Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

P1810 Impact of pulmonary hypertension on survival in patients with degenerative aortic stenosis, prospective clinical trial

Introduction

Aortic stenosis has become the most common degenerative valvular heart disease, due to aging of the population. It represents 43% of degenerative valvular disease.

Methods

We prospectively followed 196 patients with degenerative aortic stenosis, for a period of 6 years. Of these, 106 had mild aortic stenosis, 28 had moderate aortic stenosis and 62 patients had severe aortic stenosis. Of the 196 patients, 54 had mild pulmonary hypertension (PH), 22 had moderate PH and 7 had severe PH. The survival data were estimated by the Kaplan - Meier method and the logrank test. The Cox proportional- hazards regression was performed to assess the differences between the groups.

Results

During the follow-up period, of a total of 196 patients, 61 patients died. We studied if the presence of PH has an influence on survival in patients with aortic stenosis and we found out that the patients who had PH had reduced survival rates, compared with those who hadn"t. The survival rate at 5 years was lower in the group with mild PH compared with the group with normal pulmonary pressure ( p = 0.045, HR 1.84, 95%CI 1.01-3.36). In the group with mild PH, 20 patients (37.03%) died at 5 years, compared with 23 in the group without PH (20.35%). The survival rate at 5 years was also lower in the group with moderate PH compared with the group with normal pulmonary pressure ( p = 0.001, HR 5.82, 95% CI 3.02-11.22). At 5 years, 15 patients with moderate PH died ( 68.18% compared with 20.35 in the group without PH). Comparing the group with severe PH with the group with normal pulmonary pressure the results showed a reduced survival rate in those with severe pulmonary hypertension ( p = 0.139, HR 2.48, 95% CI 0.74-8.27). At 5 years, 3 patients with severe PH died (42.85% compared with 20.35 in the group without PH).

Conclusion

The presence of PH in patients with degenerative aortic stenosis has a negative impact on survival, highly statistically significant (p <0.001, HR 1.03, 95% CI, 1.02-1.04). Given these findings, perhaps an increased attention should be paid to the treatment of the patients with PH compared to those without PH.

P1513 Myocardial work analysis is a potential novel tool to diagnose subclinical cardiac dysfunction in cirrhotic cardiomyopathy

Funding Acknowledgements

This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III

Background

Cirrhotic cardiomyopathy (CCM) is defined as systolic and/or diastolic cardiac dysfunction, associated with high preload and low afterload. Thus, assessment of cardiac dysfunction in these circumstances is still debatable. Left ventricular (LV) deformation is still load-dependent, and does not reflect directly myocardial energy consumption. Since myocardial work (MW)incorporates both deformation and afterload, it might be a better alternative for the assessment of LV function in CCM.

Methods

80 subjects were assessed by 2D conventional and speckle tracking echocardiography (STE): 40 patients with liver cirrhosis (LC) (58 ± 8 years, 23 males), free of any cardiovascular disease or diabetes, and 40 age and gender matched normal, control subjects. Left ventricular ejection fraction (LVEF) and systolic/diastolic blood pressure (SBP/DBP) were measured. A new approach was used to evaluate myocardial work by 2DSTE: global constructive work (GCW), as the "positive" work of the heart; global wasted work (GWW), as the "negative" work of the heart; global work efficiency (GWE), as the GCW/(GCW + GWW) in %; and global work index (GWI), as the GCW added to GWW. E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP) were also assessed.

Results

Patients with LC had significantly lower SBP/DBP than controls, with similar LVEF (Table). GCW and GWI were decreased in patients with LC, probably due to decrease in afterload, which shifts LV work to a lower level of energy. GWE and GWW were similar to controls. By segmental analysis (18 segments model), apical and mid antero-lateral segments were the first affected in terms of myocardial work, with higher WW, low WE, but without a compensatory increase in CW in other segments, suggesting a regional myocardial dysfunction. All patients with LC presented significantly elevated E/E’ ratio, LAVi, and sPAP, compared to controls (Table).

Conclusion

Myocardial global constructive work and global work index decrease in LC patients, compared to normal individuals, probably due to augmented peripheral vasodilatation. Apical and mid antero-lateral segments are the first affected. Assessment of global and regional MW might be a potential new tool to assess CCM, and to understand the relationship between LV remodeling and increased filling pressure under different loading conditions.

