Syncope recurrence and long-term heart rate variability after cardioneuroablation for vasovagal syncope: a systematic review and meta-analysis

Background

Cardioneuroablation (CNA) has emerged as a promising therapy in patients with refractory vasovagal syncope (VVS). Well-designed randomized clinical trials (RCT) are lacking.

Purpose

To provide an estimate of the procedural success rate of CNA, including subgroup analysis by method and target of ablation, as well as serial measurements of autonomic tone after CNA with heart rate variability (HRV).

Methods

A systematic search of studies was performed in MEDLINE and EMBASE according to the PRISMA guidelines, from inception to 14 February 2022. Observational studies and clinical trials reporting success rates were included. Quality assessment was performed using the CONSORT and STROBE recommendations. The primary outcome was freedom from syncope after CNA. Meta-analysis was performed with a random-effects model. The secondary outcome was serial HRV analysis (heart rate, SDNN, rMSSD and LF/HF ratio) analysed with one-way ANOVA with Bonferroni's correction for multiple testing.

Results

A total of 465 patients were included across 14 studies (mean age 40±4 years; 54% females). All included studies were of intermediate quality (median 17, IQR 16–18). Procedural approach to CNA was variable: 50 patients (10.8%) by mapping of fractionated electrograms, 73 patients (15.7%) with the spectral method, 210 (45.2%) with high frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 patients (12.6%) with a combination. The target was bi-atrial in 168 patients (36.1%), left atrium only in 259 patients (55.7%), and right atrium only in 38 patients (8.2%).

The freedom from syncope was 91.9% (95% CI 88.1–94.6%; I2=6.9%, p=0.376; Figure 1). CNA limited to right atrial ablation was associated with a significantly lower success rate (p<0.0001; 81.5%, 95% CI 51.9–94.7%) versus left atrial ablation only (94.0%, 95% CI 88.6–96.9%) and bi-atrial ablation (92.7%, 95% CI 86.8–96.1%). Subgroup analysis according to the technique used to identify GPs did not show any significant difference in success rate (p=0.206).

Ten studies (n=317, 68.2%) reported at least one HRV parameter. Results are presented in Figure 2 with the mean and standard deviations. There were significant increases in heart rate, and significant decrease in SDNN, rMSSD and LF/HF ratios for each follow-up timepoint available (p<0.0001 for all analyses). Recovery of these parameters was observed in 2 studies, but these were not associated with an increased risk in syncope recurrence.

Conclusion

This meta-analysis suggests a high procedural success rate of CNA in VVS of 92%. CNA induces long-term changes in HRV, however some studies reported recovery of these parameters without an association with syncope recurrence. Therefore, HRV changes may not be an appropriate surrogate endpoint for clinical response. Well-designed double-blind, multi-center sham controlled RCTs are needed to provide evidence for future treatment guidelines.

Funding Acknowledgement

Type of funding sources: Foundation.

Left atrial functions in the early period after cryoballoon ablation for paroxysmal atrial fibrillation

Introduction

In patients with paroxysmal atrial fibrillation (PAF), functional changes are observed in the left atrium (LA) after pulmonary vein isolation (PVI) with catheter ablation. Although previous studies have investigated the altered mechanical functions of LA with radiofrequency (RF) ablation, changes in LA functions in the early period after cryoablation have not been clearly demonstrated.

Methods

Thirty three patients (mean age: 57±11; 54.5% men) with PAF underwent cryoablation procedure with second generation cryoballoon (CB-2). All patients were in sinus rhythm before and after the procedure. LA dimensions, LA strain parameters (LAsr-LAscd-LAsct) and left ventricular diastolic function parameters were evaluated by Doppler echocardiography before and 3 months after the procedure.

Results

Acute procedural success was achieved in all cases. No major complications were occurred. A significant recovery in LA reservoir strain (p=0.009) was observed. No significant change was demonstrated in remaining echocardiographic parameters.

Conclusion

LA reservoir strain is an indicator of left atrial compliance and significant improvement in mechanical functions may occur even in the early period after cryoballoon ablation in patients with PAF in contrast to LA function deterioration observed in RF ablation.

Funding Acknowledgement

Type of funding sources: None.

EGM characteristics of intramural outflow tract ventricular arrhythmias

Funding Acknowledgements

Type of funding sources: None.

Introduction

Successful ablation of outflow ventricular premature contractions (VPC) depends on the identification of earliest activation. Annotation of bipolar (bi) EGMs can be challenging for especially multicomponent EGMs. Universally, annotation of earliest depolarization which depends on maximum dV/dt of unipolar (uni) EGMs and uni-QS morphology identify site of origin for VPC. However, identification of uni-QS morphology has limitations due to low spatial resolution. Additionally, time difference between bi- and uni-EGM can be observed and may be associated with deeper origin. Aim of this study is to compare EGM characteristics at successful ablation site in RVOT and RVOT+LVOT VPC ablation cases.

