1995-2018. The objective of this overview was to analyse current trends in the design of commercial parenteral protein products and thereby support formulation scientists in the design of new formulations. The main data source was the publicly available European Public Assessment Reports (EPARs) published by the EMA for each authorised product. An analysis of the percentage of formulations in a liquid and lyophilised form was conducted. In addition, the number of products containing individual excipients, classified into functional categories is provided. Finally, the overview includes comprehensive details of product compositions obtained from EMA, US Food and Drug Administration (FDA) and product Marketing Authorisation Holder. Data analysis highlighted trends in the number of products approved, and the higher percentage of liquid parenteral protein formulations (66%) compared to lyophilised formulations (34%). This overview identifies the most commonly incorporated excipients employed as buffering agents, stabilisers/bulking agents, surfactants, preservatives and tonicifiers, including their concentration ranges of use in both liquid and lyophilised formulation approaches. Finally, antibody-based formulations were a particular focus of this overview. The relationship between parenteral routes of administration and antibody concentrations in approved products was also investigated.

Prevalence of isolated gastrocnemius tightness in patients with foot and ankle pathology

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

Patients and Methods

This prospective, case-matched, observational study compared gastrocnemius tightness, as assessed by the lunge test, in a control group and a group with foot and ankle pathology. Gastrocnemius tightness was calculated as the difference in dorsiflexion of the ankle with the knee extended and flexed.

Results

A total of 291 controls were paired with 97 patients with foot and ankle pathology (FAP). The mean gastrocnemius tightness was 6.0° (sd 3.5) in controls and 8.0° (sd 5.7) in the FAP group (p < 0.001). Subgroup analysis showed a mean gastrocnemius tightness of 10.3° (sd 6.0) in patients with forefoot pathology versus 6.9° (sd 5.3) in patients with other pathology (p = 0.008). A total of 12 patients (37.5%) with forefoot pathology had gastrocnemius tightness of > two standard deviations of the control group (> 13°).

Conclusion

Gastrocnemius tightness of > 13° may be considered abnormal. Most patients with foot and ankle pathology do not have abnormal degrees of gastrocnemius tightness compared with controls, but it is present in over a third of patients with forefoot pathology. Cite this article: Bone Joint J 2018;100-B:945–52.

An exploration of the prevalence and patterns of care for women presenting with mid-trimester loss

BACKGROUND

Mid-trimester loss (MTL) is an area that is poorly defined in the literature and often under reported in clinical practice. The prevalence of MTL in Ireland is uncertain and has a huge impact on the woman, her family and maternity care services.

AIMS

To explore the prevalence and patterns of care for women with MTL in a large Maternity hospital in Ireland.

METHODS

A descriptive, exploratory study was used involving a retrospective chart audit.

RESULTS

220 women presented with MTL over the 3 year data collection period (January 2011-December 2013), giving a rate of 0.8 % of all deliveries. The majority of women had no previous pregnancy losses and were multiparous (i.e., had a previous pregnancy >500 g). The mean gestational age was 17.69 weeks (SD = 2.73). The mean length of hospital stay was 1.89 days. Intra muscular (IM) analgesia was the most commonly (58.5 %) used medication. Follow up hospital care was received in over 78 % of cases. The majority of women were referred the CMS Bereavement and Chaplain services, with a small number (approx. 5 %) referred to the social worker. Over 46.4 % of families availed of the hospital burial service.

CONCLUSIONS

Results suggest the incidence of mid-trimester loss may be slightly lower than the 1 or 2 % of pregnancies reported in the literature. The incidence of mid-trimester loss in multiparous women is approximately twice that of nulliparous women. The referral services offered in the study were utilised by most of the women, as were follow-up clinic appointments.

Musculoskeletal Health, Kidney and Liver Function in Retired Jockeys

The long-term implications of making-weight daily on musculoskeletal health and functioning of the kidney and liver remain unknown. This study aimed to investigate musculoskeletal health and kidney and liver function in a group of retired jockeys. 28 retired male jockeys (age 50-70 years) provided fasting blood samples for markers of bone metabolism and kidney and liver function. A dual-energy x-ray absorptiometry (DXA) scan was performed for the assessment of bone mineral density (BMD). Established reference ranges were used for interpretation of results. Comparisons were made between retired jockeys based on the professional racing licence held: Flat, National Hunt or Dual. Mean whole-body osteopenia was reported, with no differences between groups. Bone markers, micronutrients, electrolytes and associated hormones, and markers for kidney and liver function were within clinical normative ranges. No differences existed between groups. Results indicate the retired jockeys in this study do not demonstrate compromised bone health or kidney and liver function. However, the retired jockeys may not have undergone chronic weight cycling in the extreme manner evident in present-day jockeys, indicating the next generation of jockeys may face more of a problem. Jockeys should be tracked longitudinally throughout their racing career and beyond.

Acute gastric necrosis after routine oesophagogastroduodenoscopy with therapeutic argon plasma coagulation

A 56-year-old woman presented to the accident and emergency department with peritonitis 2 days after a routine oesophagogastroduodenoscopy. She was taken to theatre with the finding of gastric necrosis. Blood and peritoneal cultures grew group A haemolytic Streptococcus. Histology revealed normal vasculature, no volvulus but marked neutrophilia in the submucosa with an intact mucosa. The stomach was resected and the patient recovered in the intensive care unit but overwhelming acidosis progressed to multiorgan failure and treatment was eventually withdrawn. Acute phlegmonous gastritis has been well described in the literature but mainly before the advent of antibiotics. The most common organism is group A haemolytic Streptococcus (commonly found in throat infections) and predisposing factors include instrumentation. Should antibiotics be given at the start of an oesophagogastroduodenoscopy and should routine procedures be delayed if active upper respiratory tract infections are present?