Comparative myocardial work indices group SBP (mmHg) DBP LVEF (%) E/E’ LAVI sPAP GWI GWE (% ) GCW (mmHg % ) GWW (mmHg %) LC (40) 111 ±14 69 ± 12 59 ± 7 8.5 ± 2.5 45.9 ± 14.5 26 ± 9 1927 ± 379 95 ± 2 2068 ± 386 90.1 ± 49 Controls (40) 126 ± 14 76 ± 8 61 ± 7 7.5 ± 2.2 31.8 ± 6.8 21 ± 8 2123 ± 353 95± 2 2302 ± 335 94.4 ± 49 P value 0.001 0.004 0.3 0.05 0.001 0.009 0.01 0.9 0.005 0.7

Abstract P1513 Figure. Myocardial Work Cirrhotic Cardiomyopathy

P324 Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy

Funding Acknowledgements

“This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III”

Background

Cirrhotic cardiomyopathy (CCM) is defined as a cardiac dysfunction that includes mainly diastolic dysfunction (DD), generated by liver cirrhosis (LC). Its present diagnosis is based mostly on 2D conventional transthoracic echocardiography (TTE), with focus on diastolic dysfunction. However, there is no standardized algorithm for diagnosis of CCM. Role of the new methods, such as speckle tracking echocardiography (STE), for the diagnosis of CCM is still controversial.

Aim. To assess left atrial (LA) function by STE in LC, on top of conventional TTE, in order to establish role of LA function for the diagnosis of CCM.

Methods

107 subjects were assessed by TTE and STE: 52 patients with LC (57 ± 9 yrs, 23 males), free of any cardiovascular disease or diabetes, and 55 age-matched normal subjects. TTE was used to measure LV indexed volumes and ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP); STE to measure global longitudinal strain (GLS) and LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure). NTproBNP was measured in all patients.

Results

LC patients vs. controls had lower SBP (112 ± 15 vs. 122 ± 12, P < 0.001), higher LV volumes and NTproBNP, but similar LVEF. They had lower GLS, and higher E/E’, LAVi, and sPAP, suggesting higher LV filling pressure (Table). Meanwhile, they had lower LA reservoir, conduit, and pump functions(Table). By using current algorithm for the diagnosis of DD, 21% of LC patients had DD, 48% had no DD, and 31% had indeterminate grade. By adding assessment of LA reservoir function by STE (LASr < 35%) to the DD algorithm, 50% of patients had DD, without any indeterminate cases.

Conclusion

LC patients have longitudinal systolic LV dysfunction, diastolic dysfunction with higher estimated LV filling pressure, and lower LA reservoir, conduit, and pump functions. By adding LA deformation analysis by STE to the current diagnosis algorithm, better characterization of CCM is possible.

Table Group (N) NTproBNP ng/ml GLS (%) E/E’ LAVi (ml/m2) sPAP (mmHg) LASr (%) LASRr LAScd (%) LASRcd LASRct LC (52) 215 ± 258 -20.8 ± 3 8.5 ± 2.3 44 ± 14 27 ± 9 28 ± 9 1.29 ± 0.4 14.7 ± 8.1 -1.2 ± 0.42 -1.64 ± 0.47 Controls (55) 44 ± 43 -22 ± 2 7.6 ±2.3 28 ±6.5 21 ± 8 35 ± 4 1.54 ± 0.4 18.3 ± 6.7 -1.7 ± 0.61 -1.93 ± 0.44 P value <0.001 0.05 0.05 0.001 0.003 0.011 0.002 0.014 0.001 0.002

Abstract P324 Figure

Optimal Teaching of Cardiopulmonary Resuscitation in Schools: Better Education, More Lives Saved

Teaching cardiopulmonary resuscitation in Romanian schools is a joint initiative of the Acute Cardiac Care Working Group of the Romanian Society of Cardiology, the Romanian National Resuscitation Council and the Romanian Society of Emergency Medicine and Disaster. Teaching young generations to save people in cardiac arrest requires a structural approach, whose starting point is the launching of a large-scale campaign in favor of introducing the basics of cardiopulmonary resuscitation (CPR) in the school curriculum. The training stages can be set according to the principle of repetition (i.e. every two years). Teachers seem to be the best candidates for the instructor position, taking into account the knowledge and skills they acquired throughout the teacher training programs, as well as, their continuous contact with the students; consequently, training teachers to become CPR instructors represents a long term investment. All acquired knowledge will implicitly spread to a secondary level (trainee's parents, relatives, etc.) and the number of individuals gaining access to CPR specific information will rise as a consequence. Entering the CPR training program should be promoted as a criterion for the accreditation and/or evaluation of primary schools, middle schools, and high schools. To begin with, this program must be implemented in Romania at first as part of the non-formal context of the special education week called "Şcoala altfel" ("School otherwise").