Methods

In this retrospective study, 40 patients who underwent successful RFA for RVOT and RVOT+LVOT VPCs were included. Local activation time (LAT), duration and voltage data of each bi- and uni-EGM at the successful ablation sites from RVOT and RVOT+LVOT cases were analyzed.

Results

28/40 (70%) of patients were ablated from RVOT and in 12/40 (30%) required both side ablation. All patients had acute PVC suppression. Bi-EGM-QRS onset was earlier (36.2±13.8 ms vs 28.8±7.3 ms, p=0.03), duration of bi-EGM was shorter (58.2±19.6 ms vs 83.8±22.3 ms, p=0.003) and Bi-voltage amplitude was higher (3.1±2.4 mV vs 1.2 ±0.9 mV, p=0.01) for patients with RVOT only ablation. Mean Bi-Uni EGM difference was 5.6±5.1ms in the RVOT group vs 13.5±5.4 ms in RVOT+LVOT group (p<0.001). Uni-QS morphology was recorded in 3.6±4.5 vs 3.3±1.9 cm2 in RVOT and RVOT+LVOT group respectively (P=0.80). In 11/40 (28%) of patients uni-QS was not identified at successful ablation site.

Conclusion

QS in uni-EGM was not a perfect predictor for successful ablation sites. Analysis of bipolar voltage amplitude and duration with Bi-uni EGM time difference may identify deeper source.

Effect of general and local anesthesia on the vagal response characteristics during ganglionated plexus ablation

Funding Acknowledgements

Type of funding sources: None.

Background

The effect of different anesthetics on the function of the autonomic nervous system (ANS) is not well known. As a relatively new treatment option, ganglionated plexus (GP) ablation aims to modify the behavior of the cardiac ANS to prevent some/all of the autonomic processes occurring in vasovagal syncope (VVS) by using endocardial ablation techniques.

Purpose

The purpose of this study was to determine the effects midazolam and propofol on the vagal response (VR) characteristics during GP ablation in patients with vasovagal syncope (VVS).

Methods

Forty consecutive patients undergoing GP ablation for VVS were divided to receive local anesthesia with midazolam (group 1, n = 29) or general anesthesia with propofol (group EA, n = 11). All GP sites were detected by using previously defined fragmented electrogram based strategy. VR was defined on 3 levels: 1) R-R interval increased by 50% (level 1); 2) R-R interval increased by 20-50% (level 2); and 3) R-R interval increase lower than 20% (level 3).

Results

Baseline characteristics and mean follow-up times were comparable between groups. In both groups, the left superior GP (LSGP) was the most common GP site at which a VR was observed. However, there was a significant difference between groups for level of VR. While ablation on the LSGP caused a level 1 VR in 89.6% of cases in group 1, level 1 VR was seen in 22.2% of cases in group 2 (p < 0.0001). Similarly, ratio of level 1 VR during ablation on the left inferior GP (LIGP) was significantly lower in group 2 (44.8% vs 9%, p = 0.034). Once cut-off for VR was decreased to level 2, the ratio of (+) VR increased to 90.9% during ablation on the LSGP in group 2. Level 2 VR was detected in 45.4% of cases during ablation on the LIGP. Ratio of positive VRs in any level was lower than 20% during ablation on the right superior and inferior GPs in both groups. During a mean follow-up time of 12.1 ± 7 months, all but 2 (5%) of 40 patients were free of syncope.

Conclusions

The autonomic nervous tone might be affected in different ways by local and general anesthesia. Propofol may reveal a shift in the sympathovagal balance toward sympathetic predominance which may cause a blunting on VR during GP ablation. Further randomized, controlled and multicenter studies should be performed to confirm these findings.

Why is neuromodulation effect of pulmonary vein isolation not same in all cases?

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac ganglionated plexi (GPs) of the autonomic system are primarily located in major epicardial fat pads adjacent to the left atrium and pulmonary vein junctions. These structures may play a central role in both the initiation and maintenance of atrial fibrillation (AF). Previous studies reported modification of GPs during pulmonary vein isolation (PVI) may increase rate of sinus node and AF-free survival. However, a deficiency certainly existed why is modification of GPs observed in some patients during PVI but not in others?

Purpose

We aimed to evaluate ratio of ablation points within classical antral circumferential ablation lines for PVI and distribution of 4 major atrial ganglionated plexus.

