Quantifying peripheral sympathetic activations during sleep by means of an automatic method for pulse wave amplitude drop detection.

Sudden drops in pulse wave amplitude (PWA) measured by finger photoplethysmography (PPG) are known to reflect peripheral vasoconstriction resulting from sympathetic activation. Previous work demonstrated that sympathetic activations during sleep typically accompany the occurrence of pathological respiratory and motor events, and their alteration may be associated with the arising of metabolic and cardiovascular diseases. Importantly, PWA-drops often occur in the absence of visually identifiable cortical micro-arousals and may thus represent a more accurate marker of sleep disruption/fragmentation. In this light, an objective and reproducible quantification and characterization of sleep-related PWA-drops may offer a valuable, non-invasive approach for the diagnostic and prognostic evaluation of patients with sleep disorders. However, the manual identification of PWA-drops represents a time-consuming practice potentially associated with high intra/inter-scorer variability. Since validated algorithms are not readily available for research and clinical purposes, here we present a novel automated approach to detect and characterize significant drops in the PWA-signal. The algorithm was tested against expert human scorers who visually inspected corresponding PPG-recordings. Results demonstrated that the algorithm reliably detects PWA-drops and is able to characterize them in terms of parameters with a potential physiological and clinical relevance, including timing, amplitude, duration and slopes. The method is completely user-independent, processes all-night PSG-data, automatically dealing with potential artefacts, sensor loss/displacements, and stage-dependent variability in PWA-time-series. Such characteristics make this method a valuable candidate for the comparative investigation of large clinical datasets, to gain a better insight into the reciprocal links between sympathetic activity, sleep-related alterations, and metabolic and cardiovascular diseases.

[72-year-old man with syncope and left hemiparesis]. / 72-jähriger Patient mit Synkope und linksseitiger Hemisymptomatik.

A 72-year-old man was admitted with left hemiparesis after a painless syncope with suspected ischemic stroke. So far he was a healthy man without any cardiovascular risk factors. A computed tomography scan of the head did not show any abnormal findings. In the clinical evaluation we revealed pulse deficits in the left-sided extremities and the blood pressure of the left arm was not measurable. The final diagnosis was an acute aortic dissection, beginning in the proximal portion of the ascending aorta, leading to the iliacal arteries. The patient was transferred and surgery was performed immediately with success. Painless acute aortic dissection presenting only with neurologic symptoms made the correct diagnosis extremely difficult. Correct diagnosis, however, is essential, otherwise thrombolytic therapy - indicated for acute-stage cerebral infarction - would have been performed, probably with a fatal outcome.

Laughing as a manifestation of rapid eye movement sleep behavior disorder.

BACKGROUND: Among the range of sleep-related behavior displayed by patients with rapid eye movement (REM) sleep behavior disorder (RBD), aggressive acts are particularly common, while pleasant behaviors have rarely been reported. We aimed at identifying the frequency and characteristics of patients who displayed laughing as a pleasant, nonviolent manifestation of RBD. METHODS: We reviewed 67 consecutive polysomnographic recordings of patients with RBD, obtained in our sleep laboratory between July 2004 and July 2009. RESULTS: We identified 14 patients (21% of our RBD patients with degenerative parkinsonism: 10 males, mean age 63 ± 11 years) who repeatedly laughed during REM sleep. Ten patients had idiopathic Parkinson's disease, 3 suffered from multisystem atrophy and 1 patient was diagnosed with dementia with Lewy bodies. Other RBD-associated behaviors included smiling, crying, aggressive behavior, screaming, and somniloquia. Nine of the 14 patients were depressed during daytime. CONCLUSION: Laughing belongs to the spectrum of behavioral manifestations of RBD. Many of our patients with RBD-associated laughter were depressed, suggesting a dissociation between emotional expression during daytime and REM sleep.

[Therapeutic advances in neurology]. / Neurologie.

This article summarizes the main therapeutic advances of 2010 in the field of neurology. It focuses on aspects that are likely to change the care of patients in clinical practice. Among these, we discuss the new oral treatments that have proved to be effective in multiple sclerosis, the results of two large studies comparing endarterectomy and stenting in carotid stenosis, novel therapeutic approaches for the treatment of non-motor symptoms in Parkinson's disease as well as the results of several pharmacological studies in the field of epilepsy.

"When Aneurysm Ain't Aneurysm": sinus of Valsalva aneurysm mimicked by healed abscess cavity under the aortic valve.

In a 70-year-old patient with severe aortic valve stenosis, preoperative standard imaging (transthoracic echocardiography and angiography) detected an unclear subannular cavity structure. Initially interpreted as an aneurysm of Valsalva, the structure was identified intraoperatively as a huge chronic abscess cavity and exclusion was carried out by pericardial patch plasty. This case draws attention to the importance of a differential diagnosis of an abscess due to infective endocarditis in cases of unclear subannular structures rashly diagnosed as aneurysm of Valsalva.

A new surgical approach for exclusion of renal artery aneurysms avoiding organ ischemia.

INTRODUCTION: Surgical treatment of renal artery aneurysms is inevitably associated with temporary renal artery occlusion and risk of ischemic injury. We present a technique for renal artery grafting and aneurysm exclusion without interrupting renal blood flow. REPORT: A symptomatic renal artery aneurysm was bypassed with a venous graft between the abdominal aorta and the very distal renal artery utilizing a distal anastomotic device without interruption of renal blood flow. The aneurysm was then excluded by means of hemostatic clips. CONCLUSION: The presented surgical technique offers the major advantage of avoiding organ ischemia and accelerating the surgical procedure.