Management of autoimmune liver disease

The management of autoimmune liver disease can be very challenging. The presentation and natural history of these disorders is highly variable and can be asymptomatic, acute or chronic. Diagnosis requires the skilled interpretation of serological markers and histological changes and sometimes of biliary tract imaging. The major treatment options are immunosuppressive therapy (steroids and azathioprine) in autoimmune hepatitis (AIH) and ursodeoxycholic acid in cholestatic conditions although other treatments continue to be developed and tested. The complications of these diseases, in particular hepatocellular carcinoma and, in PSC, cholangiocarcinoma, remain difficult to monitor or prevent. Liver transplantation remains the only therapeutic option for end stage of liver disease and determining the optimum time for a patient to undergo this procedure requires a sophisticated judgment of the risks and benefits of the procedure as they pertain to an individual patient.

Diagnosis and endovascular treatment of pediatric spinal arteriovenous shunts

Spinal arteriovenous shunts (SAVSs) are rarely diagnosed in infants and children, but they are important clinically because morbidity can be significant. Although these lesions do not form a distinct pathologic group separate from the SAVSs seen in older patients, experience with these malformations in the pediatric population has led to the identification of several important features that are characteristic of this group of SAVSs. Association with genetic abnormalities, heritable (hereditary hemorrhagic telangiectasia) and nonheritable somatic (spinal arteriovenous metameric syndrome or Cobb syndrome), is relatively common and likely underrecognized. Male predominance is more pronounced than in the adult population. Hemorrhagic presentation is more frequent than in adults, except in extremely young children. The natural history seems to be better than previously thought, with early rehemorrhage uncommon. Despite early presentation and severe symptoms, these lesions are frequently amenable to endovascular treatment, often with anatomic cure achieved and with improvement or stabilization of symptoms after partial targeted treatment.

The anastomotic venous circle of the base of the brain

SUMMARY

Adjacent to the arterial circle of Willis at the base of the brain, there is an anastomotic circle of veins linking the right and left halves of the cerebral deep venous system. This venous circle is formed by anterior and posterior transverse anastomotic channels (the anterior and posterior communicating veins), and paramedian longitudinal vessels (the basal veins of Rosenthal). This collateral venous network has received considerably less attention than its arterial counterpart, but is its functional homologue. Although inconstant, it can be seen readily with current neuroimaging techniques including three-dimensional digital subtraction venographic phase 3D arteriography (3D-DSV) and CT venography (CTV). The venous circle represents a route of contralateral venous drainage that may become important, particularly when segments of the basal vein are absent (with or without complex DVA), or in high flow states including arteriovenous shunts that access the deep venous system.We review the gross anatomy and provide examples of the radiologic imaging of this venous circle.

Echocardiographic assessment of conjoined twins

OBJECTIVE

To determine the accuracy of prenatal and postnatal echocardiography in delineating the degree of cardiac fusion, intracardiac anatomy (ICA), and ventricular function of 23 sets of conjoined twins with thoracic level fusion presenting to a single centre over a 20 year period.

METHODS

13 thoracopagus, 5 thoraco-omphalopagus, and 5 parapagus pairs presenting to the authors' institution between 1985 and 2004 inclusive were assessed. Echocardiographic data were analysed together with operative intervention and outcome. Twins were classified according to the degree of cardiac fusion: separate hearts and pericardium (group A, n = 5), separate hearts and common pericardium (group B, n = 7), fused atria and separate ventricles (group C, n = 2), and fused atria and ventricles (group D, n = 9).

RESULTS

The degree of cardiac fusion was correctly diagnosed in all but one set. ICA was correctly diagnosed in all cases, although the antenatal diagnosis was revised postnatally in three cases. Abnormal ICA was found in one twin only in two group A pairs, one group B pair, and both group C pairs. All group D twins had abnormal anatomy. Ventricular function was good in all twins scanned prenatally, and postnatally function correlated well with clinical condition. Thirteen sets of twins in groups A-C were surgically separated; 16 of 26 survived. None from groups C or D survived.

CONCLUSIONS

Prenatal and postnatal echocardiography accurately delineates cardiac fusion, ICA, and ventricular function in the majority of twins with thoracic level fusion. It is integral in assessing feasibility of separation. The outcome in twins with fused hearts remains dismal.

Pulmonary regurgitation is an important determinant of right ventricular contractile dysfunction in patients with surgically repaired tetralogy of Fallot

BACKGROUND

Evaluation of right ventricular (RV) function in patients with pulmonary regurgitation (PR) after tetralogy repair remains challenging because of abnormal RV loading conditions.