Methods

Thirty-eight consecutive patients undergoing ablation of GP for vagally mediated bradyarrhythmias were evaluated. All GP sites were detected by using previously defined fragmented electrogram based strategy which is a validated tool when compared with a combination of spectral analysis and high frequency stimulation to detect GPs. Estimated ablation lines for antral circumferential ablation was defined as a circumferential isolation line performed ≥1 cm away from the pulmonary vein ostium as identified by 3D electroanatomical reconstruction (Figure 1). The total number of ablation points in each GP sites and ratio of ablation points within estimated antral circumferential ablation lines were recorded.

Results

The great majority of ablation points were detected at the insertion of the right pulmonary veins. Number of ablation points in each GP site in descending order is as follows: (1) the right superior GP = 13.6 ± 6; (2) the left superior GP = 10.5 ± 5; (3) the right inferior GP = 5.9 ± 4; and (4) the left inferior GP = 2.5 ± 3. The ratio of ablation points within estimated antral circumferential ablation lines was higher in right-sided GPs (50.5%±24 for the right superior GP and 30.2%±31 for the right inferior GP vs 18.3%±24 for the left superior GP and 11.6%±26 for the left inferior GP. Figure 2 demonstrates total number of ablation points and the ratio of ablation points within estimated antral circumferential ablation lines in each GP site.

Conclusions

The present study shows that individual variability of distribution of GPs and how antral ablation was done during PVI might be the main contributors of neuromodulation effect. Further randomized, controlled and multicenter studies should be performed to confirm these findings. Abstract Figure 1

P1127Occurrence, management and outcomes of iatrogenic aortic dissections as a complication of catheter ablation. A multicenter study

Background

Data on occurrence, management and outcomes of iatrogenic aortic dissections (IAD) as a complication of catheter ablation (CA) do not exist.

Purpose

To evaluate multicenter data on occurrence, management and outcomes of IAD as a complication of CA.

Methods

Data on occurrence, management and outcomes of documented vascular dissections from 10 centers were evaluated.

Results

IADs occurred in 7 patients (2 females, age 63 ± 8 years). Indications for CA were frequent premature ventricular complexes (PVC)/ventricular tachycardia (VT) in 6 patients (86%) and left-sided accessory pathway in the remaining one (14%). Hypertension was most frequent comorbidity (4 pts, 57%).  All IADs occurred during retrograde advancement of ablation catheter. In the vast majority of patients creation of IAD during catheter advancement was not associated with any symptoms (6 pts, 86%). IAD was initially detected using trans-luminal angiogram in 5 (71%) and further confirmed using computed tomography (CT) (5 pts, 71%), conventional angiography (2 pts, 28%) and ultrasound (2 pts, 28%). One IAD was detected during CT scan performed for other indication after CA. There was one IAD-related death and IAD was evaluated post-mortem. Follow-up lasted 10 ± 19 months. Four patients were treated conservatively, one patient underwent descending aorta stenting and one femoral artery stenting.

Conclusions

IAD during CA is a rare but can be devastating. Early recognition can be difficult. Conservative management of IAD is an option of treatment.

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection

OBJECTIVES

Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall.

METHODS

Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC.

RESULTS

The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group.

CONCLUSIONS

According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Rapidly Progressive Malignant Fibrous Histiocytoma of Right Atrium: a Rare Case Report

We are going to present a case of malignant fibrous histiocytoma in the right atrium, which is a very rare entity. The patient had a right atrial mass, which prolapsed through the tricuspid valve into the right ventricle, causing functional tricuspid valve stenosis. The tumor was completely resected and the patient had an uneventful postoperative period. Histopathological examination reported malignant fibrous histiocytoma. The patient presented to the emergency department five weeks after discharge with dyspnea and palpitation. Echocardiography and magnetic resonance imaging revealed recurrent right atrial tumor mass. His clinical status has worsened, with syncope and acute renal failure. On the repeated echocardiography, suspected tumor recurrence was observed in left atrium, which probably caused systemic embolization. Considering the aggressive nature of the tumor and systemic involvement, our Heart Council decided to provide palliative treatment by nonsurgical management. His status deteriorated for the next few days and the patient succumbed to a cardiac arrest on the 4^th day.

