Distal thoracic aorta hemodynamics during exercise with continuous flow left ventricular assist system

Objectives: Continuous flow left ventricular assist systems (LVAS) are being discussed as a destination therapy. LVAS patients will have expanded activity of daily life, including exercise. In this study, we analyzed the effects of exercise on blood flow in the distal thoracic aorta of LVAD implanted animals. Methods: Five calves with a continuous flow LVAS exercised on treadmill at two different pump flow rates (PFR), 60–80% (high PFR) and 25–30% (low PFR) of pulmonary artery flow rate. Pump, pulmonary artery and descending thoracic aorta flow waves were recorded before, during and after exercise. Systolic and diastolic flow volume in each cardiac cycle in pump and descending thoracic aorta flow was calculated. Results: (1) Average flow rates – Pulmonary artery and descending thoracic aorta flow rates increased with heart rate during exercise and there was no difference between groups. (2) Pump flow wave – Pump regurgitation increased temporally during exercise at both PFRs, but sustained incidences of regurgitation after exercise were only observed at low PFR. Systolic and diastolic pump flow volume decreased during exercise at both PFRs, but systolic volume increased and diastolic volume decreased significantly after exercise at low PFR. (3) Descending thoracic aorta flow wave – At high PFR, systolic volume of descending thoracic aorta increased but diastolic flow volume decreased during exercise. At low PFR, both systolic and diastolic volume of the descending thoracic aorta decreased during exercise, but systolic volume increased and diastolic volume decreased after exercise. Systolic volume of the descending thoracic aorta in low PFR was significantly greater and diastolic volume was less than those in high PFR during and after exercise. Conclusion: Exercise temporarily increases pump regurgitation with continuous flow LVAS support. Average flow rate of the descending thoracic aorta was maintained by compensation from increased heart rate, although the diastolic flow of the descending thoracic aorta decreased after exercise at the lower pump flow rate. Further study will be needed to evaluate whether or not this flow decrease causes hemodynamic and/or an oxygen delivery mismatch to peripheral tissue.     

Angiolipoma of hypopharynx: A diagnostic dilemma

Fibro vascular polyps of esophagus are rare tumours. They usually arise close to cricopharyngeus muscle. The commonest symptom is dysphagia but regurgitation of fleshy mass into mouth, regurgitation of recently digested food and sensation of lump in throat are also reported. Several reports of polyp regurgitation and subsequent airway obstruction are mentioned. We present a 48-year-old male with fibrovascular polyp of hypopharynx. Diagnosis was established by barium swallow and oesophagoscopy.Transoral route was used to remove the polyp and histopathology reported as angiolipoma.     

Cornstarch thickened formula reduces oesophageal acid exposure time in infants

BACKGROUND: Infant regurgitation is a phenomenon causing worldwide parental distress and anxiety. Parental reassurance and dietary advices regarding feeding techniques and volumes are helpful in the management. Guidelines also recommend the use of thickened formula. However, the impact of thickened feeding on the frequency of acid reflux is still a matter of debate. Therefore, we evaluated the effect of a casein predominant formula thickened with a specifically selected and treated cornstarch on the frequency and duration of acid reflux episodes. METHODS: Ninety-six formula-fed infants with a mean age of 93 days, presenting with episodes of regurgitation and vomiting occurring more than five times a day and with an abnormal oesophageal pH monitoring, were randomised to a regular infant formula (n = 45) or cornstarch thickened casein predominant formula (n = 51) for 28 days. A second pH monitoring was performed at the end of the study period (26+/-5 days). Symptoms were daily recorded in a diary by the parents for 28 days. RESULTS: At inclusion, the pH-metric parameters did not differ between the control and the intervention group. Results of pH monitoring at baseline and at the end of the study did not differ in the control group on the regular infant formula. However, in the group with the casein dominant cornstarch thickened formula, all pH-metric parameters (reflux index (% of the investigation time with a pH < 4.0), number of reflux episodes >5 min, duration of the longest reflux episode) decreased significantly. The frequency of vomiting and regurgitation did not differ between both groups at baseline, remained unchanged in the control group, but decreased significantly in the intervention group. CONCLUSION: A casein dominant formula thickened with a specifically treated cornstarch reduces oesophageal acid exposure, and reduces the frequency of clinical symptoms.     