METHODS AND RESULTS

We examined 124 patients, aged 21+/-11.4 years, who had tetralogy repair at 3.7+/-3.5 years. By Doppler echocardiography, 33 patients had mild, 22 moderate, and 69 severe PR; 55 had significant tricuspid regurgitation (TR). Myocardial velocities, myocardial acceleration during isovolumic contraction (IVA), strain, and strain rate were measured at RV and LV base. Tricuspid valve annulus was measured in a 4-chamber view. QRS, QT, and JT intervals and their dispersions were measured from 12-lead electrocardiogram. IVA in the RV was lower in all patients compared with controls (0.8+/-0.4 versus 1.8+/-0.5, P<0.0001) and correlated with the severity of PR (r=-0.43, P<0.0001), whereas myocardial velocities, and strain/strain rate did not. LV IVA correlated with PR (r=-0.32, P<0.001) and with RV IVA (r=0.28, P<0.003). Patients with severe PR had a higher incidence of TR (r=0.69, P<0.0001) and lower RV IVA (1.0+/-0.4 versus 0.6+/-0.3, P<0.0001), a larger tricuspid valve ring diameter (P<0.0001), and prolonged electrical depolarization (P<0.001). Age at surgery or examination did not correlate with PR and with RV function assessed by IVA. In the RV, IVA correlated inversely with QRS duration (P<0.01).

CONCLUSIONS

Although load-dependent myocardial velocities and strain are not influenced by the severity of PR and presence of significant TR, IVA demonstrates reduced contractile function in relation to the degree of PR and may be an early, sensitive index for selecting patients for valve replacement.

Genotype-phenotype analysis of the Crohn's disease susceptibility haplotype on chromosome 5q31

BACKGROUND AND AIMS

Recent molecular data suggest that genetic factors may underlie the disease heterogeneity observed in both ulcerative colitis (UC) and Crohn's disease (CD). A locus on chromosome 5q has been implicated in susceptibility to CD, and recently refined by linkage disequilibrium mapping to a conserved 250 kb haplotype (5q31). No data regarding the contribution of this locus to clinical phenotype exist. In this case control study, we investigated the contribution of this haplotype to both susceptibility and phenotype of CD and UC.

PATIENTS AND METHODS

We studied 330 Caucasian CD and 457 UC patients recruited from a single UK centre. Association with disease susceptibility and phenotype was analysed with haplotypes reconstructed from three single nucleotide polymorphisms chosen to span this susceptibility region. Evidence for possible genetic epistasis between IBD5 and NOD2/CARD15 was sought.

RESULTS

Linkage disequilibrium across this region was confirmed, with two haplotypes comprising 88% of all chromosomes. Susceptibility to CD, but not to UC, was associated with homozygosity for a common haplotype, H2 (p(c)=0.002; relative risk (RR) 2.0). Genotype-phenotype analyses demonstrated that this association was particularly strong in patients with perianal disease (p(c)=0.0005; RR 1.7), especially in individuals homozygous for this haplotype (p(c)=0.0005; RR 3.0). Importantly, no association with H2 was found in 186 patients without perianal disease. No evidence of epistasis between IBD5 and NOD2/CARD15 was demonstrated.

CONCLUSIONS

The IBD5 risk haplotype is associated with CD only. Genotype-phenotype analysis reveals that the strongest association is observed in patients with perianal CD. While the precise gene involved is unclear, these data provide further molecular evidence for a genetic basis of the clinical heterogeneity of CD.

Basal pulmonary vascular resistance and nitric oxide responsiveness late after Fontan-type operation

BACKGROUND

The pulsatile nature of pulmonary blood flow is important for shear stress-mediated release of endothelium-derived nitric oxide (NO) and lowering pulmonary vascular resistance (PVR) by passive recruitment of capillaries. Normal pulsatile flow is lost or markedly attenuated after Fontan-type operations, but to date, there are no data on basal pulmonary vascular resistance and its responsiveness to exogenous NO at late follow-up in these patients.

METHODS AND RESULTS

We measured indexed PVR (PVRI) using Fick principle to calculate pulmonary blood flow, with respiratory mass spectrometry to measure oxygen consumption, in 15 patients (median age, 12 years; range, 7 to 17 years; 12 male, 3 female) at a median of 9 years after a Fontan-type operation (6 atriopulmonary connections, 7 lateral tunnels, 2 extracardiac conduits). The basal PVRI was 2.11+/-0.79 Wood unit (WU) times m2 (mean+/-SD) and showed a significant reduction to 1.61+/-0.48 (P=0.016) after 20 ppm of NO for 10 minutes. The patients with nonpulsatile group in the pulmonary circulation dropped the PVRI from 2.18+/-0.34 to 1.82+/-0.55 (P<0.05) after NO inhalation.

CONCLUSIONS

PVR falls with exogenous NO late after Fontan-type operation. These data suggest pulmonary endothelial dysfunction, related in some part to lack of pulsatility in the pulmonary circulation because of altered flow characteristics. Therapeutic strategies to enhance pulmonary endothelial NO release may have a role in these patients.

Patients with small duct primary sclerosing cholangitis have a favourable long term prognosis

BACKGROUND

Patients with cholestatic liver function tests and histological features of primary sclerosing cholangitis (PSC) but a normal cholangiogram are considered to have small duct PSC. The natural history of this condition is unknown.

METHODS

Thirty three patients with small duct PSC were identified among patients admitted for diagnostic workup of cholestatic liver function tests in one centre in the UK (Oxford) and one centre in Norway (Oslo). A total of 260 patients with large duct PSC were compared, and prognosis in terms of death, cholangiocarcinoma, biochemical features, histological features, and symptoms analysed.

RESULTS

Mean age at diagnosis was 38 years and 39 years in small duct and large duct PSC, respectively. Mean follow up was 106 months in small duct and 105 months in large duct patients. Four patients originally considered to have small duct developed large duct PSC. Two of these underwent liver transplantation during follow up. Of the remainder who did not develop large duct PSC, two patients died during follow up: one of liver failure and the other of cardiac death unrelated to her liver disease. A total of 122 (47%) large duct patients either required liver transplantation (34 patients) or died (88 patients). Small duct patients had a significantly better survival compared with large duct patients. Among small duct patients, none developed cholangiocarcinoma compared with 28 of 260 (11%) large duct patients.

