Influence of non-dipping pattern of blood pressure in gestational hypertension on maternal cardiac function, hemodynamics and intrauterine growth restriction.

BACKGROUND: An association between gestational hypertension (GH) and changes of maternal cardiac function was previously reported. AIM: The study assessed the effect of non-dipping pattern of blood pressure (BP) in GH on haemodynamic function and intrauterine growth restriction (IUGR). METHODS: This study included 126 women (91 with GH and 35 normotensive controls). Based on the BP values measured by ambulatory blood pressure monitoring (ABPM), all hypertensive women were classified in dipper (46 women) or in non-dipper group (45 women). All participants underwent echocardiography and ABPM during the third trimester. RESULTS: Participants with GH and non-dipping pattern had significantly lower velocity of longitudinal systolic function (s') (p<0.0005), and cardiac output index (COi) compared to dippers (p<0.0005) and controls (p=0.002). Diastolic velocities at the mitral valve annulus were also lower in non-dippers e's (non-dippers vs dippers p=0.023; non-dippers vs controls p<0.0005) and e'l (non-dippers vs dippers p=0.048; non-dippers vs controls p<0.0005). There were significant differences in the index of the left ventricle filling pressure E/e' and myocardial mass index between women with GH and controls, but with no significant difference among dippers and non-dippers. Total vascular resistance was increased in non-dipping group compared to normotensives and dippers (p<0.0005). Multivariate regression analysis revealed that the peak night-time diastolic BP, left ventricular mass index and CO index were identified as independent predictors of IUGR. CONCLUSION: Changes in maternal hemodynamics, as well as IUGR, are strongly related to the non-dipping pattern of BP.

Buffered Romanowsky-Giemsa method for formalin fixed, paraffin embedded sections: taming a traditional stain.

Romanowsky-Giemsa (RG) stains were devised during the 19th century for identifying plasmodia parasites in blood smears. Later, RG stains became standard procedures for hematology and cytology. Numerous attempts have been made to apply RG staining to formalin-fixed paraffin-embedded tissue sections, with varied success. Most published work on this topic described RG staining methods in which sections were overstained, then subjected to acid differentiation; unfortunately, the differentiation step often caused inconsistent staining outcomes. If staining is performed under optimal conditions with control of dye concentration, pH, solution temperature and staining time, no differentiation is required. We used RG and 0.002 M buffer, pH 42, for staining and washing sections. All steps were performed at room temperature. After staining and air drying, sections were washed in 96-100% ethanol to remove extraneous stain. Finally, sections were washed in xylene and mounted using DPX. Staining results were similar to routine hemalum and eosin (H & E) staining. Nuclei were blue; intensity depended largely on chromatin density. RNA-rich sites were purple. Collagen fibers, keratin, muscle cells, erythrocytes and white matter of the central nervous system were stained pinkish and reddish hues. Cartilage matrix, mast cell granules and areas of myxomatous degeneration were purple. Sulfate-rich mucins were stained pale blue, while those lacking sulfate groups were unstained. Deposits of hemosiderin, lipofuscin and melanin were greenish, and calcium deposits were blue. Helicobacter pylori bacteria were violet to purple. The advantages of the method are its close similarity to H & E staining and technical simplicity. Hemosiderin, H. pylori, mast cell granules, melanin and specific granules of different hematopoietic cells, which are invisible or barely distinguishable by H & E staining, are visualized. Other advantages over previous RG stains include shorter staining time and avoidance of acetone.

Coronary and carotid artery occlusive disease: single center experience.

BACKGROUND AND OBJECTIVE: Due to increased life expectancy, the risk profile of the patients undergoing cardiac surgery changed dramatically. This is especially important in case of concomitant coronary artery disease and carotid artery stenosis (CAS). Careful decision making and appropriate surgical strategy in these patients is critical for the success of the operation. Controversy about relationship between staged and concomitant carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) still exists. In the current study, we present our case lood in treating patients with concomitant carotid artery stenosis and coronary artery disease. PATIENTS AND METHODS: CABG with additional CEA due to neurologic symptoms or high grade (>80%) CAS has been performed in 835 patients in the period of 1982-2010. Results of evaluation of perioperative mortality and morbidity in regard to the surgical approach have been discussed. RESULTS: The average patient age was 62.6 +/- 8.7 years. Echocardiography revealed that 28% of the patients had poor left ventricle ejection fraction (<30%). Coronarography demonstrated that 21.4% of the operated patients had significant left main coronary artery stenosis (>60%). In terms of neurological status, majority of the patients (88.3%) were neurologically asymptomatic. The overall mortality regardless the sequence of procedures was 2.3% (19 patients). In the group of concomitantly treated patients 44.6% (50 patients) required triple coronary bypass while the mean number of coronary bypasses was 2.6. Postoperative neurologic complications were present in 102 patients (12.2%). Eighty-four patients (10.0%) have had TIA, while 18 patients (2.2%) have had permanent neurologic deficit while 4 patients (0.5%) died as a result of it. CONCLUSIONS: It is imperative that every patient being considered for CABG should undergo ultrasonic evaluation of the carotid arteries regardless the neurological symptomatology. Concomitant surgery on patients with severe CAS and coronary disease carries a slightly higher operative risk and, therefore, should be avoided. Concomitant surgical treatment should only be considered in patients with unstable angina and significant CAS in whom we may expect higher morbidity and mortality.