Septic knee arthritis in Crohn's disease biological therapy-free patient. Case report

A 52-year-old woman with Crohn's disease presented with septic arthrtis of the knee. This condition coincided with a symptomatic flare of her Crohn's disease due to an ileal inflammatory stenosis, manifested as a phlegmonous mass palpable in the right lower quadrant and a small bowel obstruction. Results of synovial fluid cultures showed the presence of Gram-negative bacillus, Klebsiella pneumoniae and the CT scan images were highly suggestive of abdominal abscess within Crohn's disease. The patient's condition improved after following an antibiotic treatment and after the initiation of Anti-TNF-alpha agent Adalimumab, with no further exacerbation. Septic arthritis in Crohn's disease should be considered to have a communicating source of sepsis consisting of an abdominal abscess or fistula.

ABBREVIATIONS

Anti-TNF-alpha agent = anti tumor necrosis factor alpha agent, 5-ASA = 5-aminosalicylic acid.

Assessment of the correlation between two defining criteria for bidirectional isthmic block in the ablation of typical atrial flutter

BACKGROUND

A complete, bidirectional conduction block in the cavotricuspid isthmus (CTI) represents the end-point of the typical atrial flutter ablation. We investigated the correlation between two criteria for successful ablation, one based on the atrial bipolar electrogram morphology before and after complete CTI conduction block, compared to the standard criteria of differential pacing and reversal in the right atrial depolarization sequence during coronary sinus (CS) pacing.

METHOD

We conducted a retrospective study in 111 patients (81 males, average age 62±10 years) who underwent an atrial flutter ablation during September 2007 - July 2009 in the Cardiology - Rehabilitation Hospital, UMF Cluj-Napoca. We assessed the presence of a bidirectional block at the end of the procedure using the standard criteria. We then analyzed the morphology of the bipolar atrial electrograms adjacent to the ablation line, before and after CTI conduction block.

RESULTS

A change from a qRs morphology to a rSr' morphology when pacing from the coronary sinus and from a rsr' morphology to a QRS morphology when pacing from the low-lateral right atrium was associated with a CTI conduction block. Sensitivity (Se), specificity(Sp), positive predictive value (PPV), negative predictive value (NPV) were 96%, 89%, 99% and 67% respectively.

CONCLUSION

Our study suggests that the analysis of the atrial bipolar electrogram next to the ablation line before and after CTI ablation may be used as a reliable criterion to validate CTI conduction block due to its high sensitivity, specificity and positive predictive value.

Correlations between the surface ECG and the intracavitary electrocardiogram in typical atrial flutter

Typical atrial flutter (cavo-tricuspid isthmus-dependent) has as an electrophysiological substrate a macro-reentry circuit localized in the right atrium. Depending on the right atrial depolarization sequence, the rotation of the macro-reentry circuit can be counterclockwise (with an inferior to superior activation of the right atrium free wall and superior to inferior activation of the interatrial septum), characterized by negative F waves in inferior leads (DII, DIII, aVF) and V6, and positive in V1 on the surface electrogram (ECG), or clockwise (with a superior to inferior activation of the right atrium free wall and inferior to superior activation of the interatrial septum) characterized by positive F waves in inferior leads (DII, DIII, aVF) and V6, and negative in V1. Nevertheless, it is considered that for the diagnosis of the typical or atypical nature of this arrhythmia, the surface ECG has limited value. The purpose of this study was to compare the relationship between the flutter rotation sequence determined by the intracavitary electrogram and the morphology of the F waves on the surface ECG.

METHODS

The study included 387 patients admitted to the Cardiology - Rehabilitation Hospital from Cluj-Napoca between January 2007 and May 2010, diagnosed with typical atrial flutter during an electrophysiological study. Using the intracavitary electrograms the flutter rotation sequence was determined (clockwise or counterclockwise). The F waves' aspect on the surface ECG in leads DII, DIII, aVF, aVL, V1 and V6 was then analyzed.

RESULTS

One hundred and fifty two patients (39.3%) were diagnosed with clockwise atrial flutter and 235 patients (60.7%) with counterclockwise atrial flutter. The positive predictive value (PPV) of negative F waves in inferior leads and positive in V1 was, in the case of counterclockwise atrial flutter 98%; the negative predictive value (NPV) was 79%; sensitivity (Se) was 83% and specificity (Sp) was 97%. For typical clockwise atrial flutter, the PPV of the positive F waves in the inferior leads and negative in V1 was 94% (p < 0.001); the NPV was 85%; Se was 73% and Sp was 97%.

CONCLUSION

The surface ECG has a high value in determining the macroreentry circuit rotation sequence in the case of typical atrial flutter.