Effect of pomegranate (Punica granatum L.) juice on kidney, liver, heart and testis histopathological changes, and the tissues lipid peroxidation and antioxidant status in lead acetate-treated rats

Pomegranate juice (PJ) contains relevant amounts of active biological compounds which alleviate the detrimental effects of chronic heavy metal exposure. This study investigated the protective potential of PJ against lead-induced oxidative stress. A total of forty adult male Sprague Dawley rats were divided into four experimental groups. The animals were fed a standard pellet diet and tap water ad libitum. The rats were divided into four groups (n=10 for each group): control, lead asetat (2000 ppm), low-treated PJ- a daily dose of 2.000 ppm lead plus 30µl pomegranate juice (included 1.050 µmol total polyphenols, gallic acid equivalent), and high-treated PJ- a daily dose of 2.000 ppm lead plus 60µl pomegranate juice (included 2.100 µmol total polyphenols, gallic acid equivalent). The treatments were delivered for 5 weeks. After the treatment period, the tissues samples (kidney, liver, heart and testis) were collected. Tissue lead (Pb) and mineral amounts (copper, zinc, and iron), tissues lipid peroxidation level and antioxidant status, and tissues histopathological changes were determined. The results showed that the highest rate lead loading was in the kidney and the testis. Pomegranate juice was decreased the lead levels of soft tissues examined; increased Zn amounts in tissues of which the lead accumulation was higher (kidney and the testis); decreased the copper, zinc and the iron levels of the liver and heart tissues, without creating a weakness in antioxidant capacity of these tissues, restricted the oxidative stress by decreasing lipid peroxidation, improved both of the activities of antioxidant enzymes such as superoxide dismutase (SOD) and catalaz (CAT), and the level of glutathione (GSH) in all the tissues examined in lead-treated groups. As histopathological findings, the cellular damage induced by lead in the tissues of the kidney, liver and the heart were observed to have been partially prevented by PJ treatment. The protective effect of PJ was more pronounced in the testis compared to those others.

Essure microinsert hysteroscopic tubal sterilization: eight-years follow-up results

OBJECTIVES

To evaluate the effectiveness and reliability of microinsert hysteroscopic sterilization method at short- and long-term.

MATERIALS AND METHODS

In the period between January 2004 and December 2005, 34 patients who submitted to the present gynecology outpatient clinic seeking for permanent contraception and accepted tubal sterilization with microinsert method were included in this prospective, interventional study.

RESULTS

Bilateral microinsert placement was successful in 28 (87.5%) of 32 patients that underwent the procedure. In all of the 30 patients (100%) in whom the placement procedure was attempted, bilateral tubal occlusion was documented by hysterosalpingogram (HSG) including the two patients in whom unilateral placement was carried out. First three procedures were performed under general anesthesia. Local or general anesthesia was not administered in any other cases (97.5%). The mean visual analogue scale score for pain felt during the procedure was 3.1. The mean procedure time was 11.5 ± 4.88 (5-22) minutes, the average time from beginning the procedure to discharge of the patients was 41.7 ± 18.5 (15-94) minutes. One intrauterine pregnancy was detected in one of the patients nine months after cessation of the alternative contraceptive period. This patient was excluded from the follow-up. At short-term all patients rated their microinsert-wearing tolerance as good or excellent. At eighth year, three patients were lost to follow-up. Mean follow-up time was 83.4 ± 15.0 (36-103) months. During 2,420 woman-months of follow-up, no other pregnancies were detected. Almost all of the patients were happy with the procedure and recommended it to a friend.

CONCLUSION

Essure microinsert is a safe, effective, minimally invasive sterilization method which can be performed in outpatient settings without any anesthesia requirement. It appears to be a good alternative to laparoscopic tubal sterilization. The procedure time and the time to discharge are brief. Patient tolerance during the procedure and at long-term is very good.

Assessment of follicular and serum VEGF and IGF-1 in ICSI patients: hMG vs rFSH

PURPOSE

To investigate the effect of recombinant follicular stimulating hormone (r-FSH) and human menopausal gonadotropin (hMG) on follicular microenvironment via assessment of follicular and serum vascular endothelial growth factor (VEGF) and insulin-like growth factor-1 (IGF-1) levels in intracytoplasmic sperm injection (ICSI) cycles.

MATERIALS AND METHODS

Designed as a prospective cohort study. Twenty-five patients underwent controlled ovarian hyperstimulation (COH) with r-FSH and 20 patients underwent with hMG.

RESULTS

Both groups were comparable regarding the women's mean age and body mass index (BMI). The amount of VEGF (pg/ml) in serum and follicular fluid in the group I and II were comparable (275 ± 135.3 vs 330.7 ± 190.0; p > 0.05 and 2,081.1 ± 1095.1 vs 1,971.1 ± 975.6; p > 0.05, respectively). The amount of IGF-1 (ng/ml) in serum and follicular fluid in the group I and II were also comparable (225.3 ± 69.3 vs 204.1 ± 56.3, p > 0.05 and 176.1 ± 67.2 vs 185.8 ± 48.7, p > 0.05, respectively). Pregnancy rates were also comparable between groups.