CONCLUSIONS

Patients with small duct PSC seem to have a good prognosis in terms of survival and development of cholangiocarcinoma. Small duct PSC progresses to large duct PSC in a small proportion of patients.

Comparison of once- and twice-daily clarithromycin in the treatment of adults with severe acute lower respiratory tract infections

BACKGROUND

Although the modified-release (MR) formulation of clarithromycin has demonstrated bioequivalence to the immediate-release (IR) formulation and thus can be prescribed for lower respiratory tract infections (LRTIs), a MEDLINE search from 1995 through 1998 and information on file with the manufacturer indicate that no data are available on the effectiveness of this new formulation in the treatment of severe LRTIs such as community-acquired pneumonia.

OBJECTIVE

This study was designed to compare clinical success rates (percentage of patients with clinical cure or improvement) with once- and twice-daily regimens of clarithromycin in the treatment of patients with severe, acute LRTIs requiring oral antibiotic therapy.

METHODS

In this multicenter, investigator-blinded, randomized, parallel-group study, adult patients with clinical evidence suggesting severe, acute LRTI were recruited from 22 general practices in the United Kingdom. Patients were randomly allocated to receive either clarithromycin 500 mg BID (IR tablets) or clarithromycin 1 g OD (two 500-mg MR tablets) for 7 to 14 days. The outcome measures were resolution of or improvement in clinical signs and symptoms (including resolution of cough), unscheduled visits for the same symptom, days to resumption of normal activities, and improvements in quality of life (assessed using the EQ-5D version of the EuroQoL questionnaire). Clinical, microbiologic, and serologic assessments were performed before, during, and after treatment. Efficacy and safety data were analyzed on an intent-to-treat basis.

RESULTS

One hundred sixty men (n = 83) and women (n = 77) between the ages of 19 and 88 years took part in the study, 78 receiving clarithromycin 500 mg BID and 82 receiving clarithromycin 1 g OD. At 4 weeks after the start of treatment, the high clinical success rates were comparable between groups: 84.6% with clarithromycin 500 mg BID and 90.2% with clarithromycin 1 g OD. No significant differences in outcome measures were noted between the 2 regimens. Both treatments were well tolerated, with taste disturbance being the most commonly reported adverse event (10.6% vs 6.1% with clarithromycin 500 mg BID and 1 g OD, respectively).

CONCLUSIONS

The 2 clarithromycin regimens were equally efficacious and well tolerated in the treatment of severe, acute LRTIs. However, caution should be exercised in applying these results to the general population, because the study excluded certain categories of patients who would normally be treated. In addition, the small sample size may have obscured clinically significant differences between the 2 regimens.

Urinary incontinence in female patients with chronic obstructive pulmonary disease

Background: Urinary incontinence has been experienced as a problem since 1500 BC. In the twentieth century it is still a major problem that remains a source of distress for many sufferers. A lack of literature regarding the prevalence  of stress urinary incontinence (SUI) amongst chronic obstructive pulmonary disease (COPD) patients lead to this studyObjective: To determine the prevalence of stress urinary incontinence in female COPD patients between the ages of 30 and 70 years.Methods: This cross-sectional study included 67 female COPD patients (aged 30-70 years) who were interviewed during a three month period. A structured COPD / incontinence questionnaire was used to obtain data. Statistical analysis of results included Fisher’s exact test and two-tailed t-tests. A p-value of < 0,05 was considered to be statistical significant.Results: The prevalence of SUI in female COPD patients was estimated as 82,1%. Smoking history was the only variable with a significant positive correlation regarding the patients presenting with SUI (p < 0,05). The proportion of smokers in the subjects presenting with SUI (SUI group - 29/55) is significantly higher than the subjects with no symptoms of SUI (normal group - 2/12).Discussion and Conclusion: The outcome of this study revealed a high prevalence of SUI in female COPD patients. Cigarette smoking, as the major contributing factor, revealed a strong statistical correlation between COPD and SUI.

Aetiopathogenesis of primary sclerosing cholangitis

The aetiology and pathogenesis of PSC have not yet been clearly defined. The hypothesis that PSC is an immune mediated disease is supported by associations with HLA haplotypes, the presence of autoantibodies, increased levels of total serum immunoglobulins and the association with other autoimmune diseases. PSC does not, however, have many of the characteristics of classical autoimmunity, particularly the usual female preponderance of disease and lack of a good response to immunosuppression. Non-immune mechanisms such as bacterial infection, ischaemia and toxicity are also clearly important in the development of the disease and these factors may trigger peribiliary inflammation and cytokine-induced hepatic fibrosis. PSC may be triggered in genetically susceptible individuals by toxic or infectious agents gaining access to the liver via a diseased and permeable colon.

Regional wall motion and abnormalities of electrical depolarization and repolarization in patients after surgical repair of tetralogy of Fallot

BACKGROUND

Abnormal depolarization-repolarization in patients with repaired tetralogy of Fallot (TOF) is a risk factor for malignant ventricular tachycardia and sudden death. It is unclear whether ECG abnormalities are associated with abnormal regional right ventricular (RV) function.