The common bile duct: size, course, relations

The common bile duct may present a number of anatomical peculiarities regarding its size, course and relations, which should be taken into consideration by the anatomists and by the surgeons as well, during the surgery of the gallbladder, pancreas and duodenum. In the present study, we have analyzed the anatomical peculiarities of the common bile duct in 150 adult corpses of both sexes from the Anatomy Department and 22 human fetuses from the Pathology Department, University of Medicine and Pharmacy Cluj-Napoca.

The role of radiofrequency ablation as a first line therapy in the treatment of atrial flutter

Cavo-tricuspid isthmus radiofrequency (RF) ablation is an efficient option in the treatment of atrial flutter. In the case of a well-tolerated, first episode of atrial flutter, it has a class II indication, level of evidence B, the current first-line therapeutic option being electrical cardioversion, pharmacological cardioversion or atrial overdrive pacing followed by long-term antiarrhythmic therapy. The purpose of this study was to evaluate, in a prospective manner, the recurrence rate of these two different therapeutic options after the treatment of a first episode of atrial flutter.

MATERIAL AND METHODS

Between January 2007 and May 2009, for 99 patients admitted to the hospital for a first episode of atrial flutter, cardioversion was attempted either by RF ablation (group 1-42 patients), or by electrical cardioversion, pharmacological cardioversion or atrial overdrive pacing followed by long-term Amiodarone therapy (group 21-57 patients). We compared the recurrence rate of atrial flutter in the 2 groups after a follow-up period of one year.

RESULTS

In group 1, sinus rhythm was achieved in all patients, with bidirectional isthmic block being obtained for 37 patients (88.1%). In group 2, conversion to sinus rhythm was obtained in all cases. The recurrence rate was 6 times higher in group 2 vs group 1 (57.9% = 33 patients vs 9.5% = 4 patients) (p = 0.01).

CONCLUSION

RF ablation should be considered as a therapeutic option in the treatment of the first episode of atrial flutter, due to its significant efficiency in maintaining sinus rhythm and to its low recurrence rate.

Multicystic mesothelioma--a rare case of ascites: case report

We present the case of a 37-year-old male, admitted to our clinic with abdominal tenderness, right supraclavicular tumour, and ascites. The presence of ascites was incidentally reported 6 years before, but no other evaluation was done at that moment or during this period. Abdominal ultrasound and CT scan revealed moderate ascites, perivascular adenopathies, and multiple abdominal cystic lesions, while thoracic CT scan revealed the same lesions in mediastinum. Laboratory data were within normal limits, including the tumoral markers, and the tests for hydatid cysts. A biopsy from the right supraclavicular nodule was performed, and based on usual and immunohistochemical stains (calretinin, mesotheline, CK 5/6, CK 7, CK18 diffusely positive in mesothelial cells, and CEA -M, bcl-2 and vimentin negative), suggested the diagnosis of mesothelioma. Based on these results, the diagnosis of "multicystic mesothelioma" was made. The patient was referred for surgery.

Influence of Preoperative Left Ventricular Contractile Reserve on Postoperative Ejection Fraction in Low-Gradient Aortic Stenosis

Background— Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF.

Methods and Results— Sixty-six consecutive patients with symptomatic severe AS (aortic valve area ≤1 cm 2 ), LVEF ≤40%, and mean pressure gradient ≤40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29±6% to 47±11% ( P <0.0001). LVEF improved by ≥10 EF units in 38 patients (83%) in group I and in 13 patients (65%) in group II. Mean LVEF improvement was similar in the 2 groups (19±10% versus 17±11%; P =0.54). On multivariable analysis, multivessel coronary artery disease ( P =0.05) and baseline mean transaortic pressure gradient ( P =0.01) were related to LVEF improvement, whereas contractile reserve was not.

Conclusions— LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Epidemiology of acute myocardial infarction in Romanian county hospitals: a population-based study in the Baia Mare district

The epidemiological characteristics, the methods used in treating the patients, as well as the evolution of the myocardial infarction are not known in the Romanian county and municipal hospitals.

MATERIAL AND METHODS

Six hundred and fifty one cases of acute myocardial infarction were retrospectively recorded in the Emergency County Hospital of Baia Mare from 1.01.1999 till 30.09.2003. Data on treatment delay, therapeutic strategies, duration of hospitalization and outcome were collected. The study was completed by a postal investigation which was carried out from the 1st of October until the 31st of December 2003. This investigation consisted in one application form (multiple choice answers were requested) which had been handed out to the patients who survived the acute episode and left the hospital.

