Changes in left ventricular systolic wall stress during biventricular circulatory assistance

Extracorporeal membrane oxygenation (ECMO) reduces the systolic stress integral (SSI) in the normal left ventricle. We tested the hypothesis that the SSI does not decrease in poorly contracting, dilated, ejecting hearts during ECMO. In 14 sheep, four pairs of ultrasonic crystals measured changes in left ventricular (LV) wall thickness and three LV diameters. Volume calculations were validated by balloon distention of the ventricles after death (slope = 0.85; r = 0.85). SSI was measured during ECMO flows of 20 to 100 ml/kg/min in both normal and dilated, poorly contracting hearts produced by 30 minutes of warm ischemia. After warm ischemia, end-systolic elastance, an index of contractility, decreased from 8.3 +/- 0.6 mm Hg/ml to 2.9 +/- 0.4 mm Hg/ml (p = 0.001) and peak systolic pressure decreased from 47.4 +/- 0.7 mm Hg to 37.5 +/- 0.08 mm Hg (p = 0.01). In normal hearts, as ECMO flow increased, SSI decreased from 10.5 +/- 2.2 mm Hg.sec to 7.7 +/- 0.8 mm Hg.sec at 60 ml/kg/min (p = 0.001). However, in postischemic hearts, SSI progressively increased from 6.6 +/- 0.3 mm Hg.sec before ECMO to 12.4 +/- 1.8 mm Hg.sec at ECMO = 100 ml/kg/min. These studies indicate that the initial effect of ECMO on the poorly contracting, dilated heart increases LV wall stress and that the increase in stress is proportional to ECMO flow. The increase in stress is primarily due to an increase in afterload, which more than offsets decreases in systolic and diastolic volumes.     

Posterior leaflet augmentation improves leaflet tethering in repair of ischemic mitral regurgitation

Objectives: Ischemic mitral regurgitation results from annular dilatation, leaflet tethering and leaflet flattening. Undersized annuloplasty corrects annular dilatation but worsens leaflet tethering and flattening. This exacerbation of abnormal leaflet geometry may contribute to poor repair results for ischemic mitral regurgitation (IMR). Using a sheep model of IMR, we hypothesized that posterior leaflet augmentation and less-extreme annular undersizing would relieve tethering and increase leaflet curvature. Methods: Eight weeks after posterolateral infarct, 10 sheep with ≥2+ IMR underwent either a 24-mm planar ring annuloplasty (n = 5) or a 30-mm planar ring annuloplasty with concomitant posterior leaflet augmentation (n = 5). Real-time three-dimensional echocardiography allowed measurement of indices of leaflet curvature and tethering before and after annuloplasty. Results: Comparing pre- and post-repair values in the P1, P2, and P3 leaflet regions, undersized 24-mm ring annuloplasty made no significant difference to mean septolateral curvature (0.23–0.26, 0.33–0.29, and 0.27–0.37 cm⁻¹, respectively), whereas leaflet augmentation in combination with a 30-mm ring annuloplasty increased septolateral curvature (P1 0.30–1.02, P2 0.31–1.23, and P3 0.35–0.84 cm⁻¹, p-values < 0.05). The mean tethering angle formed between the annular plane and the posterior leaflet increased in all three posterior regions for the 24-mm ring group (P1 12–23°, P2 26–31°, and P3 16–25°), but decreased in all regions for the group undergoing leaflet augmentation (P1 +5 to −6°, P2 +13 to −13°, P3 +16-15°, all p-values < 0.05). Conclusions: Undersized annuloplasty exacerbates leaflet tethering. Posterior leaflet augmentation with less severe annular reduction increases leaflet curvature and decreases tethering; this technique more completely addresses the pathogenic mechanism of IMR and may improve repair durability.     

A sensor system for monitoring the simple gases hydrogen, carbon monoxide, hydrogen sulfide, ammonia and ethanol in exhaled breath