改进空肠“Y”型吻合及粘膜瓣成形术预防返流

为防止胆肠吻合术后返流性胆管炎,改进了空肠“Y”型吻合,在此基础上,加作粘膜瓣成形术共94例。经临床观察,疗效满意,钡透无钡剂向输胆空肠返流。动物实验观察见粘膜瓣质软,有弹性,色泽与正常粘膜相同,病理所见粘膜与肌层结构正常。并讨论预防返流机理。     

Tricuspid Regurgitation Impact on Outcomes (TRIO): A Simple Clinical Risk Score

ObjectiveTo determine which clinical variables infer the highest risk for mortality in patients with notable tricuspid regurgitation (TR) and to develop a clinical assessment tool (the Tricuspid Regurgitation Impact on Outcomes [TRIO] score).Patients and MethodsA single-center retrospective cohort of 13,608 patients with undifferentiated moderate to severe TR at the time of index echocardiography between January 1, 2005, and December 31, 2016, was included. Baseline demographic and clinical data were obtained. Patients were randomly assigned to a training (N=10,205) and a validation (N=3403) cohort. Median follow-up was 6.5 years (interquartile range, 0.8 to 11.0 years). Variables associated with mortality were identified by Cox proportional hazards methods. A geographically distinct cohort of 7138 patients was used for further validation. The primary end point was all-cause mortality over 10 years.ResultsThe 5-year probability of death was 53% for moderate TR, 63% for moderate-severe TR (hazard ratio [HR], 1.24 [95% CI, 1.17 to 1.31]; P<.001 vs moderate), and 71% for severe TR (HR, 1.55 [95% CI, 1.47 to 1.64]; P<.001 vs moderate). Factors associated with all-cause mortality on multivariate analysis included age 70 years or older, male sex, creatinine level greater than 2 mg/dL, congestive heart failure, chronic lung disease, aspartate aminotransferase level of 40 U/L or greater, heart rate of 90 beats/min or greater, and severe TR. Variables were assigned 1 or 2 points (HR, >1.5) and added to compute the TRIO score. The score was associated with all-cause mortality (C statistic = 0.67) and was able to separate patients into risk categories. Findings were similar in the second, independent and geographically distinct cohort.ConclusionThe TRIO score is a simple clinical tool for risk assessment in patients with notable TR. Future prospective studies to validate its use are warranted.     

Left Ventricular Global Longitudinal Strain as a Predictor of Outcomes in Patients with Heart Failure with Secondary Mitral Regurgitation: The COAPT Trial

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Traumatic tricuspid regurgitation following cardiac massage

We report a 66-yr-old male patient who developed tricuspid regurgitation secondary to internal cardiac massage. After uneventful off-pump coronary artery bypass surgery, the subject experienced cardiac arrest in the intensive care unit. External cardiac massage was initiated and internal cardiac massage was performed eventually. A transesophageal echocardiography revealed avulsion of the anterior papillary muscle and chordae to the anterior leaflet after successful cardiopulmonary resuscitation. Emergency repair of the papillary muscle was performed under cardiopulmonary bypass.     

Behavioral interventions for rumination and operant vomiting in individuals with intellectual disabilities: a systematic review

We conducted a systematic analysis of studies that involved the treatment of rumination and operant vomiting in individuals with developmental disabilities. A total of 21 studies involving a combined 32 participants were identified and analyzed in terms of (a) participant characteristics, (b) dependent variables, (c) intervention procedures, (d) functional assessment procedures and results, (e) intervention outcomes, and (f) certainty of evidence. In comparison to previous reviews on rumination and operant vomiting, this review identified fewer studies involving punishment-based interventions and an increase in function-based reinforcement interventions. Preliminary guidelines for practitioners faced with assessing and treating these behaviors are offered and directions for future research are discussed.     

Correlation between QRS Duration,Pulmonary Insufficiency and Right Ventricle Performance in Totally Corrected Tetralogy of Fallot

Objective

Despite progresses in surgical correction of Tetralogy of Fallot, pulmonary insufficiency and progressive dysfunction of the right ventricle impress its long-term prognosis. In this study we examined the correlations between QRS duration, pulmonary insufficiency and right ventricular performance index.

Methods

We enrolled 57 repaired Tetralogy of Fallot patients. QRS duration on electrocardiogram, pulmonary regurgitation index (regurgitation time to diastolic time ratio), and right ventricular myocardial performance index were measured.

Findings

There was a strong inverse correlation between QRS duration and pulmonary regurgitation index. However, significant correlation did not exist between QRS duration and right ventricular myocardial performance index. QRS duration ≥160 ms predicted severe pulmonary regurgitation with 100% sensitivity and 87% specificity.

Conclusion

Increased QRS duration can predict severity of pulmonary regurgitation.