RESULTS

The first medical care took place for 60.9% of the patients in hospital. About 72% of these patients were male and the mean age was 66 +/- 12 years. The types of myocardial infarction with ST-segment elevation STE-MI represented 67%, followed by 29.5% with no ST-segment elevation NSTE-MI, and 3.5% with undetermined ECG. The maximum values of Killip class during the first 48 hours were: I in 55% of the patients, II in 23%, III in 14% and IV in 9% of them. The thrombolytic therapy was done in 31% of the patients who were recommended to receive a reperfusion treatment. During their first period in hospital, 37% of the patients had an effort test and 2.45% were transferred to a tertiary care hospital for invasive procedures. The overall median hospital stay was 9 days. The mortality in hospital was 13.6%, respectively 8.1% in the study group who received the reperfusion therapy and 15.2% among those who had followed the standard care. The results of the mail survey revealed that only 62% of the patients who answered the questionnaire (N=498) had regular cardiologic check ups and 43% underwent a treatment with beta-blockers and 12% a treatment with statins. Out of these patients 16% had a revascularization procedure that was performed in a specialised University Hospital. The overall mortality in the responder group was 35.5% with an estimate 7.5% year rate.

CONCLUSIONS

The analysis of the present data and especially the rate of mortality suggest until two times higher values in comparison to the European average. These results demonstrate the fact that it is imperative to generalize the thrombolytic therapy in all the hospitals in Romania and give a wider access to the myocardial revascularization therapies.

Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics

BACKGROUND

The prognostic value of dobutamine stress hemodynamic data in the setting of low-gradient aortic stenosis has been addressed in small, single-center studies. Larger studies are needed to define the criteria for selecting the patients who will benefit from valve replacement.

METHODS AND RESULTS

Six centers prospectively enrolled 136 patients with aortic stenosis (96 men; median age, 72 years [range, 65 to 77 years]; median aortic valve area, 0.7 cm2 [range, 0.6 to 0.8]; mean transaortic gradient, 29 mm Hg [range, 23 to 34 mm Hg]; cardiac index, 2.11 L x min(-1) x m(-2) [range, 1.75 to 2.55 L x min(-1) x m(-2)]). Left ventricular contractile reserve on the dobutamine stress Doppler study was present in 92 patients (group I) and absent in 44 patients (group II). Operative mortality was 5% (3 of 64 patients) in group I compared with 32% (10 of 31 patients) in group II (P=0.0002). Predictors for operative mortality were the lack of contractile reserve (odds ratio, 10.9; 95% confidence interval [CI], 2.6 to 43.4; P=0.001) and a mean transaortic gradient < or =20 mm Hg (odds ratio, 4.7; 95% CI, 1.1 to 21.0; P=0.04). Predictors for long-term survival were valve replacement (hazard ratio, 0.30; 95% CI, 0.17 to 0.53; P=0.001) and left ventricular contractile reserve (hazard ratio, 0.40; 95% CI, 0.23 to 0.69; P=0.001).

CONCLUSIONS

In the setting of low-gradient aortic stenosis, surgery seems beneficial for most of the patients with left ventricular contractile reserve. In contrast, the postoperative outcome of patients without reserve is compromised by a high operative mortality. Thus, dobutamine stress Doppler hemodynamics may be factored into the risk-benefit analysis for each patient.

[Difficulties in diagnostic of biliary ileus]

Gallstone ileus is a rare disease which can be life-threatening because of misdiagnosis preoperatively. The authors analyze the clinical observations about two women where, because of associated diseases, delayed in presentation to the hospital, volume depleted electrolyte abnormalities and, not in the last place, because of lack in accuracy of paraclinical investigations, the diagnosis was mad only intraoperatively.

CONCLUSIONS

The appearance of clinical setting of high intestinal obstruction in associating with extra-kidney azotemy in female patients with gallstone in their history and no previous abdominal operations must we make to thinking about gallstone ileus.

[Therapeutic attitude in acute necrotizing pancreatitis]

The necrosectomy, celiostomy and pancreatic drainage represent the surgical treatment of choice in necrotizing pancreatitis. We present the clinical observation of a patient 59 years old operated in surgical service of Baia Mare for acute necrotizing pancreatitis, discussing the moment of operation, tips of operations, postoperative complications as well as our experience in acute grave pancreatitis treatment.