METHODS AND RESULTS

Seventy-four patients (37 patients <18 and 37 >18 years old) who had had TOF repair at 4.0 years old (0.1 to 47 years old) were examined when they were 18.7 years old (1.7 to 61.1 years old), as were 112 control subjects with normal hearts. Regional function was evaluated with tissue Doppler imaging of the RV and left ventricular (LV) free wall and the septum. Myocardial velocities were sampled continuously from base to apex. Synchronous ECG was analyzed for QRS, QT, and JT duration and QRS, QT, and JT dispersion. All 74 TOF patients had normal LV myocardial velocities. Forty-eight patients (24 patients <18 and 24 >18 years old) had reversed myocardial velocities in diastole in the RV free wall, which were associated with reversed systolic myocardial velocities in 22 and additional reverse diastolic myocardial velocities in the septum in 19. Those 48 patients had a longer QRS duration (151+/-31 versus 124+/-27 ms) and greater QRS (47+/-18 versus 29+/-12 ms), QT (73+/-27 versus 52+/-22 ms), and JT (96+/-31 versus 67+/-35 ms) dispersion. Compared with normal control subjects, all 74 TOF patients had decreased systolic and diastolic myocardial velocities and a longer isovolumic relaxation time.

CONCLUSIONS

RV wall-motion abnormalities are a common finding late after TOF repair and are associated with repolarization-depolarization abnormalities. These data further underscore a likely mechanoelectrical interaction as an important part of the pathogenesis of RV disease in these patients.

A comparative study of clarithromycin modified release and amoxicillin/clavulanic acid in the treatment of acute exacerbation of chronic bronchitis

This phase III, investigator-blind, randomized, parallel-group study compared the efficacy and tolerability of clarithromycin modified release (MR) with those of amoxicillin/clavulanic acid in 250 adult outpatients with acute exacerbationof chronic bronchitis (AECB). Patients received either clarithromycin MR 500 mg once daily or amoxicillin/clavulanic acid 500 mg/125 mg three times daily for 7 days. Primary endpoints were sponsor-defined clinical response and pathogen outcome at the end of treatment. Secondary endpoints were sponsor-defined clinical response and pathogen outcome at study end, investigator-defined clinical response at end of treatment and end of study, resolution or improvement of signs and symptoms, eradication of baseline pathogens, serologic outcome for atypical pathogens, and occurrence of reinfection and superinfection. Adverse events and compliance were also evaluated. Clinical and bacteriologic outcomes with both treatments for all endpoints were statistically equivalent, as were total adverse events, although the incidences of digestive disturbances (13% vs 4%) and discontinuations due to adverse events (8 vs 2 patients; P < or =.05) were significantly higher with amoxicillin/clavulanic acid. Ninety-five percent of patients receiving clarithromycin MR and 80% receiving amoxicillin/clavulanic acid were 100% compliant with medication (P < or =.05). Clarithromycin MR and amoxicillin/clavulanic acid are both well tolerated and effective as therapy for AECB; however, clarithromycin produced fewer side effects and discontinuations and higher compliance rates.

Transposition of the Great Arteries

Transposition of the great arteries (TGA) is a lethal condition without intervention. Cross-sectional echocardiography is the diagnostic investigation of choice. Intravenous infusion of prostaglandin is employed to maintain ductal patency and allow mixing of blood, thus improving tissue oxygenation. Balloon atrial septostomy is recommended once the diagnosis is made. The arterial switch is accepted as the best option for simple TGA. Late follow-up includes survivors of the intra-atrial repair (Mustard and Senning operations), and the emerging cohort of survivors of the arterial switch procedure. Arrhythmia, baffle stenosis, tricuspid valve dysfunction, systemic ventricular dysfunction, and sudden death may occur late during follow-up after the Mustard or Senning procedure. There are less data for late follow-up after arterial switch; however, late death is rare, usually is related to reoperation, and important arrhythmias are uncommon. The long-term fate of the coronary circulation is unknown but coronary arterial obstruction has been reported. Continuing long-term surveillance is essential to detect the development of late problems in all groups of survivors.

Comparison of long-term outcomes of atrial repair of simple transposition with implications for a late arterial switch strategy

BACKGROUND

We report the single-institution, long-term results of 358 patients with simple transposition of the great arteries surviving >30 days after a Mustard (n=226, 1965 to 1980) or Senning (n=132, 1978 to 1992) procedure.

METHODS AND RESULTS

Outcome measures included late death, reintervention, ECG and ambulatory ECG rhythm, new arrhythmia, and functional status. Average follow-up was 13.4 (range 0.32 to 17.9) years for the Senning group and 11.7 (range 0.04 to 23.9) years for the Mustard group. The Senning group had a better survival rate at 5, 10, and 15 years (95% versus 86%, 94% versus 82%, and 94% versus 77%, respectively). In both groups, the majority of late deaths were sudden, without preceding ventricular dysfunction. Survival and survival free of reintervention were significantly better in the Senning group (relative risk [RR] 0.34, P=0.06 versus RR 0.39, P=0.027). Loss of sinus rhythm was comparable and unrelated to death. After era correction, the incidence of atrial flutter was similar and strongly associated with late death in both groups. Clinical systemic ventricular failure was uncommon, and at last follow-up, 92% of the Senning group and 89% of the Mustard group were in New York Heart Association class I. In a model exploring the implications of elective arterial switch conversion, this would only be beneficial if the hazard late after switch was markedly reduced and/or the hazard after the Senning procedure increased with time.

