Long-term follow-up of elderly patients with severe aortic stenosis treated by balloon aortic valvuloplasty. Importance of haemodynamic parameters before and after dilatation

Early and late prognosis after percutaneous balloon aortic valvuloplasty (PBAV) was assessed in 38 consecutive elderly patients (mean age, 78.5 +/- 6.1 years). Significant valve opening was achieved in 35 patients. The hospital mortality was 8% (three patients); two other patients died within the first month and three underwent aortic valve replacement. At 2 years follow-up, there were 10 additional deaths (seven cardiac deaths) and five patients had symptom recurrence managed by aortic valve replacement (3) or repeat PBAV (2). Overall, six patients underwent surgery without untoward events and six had repeat PBAV. Only two out of six patients with repeat PBAV had sustained improvement; one was referred to surgery and the remaining three died soon after the second PBAV. One- and 2-year survival were respectively 72 and 62% and percentage of survivors with persistent improvement 68 and 41%. Although aortic valve area after PBAV was associated with outcome, predictors of poor long-term prognosis were primarily related to the pre-operative haemodynamic status. Patients with pulmonary resistances greater than 400 dynes cm-1 s-5 had the poorest outcome (chi 2 = 18.4-P less than 0.0001). Overall, signs of heart failure were predictors of poor long term follow-up. These data indicate that long-term success of PBAV is mainly related to the left ventricular dysfunction noted prior to intervention.     

胸腰椎爆裂骨折椎管内骨片侵入倾向与对策

根据98例中获得随访的39例的X线、CT和MRI(24例)影像学资料,分析胸腰椎爆裂骨折椎管内骨片侵入倾向及对策。将爆裂骨折侵入椎管分为四类八型,宜采用Harrington器械钢丝或椎弓根螺钉钢板轴向撑开系统,使骨折复位,椎管容积恢复,毋需行后路椎管减压。本组取得良好效果。仅对骨片游离型需要切开椎管直接摘除骨片。     

THE CHANGES OF DEFORMABILITY OF ERYTHROCYTES AND 2.3-DPG IN RED BLOOD CELL AND BLOOD IN PATIENTS WITH CORONARY ARTERY STENOSIS

The purpose of this paper is to study the changes of deformabilityof erythrocytes and 2.3-DPG(2.3-diphosphoglycerate acid)in the patients with coro-nary artery stenosis and the effects of some factors on them.It is showed that:de-formability of crythrocyte and 2.3-DPG were inversely proportional to the degreeof the lesions of coronary vessels(P<0.01);there was a significant decrease of de-formability of erythrocytes after using contract agents(P<0.01);Salvia increaseddeformability and 2.3-DPG significantly(P<0.01).In conclusion,our data suggestthat the possible existence of microcirculation dysfunction in coronary artery dis-eases with parallelism to the impairement deformability of erythrocytcs and Salviabca good drug to action in deformability and 2.3 DPG in patients.     

Isolated tricuspid valve stenosis caused by infective endocarditis in an adult: Report of a case

We report herein the case of a 42-year-old man in whom dyspnea on exertion was found to be caused by isolated tricuspid stenosis. Two-dimensional echocardiogram showed thickening of the tricuspid valve with a markedly enlarged right atrium. A color-flow Doppler examination-revealed severe tricuspid stenosis without regurgitation and a Doppler-derived tricuspid diastolic pressure gradient of 23 mmHg. At the time of surgery, the patient was noted to have a stenotic tricuspid valve with thickened leaflets, fused commissures, and almost normal chorda tendineae. The valve leaflets were teased apart to the scattered specimen, and tricuspid valve replacement was successfully performed. Microscopic examination of the specimen demonstrated infective endocarditis. Isolated acquired tricuspid stenosis is extremely rare and, to our knowledge, this is the first case of infective endocarditis being involved as the primary cause.     

The Impact of Small Bowel Resection on the Incidence of Stomal Stenosis and Marginal Ulcer After Gastric Bypass

Background: Stomal stenosis (SS) and marginal ulcer (MU) are reported to occur in 9-20% and 2-13%, respectively, of patients undergoing gastric bypass for morbid obesity. It is hypothesized that decreasing tension on the gastrojejunostomy by performing limited small bowel resection (SBR) would decrease ischemia, thereby decreasing the likelihood of SS and MU. Methods: A retrospective review of 150 consecutive gastric bypass patients operated by one surgeon from 1993 to 1996 was performed. The incidence of SS and MU was compared in patients with and without SBR. Results: The overall rate of SS was 24.0% and that of MU was 9.3%: the incidence of both was 2.0%. The incidence of SS in patients without SBR was 26.9% and with SBR was 19.6%. The incidence of MU in patients without SBR was 8.9% and with SBR was 9.8%. Neither result was statistically significant by Fisher's exact test. Conclusion: There is a trend towards a decrease in the incidence of SS in gastric bypass patients with concomitant SBR although this did not reach clinical significance.     

Surgical technique of laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis

We report herein a new method of performing laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, using refined surgical techniques. The pyloric tumor was immobilized by grasping the first portion of the duodenum and the anterior wall of the stomach, and electrocoagulation was used prior to incising the pyloric tumor to minimize bleeding during the procedure. Although this technique has been applied in only two patients so far, we present the details herein. We believe that with technical and instrumental refinements, the speed and safety of laparoscopic pyloromyotomy will improve and it will become an alternative to open surgery in pediatric patients.     