Removal of the pro-domain does not affect the conformation of the procaspase-3 dimer

We have investigated the oligomeric properties of procaspase-3 and a mutant that lacks the pro-domain (called pro-less variant). In addition, we have examined the interactions of the 28 amino acid pro-peptide when added in trans to the pro-less variant. By sedimentation equilibrium studies, we have found that procapase-3 is a stable dimer in solution at 25 degrees C and pH 7.2, and we estimate an upper limit for the equilibrium dissociation constant of approximately 50 nM. Considering the expression levels of caspase-3 in Jurkat cells, we predict that procaspase-3 exists as a dimer in vivo. The pro-less variant is also a dimer, with little apparent change in the equilibrium dissociation constant. Thus, in contrast with the long pro-domain caspases, the pro-peptide of caspase-3 does not appear to be involved in dimerization. Results from circular dichroism, fluorescence anisotropy, and FTIR studies demonstrate that the pro-domain interacts weakly with the pro-less variant. The data suggest that the pro-peptide adopts a beta-structure when in contact with the protein, but it is a random coil when free in solution. In addition, when added in trans, the pro-peptide does not inhibit the activity of the mature caspase-3 heterotetramer. On the other hand, the active caspase-3 does not efficiently hydrolyze the pro-domain at the NSVD(9) sequence as occurs when the pro-peptide is in cis to the protease domain. Based on these results, we propose a model for maturation of the procaspase-3 dimer.

[Surgical treatment of duodenal ulcer]

The medical and endoscopic treatment of duodenal ulcer are decreasing the frequency of surgical treatment in this disease. The authors study the operations performed for duodenal ulcer within the period 1989-1999 in the County Hospital Baia Mare. The decrease of the rate of surgical interventions is the pure effect of the medical treatment, as long as the endoscopic treatment is not yet available in our service. The rate of ulcer--induced perforations remained, however, unmodified (48% of total operatory indications), as well as the postoperative morbidity and--mortality (18% respectively 9%). The last category seems not to be influenced by the type of chosen surgical procedure, but by the patient's age, duration of the disease, and associated pathology.

[Stress cardiomyopathy: report of 2 cases]

The authors reported two cases of acute catecholamines cardiomyopathy expressed clinically by chest pain and dyspnea, without any previous cardiac history. The diagnosis of human stress cardiomyopathy is established on: typically rapid onset aftermath of intense emotional stress, left ventricular apical akinesis and hyperkinetic motion of basal walls imaged by two-dimensional echocardiography. Rapid reversal clinical course and normal coronary arteriography. Similar finding have been observed in conjunction with pheochromocytoma who have been excluded by normal levels of urinary catecholamines metabolites.

[Reversible pulmonary hypertension in Basedow's disease]

BACKGROUND

An association between pulmonary hypertension and hyperthyroidism has been described. An autoimmune mechanism is usually advocated but a direct effect thyroid hormones on the pulmonary vascular system is also suggested.

CASE REPORT

A 49-year-old woman with a history of Graves' disease was admitted for sudden dyspnea. There was no evidence of ischemic stroke and the electrocardiogram and cardiac enzymes were normal. The lung scintiscan did not show any sign of pulmonary embolism. The chest computed tomography was normal. Doppler echocardiography found pulmonary hypertension with systolic pulmonary artery pressure of 68.7 mmHg. Thyroid function tests showed hyperthyroidism with recurrent Graves' disease. Pulmonary hypertension markedly decreased after the euthyroid state was achieved with antithyroid therapy.

DISCUSSION

This patient had pulmonary hypertension associated with hyperthyroidism due to Graves' disease. The rapid reversibility of pulmonary hypertension in this case after the achievement of the euthyroid state suggest a pathogenic link between these two disorders and a possible direct effect of thyroid hormones on the pulmonary vascular system.

[Reinterventions in classic and laparoscopic surgery of biliary ducts]

The study suggests to make a comparative analysis between the complications happened after classic and laparoscopic surgery require a surgical reintervention. The study was realised in the Surgical Department of the Districtual Hospital Baia Mare between 27.04.1997-27.04.1999, which means the precursory year of beginning laparoscopic surgery and the first year with experience in laparoscopic surgery. The conclusions of this study prove that the number of reinterventions after laparoscopic surgery is less than after classic surgery of biliary ducts.

[Dobutamine doppler echocardiography in severe aortic stenosis with left ventricular dysfunction. Comparison with postoperative examination]

The association of left ventricular dysfunction with aortic stenosis worsens the spontaneous prognosis and increases operative mortality. The aim of this prospective study was to assess the predictive value of dobutamine Doppler echocardiography on the indices of left ventricular contractile function in patients with aortic stenosis and left ventricular dysfunction (LVEF < 0.45) undergoing aortic valve replacement. Eighteen patients, including 9 with coronary artery disease, were included in a protocol consisting of analysis of left ventricular function and of the severity of aortic stenosis before, during dobutamine infusion, and after valvular replacement. The dobutamine was given in progressive increments of 5 micrograms/Kg up to a maximum of 20 micrograms/Kg. During pharmacological stress, the functional aortic valve area increased from 0.46 +/- 0.15 to 0.56 +/- 0.23 cm2. Tolerance of the procedure was good. All but 2 patients improved their postoperative ejection fraction with values equivalent to those observed during the last increment of dobutamine (r = 0.73; p < 0.003). The patients with initial mean pressure gradients > 50 mmHg normalised their LVEF after valve replacement. The authors conclude that dobutamine echocardiography is useful for predicting the values of postoperative left ventricular contractile indices when severe aortic stenosis is associated with systolic dysfunction. It allows evaluation of the expected short term benefits to these indices after aortic valve replacement.