Myocardial revascularization with skeletonized left mammary artery.

Graft selection has a direct influence on overall morbidity and mortality in patients selected for coronary artery bypass grafting (CABG) procedures. In the last decade internal mammary artery has been established as a conduit of choice for myocardial revascularization. However, there is still no official policy which operative technique has advantage in harvesting of the internal mammary artery (IMA). Current dilemma is whether pedicle or skeletonized grafts are better in immediate and long term results. Method of skeletonization of IMA increases surgeon's technical demands, but on the other hand has many advantages. Precise operative technique and selective preparation of IMA without concomitant elements reduces trauma to the chest wall, enables elongation and ideal graft positioning, and reduces graft compression by hyperinflated lungs. Complete graft visualization allows inspection of internal mammary artery in entire length, which excludes possibility to implant dissected or hypoplastic graft. From June 1996 we started using the method of skeletonization of IMA, and until February 1st 1999 skeletonized IMA was used as a conduit in 1001 patients. In our hands myocardial revascularization with IMA is a procedure with minimal morbidity and mortality. Precise operative technique during the harvesting of IMA is advantage especially in diabetics, old patients and patients with chronic obstructive pulmonary disease (COPD), that were considered as limiting factors for IMA use in the past. Our initial results with the quality of this conduit encourage us to extend the indication for using IMA as a dominant graft in multiple myocardial revascularization.

[Late results of myocardial revascularization in patients with coronary artery endarterectomy]. / Kasni rezultati revaskularizacije miokarda kod pacijenata kod kojih je radena endarteriektomija koronarnih arterija.

INTRODUCTION: The aim of this study was to evaluate long-term results after myocardial revascularization in patients with diffuse and distal coronary disease, and to compare this procedure with the classical approach--indirect myocardial revascularization (revascularization without endarterectomy). MATERIAL AND METHODS: This retrospective study was done in the period of three years, and includes patients operated between January 1, 1985 and December 31, 1990 at the University Clinic of Cardiovascular Surgery, Novi Sad. 500 patients were included and two groups were made. The investigated group consisted of 251 patients with endarterectomy and control group of 249 patients without endarterectomy. Other parameters (age, gender, preoperative hemodynamic parameters etc.) were practically the same. RESULTS: Postoperative mortality (PM) during immediate 30 postoperative days was 4.64% in the investigated group, and 1.97% in the control group (total PM = 2.66%). The main causes of death were cardiac (3.74%), and the rest of them were respiratory, renal and cerebral. The highest postoperative mortality according to the localization of endarterectomy was left artery descendent (LAD) in the position of the first septal artery (36.36%). The follow-up study included 500 operated patients. The mean follow-up period was 9 years (0-13 years). Cumulative survival curve and postoperative myocardial infarction curve made by Wilcocxon (Gehan) and Kaplan-Meier methods showed no statistically significant difference between groups after 13 years of follow up. Lower incident of new angina was found in the investigated group (p < 0.01). Most of patients show good physical condition, well toleration of the stress test (Bruce protocol) and no significant impairment of ejection fraction. DISCUSSION: Despite its long history and development, endarterectomy of coronary arteries is one of the most controversial methods in cardiac surgery. Application of this method was very restrictive mostly because its complexity and very controversial results from one institution to another. Endarterectomy of the first septal artery has the highest operative risk, but it is the method of choice in full revascularization of this region. Despite higher operative mortality, the immediate and long term results of this study show that endarterectomy of the coronary arteries is a method with very acceptable operative risk. CONCLUSION: Endarterectomy is a good and effective method for direct myocardial revascularization in cases with diffuse coronary disease. It is the best procedure for revascularization of the septum. The number of endarterectomies and low ejection fraction are independent predictors for early and long-term mortality. Endarterectomy is also a method of choice in patients with low ejection fraction and poor coronary bed. Frequent and repeated application of angioplasty, higher incidence of diffuse and distal coronary disease and no available donors for heart transplantation will increase the application of this method. In the future we expect further improvement and complete affirmation of endartrectomy of coronary arteries.