CONCLUSIONS

Late outcomes after the Senning procedure are superior to those after the Mustard procedure. Both groups had late sudden deaths that were not associated with clinical systemic ventricular failure. Good functional status after the Senning procedure suggests that a strategy of elective switch conversion cannot be justified for patients with isolated transposition.

Anomalous coronary artery with tetralogy of Fallot and aortopulmonary window

Anomalous origin of the left main coronary artery from the pulmonary artery is rarely associated with other conditions. We report the case of an infant born with tetralogy of Fallot and aortopulmonary window who at the time of surgical repair was found to have an anomalous left main coronary artery originating from the right pulmonary artery.

Early age at repair prevents restrictive right ventricular (RV) physiology after surgery for tetralogy of Fallot (TOF): diastolic RV function after TOF repair in infancy

OBJECTIVES

To assess diastolic right ventricular (RV) physiology after tetralogy of Fallot repair in infancy.

BACKGROUND

Restrictive RV physiology after tetralogy of Fallot repair is related to type of repair, pulmonary regurgitation, and late arrhythmias.

METHODS

Forty-seven patients were investigated, 27 and 20 patients in Lund and London, respectively. Median age at repair was 0.78 years (0.08-0.99) and median follow-up was 3.0 years (0.08-10.4). Restrictive RV physiology was assessed by Doppler echocardiography.

RESULTS

Thirteen patients (28%) had restrictive RV physiology at follow-up, three of 19 patients (16%) with transatrial repair and 10 of 28 patients (32%) with transventricular repair, respectively (p=0.1). Ten percent of the patients repaired before 6 months of age were restrictive at follow-up, increasing to 38% with repair after 9 months. Transannular patch (TAP) repair was performed in 55% of the patients, including eight of 10 patients (80%) with repair before 6 months of age. Thirty-one percent of the patients with TAP repair were restrictive. These restrictive patients had more severe preoperative pulmonary stenosis (p < 0.05), were older at repair (p < 0.05), and had shorter duration of pulmonary regurgitation (p < 0.001) at follow-up.

CONCLUSIONS

Restrictive RV physiology is inversely related to age at repair and independent of type of outflow tract repair. Since TAP repair is more common in early repair, and restriction seems to be less frequent, long-term follow-up to assess adverse effects of pulmonary regurgitation is mandatory.

Does restrictive right ventricular physiology in the early postoperative period predict subsequent right ventricular restriction after repair of tetralogy of Fallot?

OBJECTIVE

To assess the relation between immediate postoperative right ventricular (RV) diastolic physiology and subsequent diastolic function in patients after repair of tetralogy of Fallot.

DESIGN

Serial prospective echocardiographic study early after surgical repair of tetralogy of Fallot and at mid-term follow up.

SETTING

Tertiary referral centre.

PATIENTS

34 patients who had repair of tetralogy of Fallot between 1992 and 1995 were studied.

MAIN OUTCOME MEASURES

Restrictive RV physiology defined as antegrade flow in the pulmonary artery in late diastole throughout the respiratory cycle.

RESULTS

Sixteen of the 34 patients had early restrictive RV physiology. The need for transannular patch repair was an independent variable predictive of early restriction (odds ratio 4.3 (1.1-47), p < 0.05). Nine of 16 patients with early restriction also had restriction at follow up, while 15 of 16 patients without restrictive RV physiology continued without restriction. Early restriction was the only independent variable predictive of late restriction (odds ratio 6.0 (1.9-273), p = 0.01).

CONCLUSIONS

Early and mid-term restrictive RV physiology after repair of tetralogy of Fallot is related to the repair type. Although evidence for this physiology tends to resolve in the first few days after operation, it is highly predictive of subsequent abnormalities of RV diastolic function. Similarly, normal RV diastolic physiology without restriction in the immediate postoperative period persists in the mid-term and may be associated with the long term problems of progressive RV dilatation.

Carotid artery pseudoaneurysm as a complication of ECMO

Any pulsatile neck mass after extracorporeal membrane oxygenation (ECMO) must be viewed as a pseudoaneurysm of the carotid artery until proven otherwise. Prompt diagnosis is necessary utilizing ultrasound. Angiography may not be necessary. Carotid artery pseudoaneurysm requires urgent surgical intervention to prevent catastrophic hemorrhage. The utilization of cardiopulmonary bypass may facilitate safe repair.

The growth and cardiovascular effects of high dose growth hormone therapy in idiopathic short stature

OBJECTIVE

It is possible that high dose GH treatment may have beneficial effects on growth but important adverse effects on cardiac function. We have therefore investigated the efficacy and cardiovascular effects of high dose biosynthetic human GH (r-hGH) treatment in children with idiopathic short stature and a normal pretreatment height velocity.

STUDY DESIGN

Randomized controlled study.

PATIENTS

Twenty-nine short (height SDS < 1.5), normally growing (height velocity SDS > -1.5), prepubertal children referred to two specialist growth clinics.

INTERVENTIONS

Children were randomly assigned to an observation group or to receive 'standard' (20 IU/m2/week) or 'high' (40 IU/m2/week) dose r-hGH by daily subcutaneous injection. At the end of 1 year the observation group were randomly assigned to 'standard' or 'high' dose r-hGH therapy for the second year of the study. Regular growth, biochemical and echocardiographic monitoring were performed throughout the study period.

MAIN OUTCOME MEASURES

Changes in height velocity, HtSDS for bone age (HtSDSBA), left ventricular mass index (LVMI) and left ventricular function (fractional shortening) during 2 years treatment.