Value of Doppler ultrasound for the diagnosis of renal artery stenosis in children

To evaluate the reliability of Doppler ultrasonography (US) in identifying children with renal artery stenosis (RAS) among those with hypertension, we compared Doppler US results in 22 hypertensive children (mean age 8.9±4.3 years), with (13 cases) and without RAS at angiography, and in 33 normotensive children (mean age 8.8±4.7 years). We observed 2 false-negatives and 2 false-positives with Doppler US. Of the 2 false-negative diagnoses, 1 had RAS on an accessory renal artery located behind a normal upper polar artery and the other was observed in a patient with bilateral multiple stenosis of the very distal segments of renal arteries. The 2 false-positive diagnoses were due to sinuous left renal artery and to technical reasons, respectively. In another patient, Doppler US showed a tight RAS, while arteriography was normal. RAS was subsequently confirmed by a second arteriography. Peak systolic velocity values of Doppler US were significantly higher in patients with proven angiographic RAS (3.44±0.66 m/s) than in hypertensive patients with normal renal arteries at angiography (0.99±0.35 m/s, P <0.0001) and normotensive healthy children (1.04±0.23 m/s, P <0.0001). With the use of multiple views, and the experience acquired with practice, false-negatives or false-positives due to the geometry of the renal artery can be avoided. Nevertheless, very distal stenosis can be missed by Doppler US. Received October 30, 1995; received in revised form April 16, 1996; accepted May 14, 1996     

Non-invasive variant of Gorlin formula can be used to identify severe aortic stenosis

Summary. In recent years the continuity equation has been established as a valuable non-invasive method for calculating aortic valve area. The continuity equation cannot be used if there is calcification or sub-valvular stenosis in the left ventricle-outflow tract, because the area of the outflow trace is not circular in those cases. The authors have tested the value of a non-invasive variant of the Gorlin formula, as an alternative method of identifying severe aortic stenosis. They examined 32 consecutive patients with aortic stenosis with both methods. Seventeen patients had severe stenosis (valve area^0–7 cm²), calculated by the continuity equation. The other 15 patients had moderate stenosis (valve area 0–7–1–0 cm²). Using the non-invasive variant of the Gorlin formula, the authors were able to identify 16 of the 17 cases with severe stenosis, thus showing that the method is useful for identifying severe aortic stenosis. (P<0–001 by x²-test).     

Brucellosis of the spine with a synchronous Staphylococcus aureus pyogenic elbow infection

Staphylococcus aureus osteomyelitis and pyogenic arthritis has a different pattern in the elderly than in the young. The axial skeleton is the most frequent site of infection and treatment is usually by intravenous antibiotics. We report a case ofStaph. aureus septic arthritis of the elbow with concomitant osteomyelitis of the spine that was thought to be due toStaph. aureus, but culture of debrided material from the lesion grewBrucella in culture. We suggest that in the elderly it is advisable to obtain a tissue culture diagnosis and not to instigate therapy based on positive blood cultures or a concomitant infection.     

MRI gadolinium enhancement of bone marrow: age-related changes in normals and in diffuse neoplastic infiltration

 Objective: To quantify gadolinium-related enhancement in the bone marrow of the spine in normals and in patients with homogeneous diffuse malignant bone marrow infiltration. Design and patients: The patients consisted of two groups: group 1 comprised 94 healthy adults (18–86 years) without bone marrow disease and group 2 comprised 30 patients with homogeneous diffuse malignant bone marrow infiltration due to myeloma (n=20) or breast carcinoma (n=10). All patients received intravenous gadopentetate dimeglumine (Gd-DTPA), 0.1 mmol/kg body weight. Pre- and postcontrast signal intensity (SI) on T1-weighted spin-echo (SE) images (TR/TE: 572 ms/15 ms) was measured over a region of interest (ROI) and the percentage SI increase was calculated. The results were confirmed by bone marrow biopsy (n=20) and clinical parameters (n=10). Dynamic contrast-enhanced studies using a spoiled gradient-recalled-echo (GRE) sequence (TR/TE/α: 68 ms/6 ms 75°) were performed in 10 controls with normal bone marrow. Results and conclusion: Contrast material enhancement in healthy persons can vary greatly (range 3–59%, mean 21%, SD 11%). With increasing age there is a significant decrease in contrast enhancement (Pearson’s correlation, P<0.01). The percentage SI increase in patients with intermediate-grade (biopsy 20–50 vol%) and high-grade (biopsy >50 vol%) diffuse malignant bone marrow infiltration was significantly higher than in normals (mean 67%, SD 34%, P<0.001). Low-grade (biopsy <20 vol%) diffuse malignant bone marrow infiltration can not be assessed by non-enhanced T1-weighted SE images or Gd-DTPA application. In conclusion, contrast material enhancement in healthy persons can vary greatly and is dependent on age, while intermediate-grade and high-grade diffuse malignant bone marrow infiltration can be objectively assessed with SI measurements.