CONCLUSIONS

The hMG and r-FSH in COH produced comparable follicular microenvironment regarding follicular VEGF and IGF-l.

A case with bilateral radio-ulnar synostosis

Congenital radio-ulnar synostosis may be an isolated abnormality or additional abnormalities may accompany it. It may also be found as a part of well-known syndromes. We present a case with bilateral congenital radio-ulnar synostosis, speech delay, dimple on shoulders, café au lait spot and characteristic facial appearance. The proband has a brother with similar clinical findings with the exception of congenital radio-ulnar synostosis. We discuss the possible relationship between our case and previously described syndromes with congenital radio-ulnar synostosis, and distinct phenotypic features of the presented case.

Elevated second trimester serum homocysteine levels in women with gestational diabetes mellitus

OBJECTIVE

Our aim was to investigate the association between total serum homocysteine, vitamin B12 and folate levels in pregnant women with gestational diabetes mellitus (GDM), glucose intolerance and compare them with those of glucose tolerant pregnant women.

MATERIALS AND METHODS

Serum homocysteine, vitamin B12 and serum folate levels were prospectively measured in a total of 223 pregnant women who were grouped according to their status of glucose tolerance as gestational diabetes (abnormal 1-h and 3-h glucose tolerance test; n = 30), glucose intolerant (abnormal 1-h, but normal 3-h glucose tolerance test; n = 46) or normal controls (normal 1-h glucose test; n = 147).

RESULTS

Mean serum homocysteine concentration of women in gestational diabetes, glucose intolerants and normal controls at 24-28 weeks of gestation was 9.0 +/- 3.1, 8.1 +/- 2.5 and 7.4 +/- 1.6 micromol/l, respectively. The only statistically difference in homocysteine levels was observed between women with gestational diabetes and normal controls (P < 0.01). However, no difference was observed for vitamin B12 and folate levels.

CONCLUSION

Second trimester serum homocysteine concentrations are higher among women with GDM, as compared to normal controls.

Quantitative telomerase activity in malignant, benign and normal gynecological tissues

OBJECTIVE

The aim of this study was to evaluate quantitative telomerase activity in malignant, benign and normal gynecological tissue samples by using the Telomerase-PCR ELISA kit, and to determine a cut-off level for malignancy by this quantitative method.

MATERIALS AND METHODS

Fifty gynecological tumors, 27 benign gynecological disorders and 29 normal tissues were analyzed by the Telomerase-PCR ELISA kit. All tissues were confirmed by a pathologist. A ROC (receiver operator characteristic) curve was drawn to determine a threshold level best discriminating malignant tissues from benign pathologies and normal tissues. Telomerase activity was compared in malignant, benign and normal tissues.

RESULTS

The mean level of telomerase activity of the malignant tumor samples (1.03 +/- 0.53 units) was significantly (p < .001) higher than the normal tissues (0.13 +/- 0.07 units) and benign pathologies (0.37 +/- 0.25 units). The cut-off point to differentiate malignant samples from benign samples was set at 0.42 units, where the sensitivity was 93.8% and the specificity was 89.3%. Positive predictive value was 84% and negative predictive value was 89.3%. There was a significant difference in telomerase activity between malignant, benign and normal tissues within each histological group.

CONCLUSION

In this preliminary study, the telomerase-PCR ELISA method was found to have a high sensitivity and specificity to differentiate malignant gynecological tissues from benign tissues.

Nuchal cord type B associated with an excessively long umbilical cord as a cause of stillbirth: a case report

Nuchal cord (NC) is defined as the umbilical cord being wrapped 360 degrees around the fetal neck. It is one of the most common complications of the umbilical cord and any pregnancy might be complicated with a nuchal cord. If a nuchal cord occurs in a pregnant woman with decreased fetal movements, it should be considered to be at high risk, particularly for fetuses with multiple nuchal cords. We report a case in breech presentation with an excessively long umbilical cord (190 cm) which was complicated with five nuchal loops around the fetal neck and resulted in intrauterine death at the 37th week of pregnancy.