RESULTS

Twenty-seven children completed the study. Ht velocity SDS increased with r-hGH therapy in a dose dependent fashion. First-year height velocity SDS was +5.7 in the high dose r-hGH group compared with +2.7 in the standard dose r-hGH group and -0.5 in the observation group (P < 0.001). In those children treated for 2 years HtSDSBA was -0.5 in the high dose group but had not changed significantly in the standard dose group (-1.7) (P = 0.01). After one year r-hGH treatment LVMI was 71 g/m2 (observation group), 73 g/m2 (20 IU/m2/week group) and 74 g/m2 (40 IU/m2/week group) (P = 0.77). LVMI increased significantly from baseline to 76 g/m2 after 2 years therapy with 40 IU/m2/week r-hGH (P = 0.04) but nevertheless remained within the normal range. Fractional shortening did not change significantly over 2 years of r-hGH therapy.

CONCLUSIONS

High dose (40 IU/m2/week) r-hGH treatment of children with idiopathic short stature resulted in a greater short-term acceleration in growth rate than 'standard' dose therapy without an excessive advance in skeletal maturity and probably represents the optimal growth promoting dose for short, normally growing children. Whether continued high dose r-hGH therapy increases final height requires further study. Left ventricular morphology and function remained within the normal range during r-hGH therapy but regular monitoring of cardiovascular status should continue in non-GHD children receiving r-hGH in high doses over a longer time period.

Snoring and sleep apnea. A population study in Australian men

Snoring and sleeping apnea are reportedly associated with morbidity. We used home monitoring (MESAM IV) to measure snoring and sleep apnea in 294 men aged 40 to 65 yr from the volunteer register of the Busselton (Australia) Health Survey. In this group, 81% snored for more than 10% of the night and 22% for more than half the night; 26% had a respiratory disturbance index (RDI) > or = 5, and 10% had an RDI > or = 10. There was a relatively low correlation between percentage of night spent snoring and RDI (rho = 0.47, p < 0.005). Subjective daytime sleepiness plus RDI > or = 5 occurred in a minimum of 3%. Obesity was related to snoring, RDI, and minimum SaO2 (all p < 0.0001). There was no relationship between age and either RDI or snoring, but increased age was related to minimum SaO2 < 85% (p < 0.05). Alcohol consumption was not related to sleep-disordered breathing. Smokers snored for a greater percentage of the night than nonsmokers (41 versus 31%, p = 0.01). We conclude that, in middle-aged men, both snoring and sleep apnea are extremely common, and in this age range both are associated with obesity but not with age. However, a high percentage of snoring is not essential for the occurrence of sleep apnea, nor does it necessarily indicate that apnea is present.

Right ventricular diastolic function 15 to 35 years after repair of tetralogy of Fallot. Restrictive physiology predicts superior exercise performance

BACKGROUND

We have shown previously that transient right ventricular restriction after tetralogy of Fallot repair prolongs postoperative course. This is a prospective study of right ventricular diastolic performance in late follow-up patients.

METHODS AND RESULTS

We studied biventricular function, using Doppler echocardiographic examination. Pulmonary arterial, tricuspid, and mitral valves and superior vena cava Doppler spectrals were obtained in 41 patients (mean age, 28.8 years), 15 to 35 years (mean, 23.6) after complete repair of tetralogy of Fallot. Patients were considered to have evidence of right ventricular restriction if antegrade diastolic flow was detected in the main pulmonary artery, coinciding with atrial systole (A wave), throughout the respiratory cycle. Exercise function was measured by graded treadmill testing with respiratory mass spectrometry. Three patients were excluded because of pulmonary outflow obstruction (Doppler gradient > 40 mm Hg) or residual intracardiac shunts. Of the 38 patients, 37 were in sinus rhythm. Twenty (52.6%) had definite evidence of restriction with an A wave in the pulmonary artery, augmented during inspiration. In all 20 cases, there was superior vena caval flow reversal with atrial systole. Both inspiratory and expiratory transtricuspid E-wave deceleration time was significantly shorter in the restrictive group (P < .003 and P < .03, respectively). All patients had Doppler evidence of pulmonary regurgitation, but its duration was shorter in the restrictive group (P < .01) during inspiration. Cardiothoracic ratio was significantly lower in the restrictive group (P < .01), suggesting less severe pulmonary regurgitation. Both restrictive and nonrestrictive groups had reduced exercise MVO2 compared with healthy age- and sex-matched control subjects, but those with restrictive physiology had significantly better maximum oxygen uptake than the nonrestrictive group (P < .001).

CONCLUSIONS

Isolated right ventricular restriction late after tetralogy of Fallot repair is common. Although it reflects abnormal hemodynamics, the A wave contributes to forward pulmonary arterial flow and shortens the duration of pulmonary regurgitation. Consequently, there is less cardiomegaly and improved exercise performance in those patients.

Characterization of right ventricular diastolic performance after complete repair of tetralogy of Fallot. Restrictive physiology predicts slow postoperative recovery

BACKGROUND

Prolonged postoperative recovery caused by a low cardiac output state occurs in some patients after complete repair of tetralogy of Fallot. Biventricular systolic function is usually well preserved in these patients. The contribution of impaired diastolic function, particularly of the right ventricle, has not been studied in detail; therefore, we performed a prospective study of right ventricular diastolic function in this patient group.