[The primary prevention of arterial hypertension. A meta-analysis of controlled clinical studies]

OBJECTIVE

To assess the efficacy of non pharmacological primary prevention of hypertension.

METHODS

Analysis of all the available trials with a minimal one-year follow-up and one recently study with 8 weeks follow-up. The outcomes consisted in blood pressure changes and incidence of hypertension at the end of the study.

RESULTS

Five reviewed randomized controlled trials with a minimal one year follow-up and one recently study with eight weeks follow-up assessed the following intervention: advice about sodium restriction, weight reduction, physical exercise and relaxation, a diet rich in fruits vegetables and low fat dairy foods. All the results were available according to the "intention to treat principle". The feasibility appeared to be initially good, but decreased with time, confirming the difficulty of long term prevention. The prevention effect was mild with a decrease in hypertension incidence of a few percent (2%) and blood pressure decrease of only a few mmHg reduction (mean of 3 mmHg). Three community studies were reviewed. The prevention interventions were carried out on entire populations. The feasibility was bad (great number of lost-follow-up). The results on the blood pressure incidence were available in only one study and the blood pressure decrease estimates were heterogeneous, so the results cannot be generalized.

CONCLUSION

The primary prevention of hypertension shows disappointing results when the intervention duration is above one year. It leaves little hope for a significant effect on blood pressure dependent cardiovascular events.

[Incidental discovery of asymptomatic Loeffler fibroplastic endocarditis. Report of a case]

The authors report a case of fibroplastic endocarditis discovered during echocardiography in an asymptomatic patient in the context of assessment of systematized electrocardiographic modifications. The diagnosis, strongly suspected on the basis of the cardiac MRI findings, was finally confirmed by endocardial biopsy.

[Clinico-tomographic correlations in acute pancreatitis]

In the surgery ward from Baia Mare, in the period 1989-1997 have been operated yearly, on an average, 16-17 acute pancreatitis, out of which 8-9 were necrotic-haemorrhagic acute pancreatitis. The possibility of carrying out the computerized tomography allowed a more precise pre-surgery diagnosis and after surgery was improved observation of evolution of the inflammatory phenomena from the pancreatic zone so that the volume, the structure and the outline of the pancreas, the abdominal or pleural liquid collections and the aspect of the neighboring tissues have been correlated in dynamics, with the clinic aspect of the acute pancreatitis and the prognostic indexes. Even if the computerized tomography allowed a more correct evaluation of the patients suffering of acute pancreatitis, there have been 4-6 decreases due to this affection and its complications, the post-surgery death rate remaining at 17-21%.

[Postpartum myocardial infarction induced by Parlodel]

The authors report the case of a 28 year old woman who developed antero-septoapical myocardial infarction in the post-partum period. This was detected by surface ECG and echocardiography performed after a systemic embolism. The infarction followed treatment with Parlodel for inhibition of lactation. Coronary angiography, performed one month post-partum, was normal and the methergin test was negative. The physiopathological mechanism of myocardial infarction resulted from the association of an iatrogenic spastic phenomenon favourised by the patient restarting to smoke and the physiological arterial hyperactivity of the post-partum period. This mechanism raises the question of preventive measures in cases of inhibition of lactation in the post-partum period, notably stopping smoking.

[Total gastrectomy with mechanical sutures]

Between 1994-1996, nine consecutive patients underwent total gastrectomy with stapled sutures for II, III or IV TNM stage carcinoma (8 patients) or lymphoma (1 patient) of the middle or upper stomach. Digestive continuity was established by stapled end-to-side "ended", end-to-side and end-to-end Roux-en-Y (7 patients) and omega loop (2 patients) esophagojejunal anastomoses using circular staplers (EEA or ILS). The duodenal stump and the end of the Roux loop were closed with TA 55 or TA 30 linear stapler. Interjejunal anastomoses were hand sewn. Nasojejunal feeding catheter was placed for ten days in all patients. No postoperative mortality non anastomotic fistula occurred. One patient had duodenal stump leakage which closed spontaneously. In three patients postoperative chemotherapy with 5-FU and Leucovorian was associated. At late follow-up, there were two patients with reflux esophagitis cured by medical treatment and one patient with peritoneal and hepatic metastases at relaparotomy. In conclusion, the use of stapled sutures in total gastrectomy facilitates esophagojejunal anastomosis and improves suture reliability.