Oncologic and reproductive outcome after fertility-saving surgery in ovarian cancer

The rate of ovarian tumour diagnosis in reproductive age woman has increased parallel to the improvements in diagnostic methods and regular gynaecological visits. Because of this organ saving surgical procedures for the preservation of reproductive and endocrine functions have gained more interest. Conservative surgical approaches for ovarian tumours after surgical staging include cystectomy, unilateral salpingo-oophorectomy and unilateral salpingo-oophorectomy plus contralateral cystectomy. Ovarian tumours diagnosed in young ages tend to be low-stage low-grade malignancies. This not only enables but also necessitates preserving the fertility of women who have not completed their family. In invasive ovarian cancer, fertility saving surgery is confined to early-stage and low-grade disease. But, it also had been reported in advanced stages (up to Stage IIIc). Candidates for those procedures were selected according to the FIGO stage, grade, ploidy state, histological subtypes and patients' desire. Adjuvant chemotherapy is necessary for high-risk patients. The rate of recurrence following conservative and radical surgical procedures in low-stage and low-grade tumours are 9% and 11.6%, respectively; and disease-free and overall survival rates do not differ significantly. Prognosis of borderline ovarian tumours is excellent. Five and 20-year survival rates are 95% and 80%, respectively. Management of borderline tumours has evolved significantly in the last few decades. In contrast to invasive ovarian cancer, borderline tumours can be operated on conservatively at all stages. Chemotherapy is rarely prescribed even in advanced stages. Eighty percent of malignant germ cell tumours are diagnosed less than 30 years of age, and 70-75% of patients have Stage I disease. Conservative surgery is generally used in malignant germ cell tumours even in advanced stages. The relation between ovulation induction and tumour recurrence is not consistent in the literature. Spontaneous pregnancy rates following fertility saving surgery has been reported as 60-88%. Because of this over-treatment of these patients for fertility should be avoided. Briefly, fertility saving surgery can be performed safely in germ cell, borderline and early stage epithelial ovarian tumours in selected cases. Any increment in the rate of tumour recurrence following ovulation induction has not yet been demonstrated. Menstrual irregularities caused by chemotherapy are transient. The congenital malformation rate of ovarian cancer patients is slightly higher than that of the normal population, but no significant difference has been observed between patients who received or did not receive chemotherapy.

Surgical stage III endometrial cancer: analysis of treatment outcomes, prognostic factors and failure patterns

OBJECTIVE

The purpose of this study was to evaluate the survival estimates of stage III endometrial cancer patients, and also to detect the prognostic factors and failure patterns.

MATERIALS AND METHODS

Sixty-eight surgical Stage III endometrial cancer patients treated at Hacettepe University Hospital were included. All patients underwent surgical staging procedures consisting of peritoneal cytology, infracolic omentectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and complete pelvic-paraaortic lymphadenectomy. By surgical staging 26 (38%) patients had Stage IIIA and 42 (62%) patients had Stage IIIC disease. The mean resected lymph node number was 26 (median, 25; range, 15-58).

RESULTS

The median age was 60 years (range, 38-77), and the median follow-up period was 62 months (range, 36-90 months). The 5-year disease free survival rate was 58% and the 5-year overall survival rate was 64%. These figures for Stage IIIA were 60% and 68%, respectively; and for Stage IIIC they were 57% and 62%, respectively. No significant survival difference was detected between Stage IIIA and IIIC (p = 0.60 for disease-free survival and p = 0.48 for overall survival). High grade and positive peritoneal cytology predicted poor survival in both univariate (p = 0.004 and p = 0.006, respectively) and multivariate (p = 0.05 and p = 0.04, respectively) analysis. Twenty-eight patients (41%) had recurrence with a median time of 23 months (range, 10-54 months). Nine patients (13%) had only local, 13 patients (19%) had only distant and six patients (9%) had both local and distant relapse.

CONCLUSION

Surgical staging is important in the management of Stage III endometrial cancer, and the main problem is still distant failure. In multivariate analysis high grade and positive peritoneal cytology predicted poor survival significantly.

Comparison of the soft-tissue release methods in idiopathic clubfoot

The aim of this study was to compare the clinical and radiologic results of three different surgical procedures (posterior release with lengthening of the tendo calcaneus and posterior capsulotomy, Turco's technique of posteromedial release, and Simons' technique of complete subtalar release) in idiopathic clubfoot in 77 patients who were operated on at 10 months of age or younger. The clinical examination alone is not sufficient to determine the type of the surgical intervention needed in idiopathic clubfoot; the decision must be supported by the radiologic parameters (anteroposterior and lateral talocalcaneal, first metatarsal-talar, and lateral tibiotalar angles) and all the components of the multiplanar deformity must be corrected at the same time. Simons' technique of complete subtalar release was found to be the most efficient method of surgery both functionally and radiologically in cases of idiopathic clubfoot in infants. The overcorrection of the deformity as a consequence of the concern that the tarsal alignment did not improve adequately is a mistake we make not infrequently and in our opinion this may be avoided by taking perioperative radiographs.