A sensor array system was constructed incorporating electrochemical sensors for hydrogen, carbon monoxide, hydrogen sulfide and ethanol, a ceramic sensor for total volatiles and a dye-based optical ammonia sensor. The system was calibrated using standard gases balanced with dry air. Limit of detection and % relative standard deviation values (n = 10) for the sensors in the array are hydrogen (0.1 ppm, 2.6%), carbon monoxide (0.4 ppm, 2.1%), ethanol (0.5 ppm, 1.5%), hydrogen sulfide (0.1 ppm, 1.5%) and ammonia (0.6 ppm, 10.7%). Humidity effects were assessed by calibrating with humidified standard gases (hydrogen, carbon monoxide) or spiked breath samples in Tedlar bags (hydrogen sulfide, ethanol and ammonia). The calibration data were used to establish a cross-sensitivity matrix. The concentration of breath volatiles was found to be dependent on exhalation rate and exhalation volume. A test protocol based on these data required volunteers to exhale 1 litre of breath at a rate between 7.5 and 17.5 l min(-1). Sensor responses were measured for 40 s then purged at 7 l min(-1) (150 s). A longitudinal study was undertaken of ten asymptomatic volunteers over a five-day period. Volunteers ate an ad hoc diet, but fasted prior to giving the first breath sample and then gave samples every hour for 8 h. Breath hydrogen levels for volunteers showed large variations within a day and also from day to day. Fasting levels ranged between 0.3 and 34.1 ppm (mean 9.1 ppm). The carbon monoxide levels for non-smokers were between 0.6 and 4.9 ppm (mean 2.1 ppm), whilst for smokers they were between 8.3 and 18.7 ppm (mean 12.8 ppm). The measured levels of other gases on breath were as follows: hydrogen sulfide (0-1.3 ppm, mean 0.33 ppm), ethanol (0-3.9 ppm, mean 0.62 ppm) and ammonia (0-1.3 ppm mean 0.42 ppm). The system was capable of direct quantitative measurements of low concentrations of a range of volatiles on exhaled breath. The measured values for compounds on the breath of asymptomatic volunteers were in broad agreement with quoted literature ranges. The system will now be assessed in a clinical setting.     

Construction of modern Australian first trimester ultrasound dating and growth charts

Accurate pregnancy dating is vital to obstetric management. However, first trimester fetal charts commonly used in Australia rely on data reported more than three decades ago. This study reports first trimester dating and growth charts for crown‐rump length between 5 and 14 weeks of gestation and biparietal diameter between 9 and 14 weeks of gestation on an Australia population using modern real‐time ultrasound equipment. All consenting eligible women attending a large Sydney clinic for first trimester ultrasound between March 2005 and December 2006 were recruited. Measurements were carried out to Australasian Society for Ultrasound in Medicine standard protocols. Statistical analyses were undertaken using polynomial regression models and thorough diagnostic checks made. Overall 396 eligible women consented to the study, with 268 between 9 and 14 weeks of gestation. The average participant age was 34 years (range 22–45 years), 371 and all yielded valid biometry measurements. Equations, means and 90% reference intervals for crown‐rump length measurements and biparietal diameter measurements were derived using polynomial regression models. Thorough residual and diagnostic checks were made. Once validated by others, we believe they will warrant consideration for use by Australasian Society for Ultrasound in Medicine.     

Cerebrospinal fluid exchange after intrathecal methotrexate overdose. A report of two cases

Two patients aged 11 and four years, were accidentally given a 10-fold overdose of intrathecal methotrexate while being treated for malignant disease. Neither patient developed any signs of neurotoxicity and exchange of lumbar cerebro-spinal fluid was started 3 and 5 h later, respectively. In one of the patients, who received 120 mg of methotrexate intrathecally, 31% of the given dose was recovered during 2 h of cerebrospinal fluid exchange that was started 3 h after the accidental overdosage. No sequelae were observed in any of the patients. Cerebrospinal fluid exchange is safe and can be recommended in all cases of intrathecal methotrexate overdosage. Ventriculo-cisternal perfusion is not necessary in cases of a 10-fold overdose if the patient has no signs of acute neurotoxicity.     

Home parenteral nutrition in chronic intestinal failure

In children with severe failure of intestinal function, intravenous nutrition is at present the only treatment able to maintain adequate nutrition for prolonged periods of time. Over the last five years we have discharged 10 patients home on parenteral nutrition for a total of 25 patient years and here the outcome of these children is presented. Of the 10 patients, one has discontinued home parenteral nutrition (HPN), seven patients remain well, one patient has recently moved to the USA, and one patient has died after major abdominal surgery. All children had either normal or an accelerated rate of growth on HPN and developmentally all have progressed well. All the children over 5 years attend normal schools. The major complication of treatment was line sepsis with an overall rate of one episode in 476 days and a total of nine central lines (five patients) have required replacement giving an average line life of 680 days. For those children unfortunate enough to suffer from severe intestinal failure, HPN is preferable to prolonged hospital treatment and offers the chance of a good quality of life with prolonged survival.