ABSTRACT
BACKGROUND AND AIMS OF THE STUDY: Cerebral complications constitute a major source of morbidity and disability after cardiac valve surgery. These may be the result of macroembolization (air/debris) or inadequate perfusion pressure. In an attempt to reduce the incidence of cerebral vascular accident (CVA)/transient ischemic attack (TIA), we have routinely performed three minutes of passive retrograde cerebral perfusion (PRCP) on all valve cases. Here, we retrospectively determined our perioperative (0-30 day) incidence of CVA/TIA. METHODS: In all cases, the extracorporeal circuit consisted of an ascending aortic cannula and either one two-stage or two single-stage venous cannulae. Three minutes of PRCP was instituted in all cases upon discontinuation of anterograde cardiopulmonary bypass (CPB) via a shunt distal to the heart/lung machine between the arterial and venous cannulae. Mean systemic blood pressure was maintained at 60 mmHg with Neo-Synephrine. Central venous pressure never exceeded 25 mmHg. In 10 cases, transcranial Doppler ultrasonography (TCD) was used to assess middle cerebral artery (MCA) blood flow. In total, 209 consecutive valve procedures with PRCP (group A) were compared with 164 consecutive valve procedures with no PRCP (group B). All data were compared using Fisher's exact probability test. The incidence of CVA/TIA was also compared with published retrospective and prospective data. RESULTS: TCD demonstrated blood flow reversal in the MCA after a minimum of 30 s. The incidence of CVA/TIA was 0% (0/209) in group A, and 2.4% (4/165) in group B (p = 0.0386). The incidence of CVA/TIA in published retrospective data is 0.7-3.8% and 4.8-5.2% in prospective data. CONCLUSIONS: We have demonstrated in 209 consecutive valve cases that, upon discontinuation of CPB, routine three-minute PRCP not only reversed MCA blood flow, but also reduced the incidence of neurologic events.
Subject(s)
Cerebrovascular Circulation/physiology , Cerebrovascular Disorders/prevention & control , Heart Valve Prosthesis/adverse effects , Ischemic Attack, Transient/prevention & control , Reperfusion/methods , Cerebrovascular Disorders/epidemiology , Cerebrovascular Disorders/etiology , Female , Humans , Incidence , Ischemic Attack, Transient/epidemiology , Ischemic Attack, Transient/etiology , Male , Regional Blood Flow/physiology , Retrospective Studies , Survival Rate , Treatment OutcomeABSTRACT
BACKGROUND: Despite reported successes with progressive addition lenses, lined multifocals remain the lens of choice for previous lined multifocal wearers. METHODS: To explore the feasibility of switching lined multifocal wearers to PALs, in a prospective clinical trial we interviewed 265 lined multifocal wearers, prescribed a new PAL (Varilux Comfort) and then interviewed them again to compare the lens types and patient preferences. RESULTS: PALs ranked significantly higher than lined multifocals for all questions and were preferred by 92 percent of the patients. CONCLUSIONS: PALs should be the lens of choice for previous bifocal wearers.
Subject(s)
Adaptation, Ocular/physiology , Eyeglasses , Patient Satisfaction , Presbyopia/therapy , Adult , Aged , Humans , Middle Aged , Presbyopia/physiopathology , Prospective Studies , Prosthesis Fitting , Surveys and Questionnaires , Visual AcuityABSTRACT
Routine intraoperative imaging of the carotid artery following carotid endarterectomy can detect defects at the site of endarterectomy that may lead to neurologic morbidity. A number of methods have been used to evaluate the completed endarterectomy. In this prospective study we compared subjective methods of assessment (hand-held, continuous-wave Doppler imaging with audible interpretation of signals) and objective methods of assessment (duplex ultrasonography with color flow and digital subtraction arteriography) with respect to their ability to detect operative abnormalities. Fifty-three carotid endarterectomies were evaluated by means of all methods of assessment. Six patients had significant abnormalities in which the vessel was reopened and the abnormality confirmed. The sensitivity and specificity for detecting abnormalities for each method are, respectively: duplex ultrasonography with color flow, 100% and 100%; digital subtraction arteriography, 66% and 95.7%; and continuous-wave Doppler imaging with audible interpretation of signals, 16% and 97.8%. There was one (1.8%) operative carotid neurologic complication during the postoperative period and follow-up (stroke due to vein patch rupture on postoperative day 2). These data suggest that an objective rather than a subjective method of assessing carotid endarterectomy is more useful in detecting operative abnormalities and that duplex ultrasonography with color flow is as useful as digital subtraction arteriography.