Benign epithelial ovarian tumors

Two hundred and twelve patients with benign epithelial ovarian tumors managed consecutively at Hacettepe University Hospital between 1974-1994 were analyzed retrospectively. Benign epithelial tumors constituted 9.5% (212/2216) of all ovarian tumors and 28.5% (212/743) of the primary epithelial ovarian tumors during the study period. Of the patients with benign epithelial tumors, 104 (49.0%) had serous, 94 (44.3%) had mucinous and the remaining 14 (6.7%) had Brenner tumors. The surgical procedures varied from cystectomy to total abdominal hysterectomy according to the age of the patient. Bilaterality was encountered in 12.8% of serous and 10.6% of mucinous tumors. Ovarian carcinoma occurred synchronously in two patients. In two patients, serous cystadenoma was detected in the preserved ovaries following 3 and 7 years of initial conservative surgery, respectively. Serous tumors were relatively more common constituting approximately one half of the cases. Most of the patients presented with an abdominopelvic mass.

Results of Second-Look Laparoscopy Following Removal of Endometriomata

Despite widespread use of operative laparoscopy for removal of endometriomata, there are inadequate data regarding subsequent adhesion formation. We performed second look laparoscopy (SLL) within 6 months of laparoscopic endometriosis cystectomy in 21 infertile women. Mean age and mean duration of infertility were 30.5 &plusmn; 4.4 and 7.1 &plusmn; 4.9 years respectively. Cysts were removed with the following technique: incision of the ovarian cortex, cystoscopy (biopsy when necessary), and total stripping of the cyst capsule. All patients received postoperative suppressive therapy for 3 months. Total AFS score decreased significantly in all patients (34.1 &plusmn; 14.7 vs 12.3 &plusmn; 10.7; P<0.001). The adhesion score assessed at SLL improved in 3 (14.3%) remained the same in 13 (61.9%) and worsened in 5 (23.8%). Mean adhesion score at SLL was significantly less compared with adhesion score during cystectomy (7.1 &plusmn; 5.2 vs 8.7 &plusmn; 6.4; P=0.038). None of the patients had de novo adhesions. Adhesion scores were similar in women where ovarian cortical defect was left open or suture closed. Of the 21 women, 4 (19%) conceived within six months of SLL. In conclusion, laparoscopic removal of ovarian endometriomata was not associated with increased adhesion formation at SLL. Adhesions at SLL were mainly dependent upon adhesions at laparoscopic cystectomy.

Salpingoscopic findings in women with occlusive and nonocclusive salpingitis isthmica nodosa

STUDY OBJECTIVE

To characterize ampullary endosalpingeal findings in women with occlusive or nonocclusive salpingitis isthmica nodosa.

DESIGN

Prospective case study.

SETTING

Obstetrics and Gynecology Department of a University Hospital.

PATIENTS

Twenty women (38 tubes) with occlusive or nonocclusive salpingitis isthmica nodosa were studied.

INTERVENTIONS

Salpingoscopy was performed during diagnostic laparoscopy in 20 women (38 tubes) with hysterosalpingographic evidence of salpingitis isthmica nodosa.

MAIN OUTCOME MEASURES

Salpingoscopic findings were recorded and the patients were managed accordingly.

RESULTS

Of the 38 tubes 10 appeared radiographically and laparoscopically normal. Two tubes were occluded distally. Of the 26 tubes with occlusive or nonocclusive salpingitis isthmica nodosa, 5 (19.2%) showed varying degrees of endosalpingeal abnormality. Patients with abnormal salpingoscopy were regarded as having bipolar tubal disease and were referred for assisted conception. The remaining patients were scheduled for microsurgical tubal reconstruction.

CONCLUSIONS

One in five patients with proximal tubal disease may have ampullary endosalpingeal damage of varying degrees. However, the significance of this finding in relation to subsequent management strategies and fertility outcome is yet to be characterized.

Laparoscopic CO2 laser uterine nerve ablation for treatment of drug resistant primary dysmenorrhea

Twenty women with drug-resistant primary dysmenorrhea were subjected to laparoscopic CO2 laser uterine nerve ablation. Menstrual pain assessed by a linear analog pain score showed a reduction of 33%, decreasing from 7.5 +/- 0.5 preoperatively to 5.0 +/- 1.7 postoperatively. The procedure was free of major complications and should be considered as a second-line therapeutic option in women who have failed medical treatment using nonsteroidal antiinflammatory agents or OCs.