METHODS AND RESULTS

We studied biventricular systolic and diastolic function using Doppler echocardiographic examination. Tricuspid valve, superior vena caval, pulmonary arterial, and mitral valve Doppler spectrals were obtained during the first postoperative day in 35 patients aged 6 months to 45 years who underwent complete repair of tetralogy of Fallot. Biventricular systolic function was grossly normal in all patients. Isolated restrictive right ventricular physiology characterized by pulmonary arterial antegrade flow coincident with atrial systole and associated with prominent retrograde superior vena caval flow was seen in 17 of the 35 patients (group 1). This flow was augmented during the expiratory phase of positive pressure ventilation and abolished or greatly diminished during the inspiratory phase (P < .001). An increase in the duration of pulmonary regurgitation occurred during the inspiratory phase of positive pressure ventilation in these patients (P < .01). All patients with right ventricular restriction had a clinical picture compatible with a low cardiac output state, requiring prolonged stays in intensive care and the hospital. Clinical improvement was mirrored by resolution of the Doppler markers of right ventricular restriction in most of the patients.

CONCLUSIONS

Isolated right ventricular restriction is characterized by antegrade diastolic pulmonary arterial flow on Doppler echocardiography and is responsible for the slower postoperative course and clinical evidence of low cardiac output state in some patients after complete repair of tetralogy of Fallot.

Transcatheter closure of a ruptured aneurysm of the sinus of Valsalva

A ruptured aneurysm of the sinus of Valsalva in a man of 34 was closed by a transcatheter technique with a 12 mm modified Rashkind umbrella device.

Prognostic significance of ventricular arrhythmia after repair of tetralogy of Fallot: a 12-year prospective study

OBJECTIVE

The aim of this study was to examine the prognostic significance of ventricular arrhythmia on the ambulatory electrocardiogram (ECG) after repair of tetralogy of Fallot.

BACKGROUND

Ventricular arrhythmia is common after repair of tetralogy of Fallot and has been proposed as the basis for late sudden death. The prognostic significance of ventricular arrhythmia on ambulatory ECG and the indications for therapy are uncertain.

METHODS

We performed a 48-h ambulatory ECG in 86 patients (3 to 45 years old [mean age 14 years]) after repair of tetralogy of Fallot. These patients were then followed up prospectively for 12 years.

RESULTS

At initial assessment in 1980, 47 patients (55%) had infrequent uniform ventricular extrasystoles (16 patients) or normal cardiac rhythm (31 patients) Group 1), and 39 patients (45%) had frequent uniform ventricular extrasystoles (> 30/h, 2 patients), complex extrasystole (30 patients) or nonsustained ventricular tachycardia (7 patients) (Group 2). There were no significant clinical or hemodynamic differences between the groups. In addition, nine patients had supraventricular tachyarrhythmia. Antiarrhythmic therapy was prescribed only for the 10 patients who had symptoms attributable to arrhythmia. There were two sudden deaths in Group 1 (4%) and one nonsudden death in Group 2 (2.5%). The absolute difference in mortality between groups was therefore 1.5% (95% confidence limits -6% to +9%), excluding a clinically significant difference in outcome. All but 1 of the 39 patients with complex ventricular arrhythmia are alive and well, including those with elevated (> or = 60 mm Hg) right ventricular pressure.

CONCLUSIONS

Nonsustained ventricular arrhythmia on ambulatory ECG does not identify patients at high risk for sudden death after repair of tetralogy of Fallot. There does not appear to be any advantage in potentially dangerous long-term antiarrhythmic therapy for asymptomatic postoperative patients.

Ebstein's anomaly: presentation and outcome from fetus to adult

OBJECTIVES

This study was conducted to investigate the presentation and outcome of patients with Ebstein's anomaly of the tricuspid valve.

BACKGROUND

Ebstin's anomaly may present at any age and has a highly variable clinical course. Previous natural history studies have been based on clinical and angiographic diagnosis and have included mainly older children and adults. Echocardiography, however, has facilitated fetal and neonatal diagnosis so that the natural history needs to be redefined.

METHODS

We reviewed 220 cases of Ebstein's anomaly presenting from fetal to adult life between 1958 and 1991, with 1 to 34 years of follow-up.

RESULTS

The most common presentation in each age group was abnormal routine prenatal scan for fetuses (86%), cyanosis for neonates (74%), heart failure for infants (43%), incidental murmur for children (63%) and arrhythmia for adolescents and adults (42%). Early presentation was frequently associated with other cardiac lesions, usually pulmonary stenosis or atresia. Surgery was undertaken at some stage in 86 (39%) of the 220 patients. Actuarial survival for all liveborn patients was 67% at 1 year and 59% at 10 years. There were 58 deaths, including 26 from heart failure, 19 perioperative and 8 sudden. Predictors of death included echocardiographic grade of severity at presentation (relative risk 2.7 for each increase in grade, 95% confidence limits 1.6 to 4.6), fetal presentation (6.9, confidence limits 1.6 to 16.5) and right ventricular outflow tract obstruction (2.1, confidence limits 1.1 to 4.4). Morbidity was mainly related to arrhythmias and late hemodynamic deterioration. Of 155 survivors, 129 (83%) were in functional class 1 and 104 (67%) were receiving no medical therapy.

CONCLUSIONS

In Ebstein's anomaly, fetal and neonatal presentation is associated with a poor outcome and can be predicted by the echocardiographic appearance and presence of associated lesions. In older children and adults, incidental findings and arrhythmia are common and the long-term outcome is superior.