Primary aldosteronism and adrenal incidentaloma

Adrenal incidentaloma are usually found during the assessment of non adrenal disease. In this paper we report the association between a bilateral adrenal hyperplasia and a macronodule of adrenal cortex (adrenal incidentaloma) which is a rare and misleading cause of primary aldosteronism. In the light of this association even if it is likely to remain rare and of those previously published, its existence is an additional reason for suggesting surgical treatment of primary aldosteronism only to patients who satisfy the following criteria: 1) satisfactory control with spironolactone; 2) poor spironolactone tolerance and poor control with other drugs; 3) accept to be operated on and the risk of a possible error.

Ventricular fibrillation in preconditioned pig hearts: role of K+ATP channels

ATP-dependent potassium (K+ATP) channels play a role in the infarct size-limiting effect of preconditioning in pigs. We previously demonstrated that preconditioning shortens monophasic action potential duration (MAPD) and accelerates the time to ventricular fibrillation (VF) during a prolonged ischemia in pigs. We sought to determine whether the mechanism of the reduced time to VF in preconditioned pigs is a consequence of K+ATP, channel activation. Pigs underwent 40 min of coronary occlusion and 2 h of reperfusion. Before this, animals received either no intervention (control), 10 min of ischemia and 10 min of reperfusion (preconditioned), or an intravenous infusion of nicorandil, a K+ATP channel opener. Additional control, preconditioned, and nicorandil-treated pigs were pretreated by glibenclamide, an antagonist of K+ATP channels. Because 1) the K+ATP channel activator nicorandil did not produce shorter time to VF, 2) the K+ATP channel inhibitor glibenclamide did not block the acceleration of VF by preconditioning, and 3) there was no relationship between time to VF and infarct size or MAPD, the major conclusion is that reduced time to VF in preconditioned animals is not a consequence of K+ATP channel activation.

The risk of infective endocarditis after cardiac surgical and interventional procedures

The risk of infective endocarditis after cardiac surgery relates mainly to the risk of infective endocarditis on prosthetic valves. The frequency of prosthetic infective endocarditis varies according to the criteria used in the literature, ranging from 0.4 to 1.3% for early infective endocarditis, with an annual linear risk of late infective endocarditis of 0.5%. This figure seems to be independent of either the type or the location of prostheses, but it does nevertheless increase if more than one valve has been replaced. The most commonly isolated microorganisms in early infective endocarditis are staphylococci. The bacteriological findings in late prosthetic infective endocarditis are similar to those seen in the native disease. The portal of entry is more easily identified in early than in late infective endocarditis (50%). The risk of infective endocarditis in surgically treated congenital heart disease is very low when the patient has a left-to-right shunt or valvar stenosis; it increases amongst patients with tetralogy of Fallot and patients with complex cyanotic congenital heart disease, mainly when there is a residual ventricular septal defect or prior palliative surgery. The risk of infective endocarditis in patients with intracavitary electrodes such as pacemakers and defibrillators, after the interventional procedure itself and after heart transplant, is very low. This leads us to conclude that antibiotic prophylaxis is only warranted in those patients with a prosthetic valve and after surgical treatment of tetralogy of Fallot and other complex cyanotic congenital heart diseases.

[Risk of bacterial endocarditis after cardiac surgery]

The risk of infective endocarditis (IE) after intracardiac surgery is dominated by the risk of IE on valvular prostheses. The reported prevalence of IE on prosthetic valves varies according to the chosen diagnostic criteria of IE and its timing. The risk of early IE is 0.4 to 1.3% and the linearized annual risk of late IE is about 0.5%. These values appear to be identical irrespective of the type and site of the prosthesis: the risk is higher in multiple valve replacement. In early IE, the commonest infecting organism is the staphylococcus: the bacteriological spectrum of late IE is the same as that of IE on native valves. The portal of entry is often detected in early IE but more rarely (50%) in late IE. The risk of IE in operated congenital heart disease is very low after surgery of left-to-right shunts or valvular stenosis; it is higher for patients with Tetralogy of Fallot and those with complex cyanotic disease, especially in cases with residual ventricular septal defects and with palliative surgery such as systemico-pulmonary anastomosis. The risk of IE on endocavitary catheters (pace-maker, defibrillator) after interventional cardiac procedures and after cardiac transplantation, seems to be very low. These results show that preventive measures against IE are only routinely required in prosthetic valve patients and after surgery of Tetralogy of Fallot and complex cyanotic cardiac disease.