The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries

Laparoscopic Nd-YAG laser photocoagulation of the ovaries was performed in 40 anovulatory women with clomiphene citrate-resistant polycystic ovary disease. Following this procedure, the subjects were randomly assigned to have either a second-look laparoscopy with lysis of adhesions within 3-4 weeks of the initial laparoscopy (N = 19) or expectant management (N = 20). One patient assigned to the laparoscopy group refused the procedure. Minimal and mild adhesions that did not distort the normal tubo-ovarian relationship were encountered in 13 patients (68%) in the second-look laparoscopy group; these adhesions were easily lysed using sharp or blunt dissection. The pregnancy rates over 6 months were similar in the two groups (47% in the second-look group and 55% in the expectant-management group; P greater than .05). These data suggest that early laparoscopic lysis of adhesions does not improve short-term conception rates following laparoscopic Nd-YAG laser photocoagulation of polycystic ovaries.

Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease

The incidence and fertility effects of postoperative adhesion formation after laparoscopic ovarian electrocautery or laser photocoagulation of polycystic ovaries has not been adequately analyzed. Short-interval second-look laparoscopy appears to be a useful method for addressing this issue. Employing short-interval second-look laparoscopy 3 to 4 weeks after the initial laparoscopic intervention, we were able to demonstrate adhesions in 6 of 7 patients (85%) treated with ovarian electrocautery and 8 of 10 patients (80%) submitted to laser therapy. The adhesions were amenable to laparoscopic lysis in 12 of 14 patients (85%). The subsequent conception rates within 6 months of second-look laparoscopy that were 57% and 40% in the electrocautery and the Nd:YAG laser groups, respectively, may in part be attributed to the restoration of normal pelvic anatomy during this procedure.

Radionuclide hysterosalpingography. A simple and potentially useful method of evaluating tubal patency

A prospective study was undertaken to evaluate the efficacy of radionuclide hysterosalpingography (RN-HSG) using 99mTc-labeled human albumin microspheres to assess the patency of the fallopian tubes in 36 women (72 tubes). The study group consisted of 20 women with proven fertility undergoing laparoscopic tubal ligation, 8 with male factor infertility and 8 with bilateral isthmic tubal occlusion. All RN-HSG scan results were correlated with the findings at laparoscopy when tubal patency was ultimately assessed with chromopertubation. The sensitivity and specificity of RN-HSG were 100% and 94.6%, respectively. The positive predictive value (probability of occlusion when RN-HSG was positive) was 84%, whereas the negative predictive value (probability of no occlusion when RN-HSG was negative) was 100%. RN-HSG is a simple and potentially useful method of assessing the patency of the fallopian tubes.

The value of human menopausal gonadotropin treatment in patients with unexplained infertility

The role of multiple ovulation with human menopausal gonadotropin (HMG) in the treatment of unexplained infertility is evaluated. Of a total 73 patients with unexplained infertility, 39 received four cycles of HMG, whereas, 34 were left untreated. Eight (20.5%) women conceived during HMG treatment, in comparison to only 1 (2.9%) in the control group (P less than 0.05). This study gives further credit to the value of HMG treatment for unexplained infertility.

Complications and bilaterality of mature ovarian teratomas (clinicopathological evaluation of 286 cases)

Bilaterality, complications and associated pathology were reevaluated in 286 cases of mature teratoma of the ovary, treated in the last 25 years. Torsion was the most frequent complication, occurring in 22 (7.7%) patients. Rupture, infection and secondary malignant change were uncommon complications, occurring in 11 (3.8%), 7 (2.4%) and 1 (0.3%) patients, respectively. Both ovaries were evaluated histologically in 226 patients, 31 (13.7%) of whom were shown to have bilateral tumours, including 2 patients with tumour in the normally appearing ovary, contralateral to the gross tumour.

Evaluation of the functional status of the fallopian tubes in unexplained infertility with radionuclide hysterosalpingography

The functional status of the Fallopian tubes in patients with unexplained infertility (UI) was evaluated with radionuclide hysterosalpinography (RN-HSG). The rate of bilateral tubal occlusion with RN-HSG in women with UI (3/18 = 16.7%) was considerably higher than in a group of fertile and male-infertile women (0/28 = 0%), implying that a number of cases with UI might be associated with functional rather than anatomical tubal defects. RN-HSG is a simple, innocuous and potentially useful method for assessing functional tubal occlusion, and it might give a better understanding of the functional status of the tubes in UI.

Serum and peritoneal fluid CA-125 levels in early stage endometriosis

Serum and peritoneal fluid (PF) CA-125 levels were assayed using the immunoradiometric assay in 17 women with minimal endometriosis and 21 control women at the time of laparoscopy. Serum levels of CA-125 were not significantly higher in women with minimal endometriosis. Minimal endometriosis was diagnosed with a 70.6% rate of sensitivity and a 71.4% rate of specificity with 16 U/ml as the upper limit of normal. PF CA-125 levels were significantly higher than serum levels but showed no significant difference between control and endometriosis patients.