Bilateral segmental agenesis of the vertebrobasilar junction: developmental and angiographic anatomy.

BACKGROUND AND PURPOSE: Bilateral vertebrobasilar junction agenesis is an exceptional anatomic variation. This article explores the angiographic characteristics of this variant and its embryologic mechanisms. MATERIALS AND METHODS: Two observations of bilateral agenesis of the vertebrobasilar junction are reported. A case of atheromatous disease of the vertebrobasilar junction is shown to highlight characteristics distinguishing such a lesion from the reported variant. RESULTS: In the 2 reported cases, the distal segment of both vertebral arteries (VAs) and the proximal portion of the basilar artery (BA) were absent. In addition, distal connections of the BA with the posterior cerebral arteries (PCA) were also lacking. As a consequence, the remaining portion of the BA was isolated from its usual sources of blood supply, which was provided by a persistent carotid-basilar anastomosis. CONCLUSION: The developmental mechanism underlying bilateral agenesis of the vertebrobasilar junction likely involves the anterior radicular artery of C1. This branch of the proatlantal artery normally becomes the adult distal VA and the proximal BA. The lack of cranial connection of the BA with the PCA may be secondary to the proximal vertebrobasilar agenesis and the resulting paucity of antegrade flow within the BA. Alternatively, the absence of both the proximal and distal connections of the BA could be the result of a similar, yet unknown, developmental mechanism. From a clinical standpoint, this vascular anomaly was discovered incidentally in our 2 patients, a finding consistent with the assumed congenital nature of the variant.

Developmental anatomy of the distal vertebral artery in relationship to variants of the posterior and lateral spinal arterial systems.

BACKGROUND AND PURPOSE: A certain number of anatomic variants involving the distal vertebral artery (VA) are explained by variations in size and connection of the lateral spinal artery (LSA). This study examined the possible role of another branch of the VA, the posterior spinal artery (PSA), in the development of similar vascular variations. MATERIALS AND METHODS: Four types of variations in the distal VA, including the C1 and C2 origins of the posterior inferior cerebellar artery (PICA), the duplication of the distal VA, and the aberrant course of the distal VA, are illustrated by 9 angiographic observations. RESULTS: For each type of VA variant listed above, examples resulting from variations in size and connection of the LSA and PSA could be matched. CONCLUSION: Variation in size and connection of the PSA is at the origin of a set of anatomic variations of the distal VA similar, but not identical, to the vascular variants linked to the LSA.

Surgical interventions in ischemic ventricular tachyarrhythmias--endocardial resection or implanted cardioverter/defibrillator.

The surgical therapy of ventricular tachyarrhythmias (VTA) in ischemic heart disease is attracting attention, since current medical therapies are showing limited long-term efficacy. The curative concept of electrophysiologically guided endocardial resection (ER) and palliation with the implantable cardioverter/defibrillator (ICD) are compared retrospectively. From 1980-1992, 121 patients (55 +/- 9 years, 108 males, 13 females) underwent ER and 203 patients (59 +/- 9 years, 195 males, 8 females) received an ICD for ischemic VTA. Concomitant coronary revascularization was performed in 38/121 patients with ER (31%) and in 62/203 patients (31%) with ICD. Perioperative mortality was 8% (10/121 patients) for ER and 5% (10/203 patients) for ICD (P = n.s.). Hundred eleven patients with ER (mean follow-up 41 +/- 37 months) and 193 with ICD (mean follow-up 22 +/- 20 months) were available for survival analysis: freedom from sudden death was comparable for the two groups at 1 year (99% for ICD, and 94% for ER) and at 5 years (90% for ICD and 90% for ER) (P = n.s.). Freedom from cardiac death also showed no differences between the groups at 1 year (94% for ICD, and 84% for ER) and at 5 years (74% for ICD and 74% for ER) (P = n.s.). Left ventricular function, indicated by left ventricular ejection fraction, was comparable (34 +/- 9% in ER, 30 +/- 11% with ICD) (P = n.s.) in the two groups. The linearized incidence of DC-shocks was 10.3/year in ICD patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative in vivo study on the healing qualities of four different presealed vascular prostheses.

PURPOSE: The purpose of this article is to assess the healing qualities of presealed knitted polyester prostheses. METHODS: Thoracic aortic replacement was performed with grafts with four different coating materials-collagen (CP), albumin (AP), and two with gelatin (GP1/GP2)-in four groups of 15 pigs each. Two weeks, 6 weeks, and 6 months after operation, five pigs of each group were killed. Healing quality was assessed by morphometric analysis of the remaining coating, the extent of tissue ingrowth, and the thickness of the inner layer. RESULTS: The sealant was rapidly absorbed in all prostheses except for the AP (remaining coating at 2 weeks: GP1 22.1%, GP2 34.7%, and CP 68.0% vs AP 97.1% [p < 0.05]), remaining coating at 6 weeks: GP1/GP2 0% and CP 2.5% vs AP 76.7% (p < .01). At 6 months, remaining coating was only detectable in AP (21.5%). At 2 weeks the extent of tissue ingrowth ranged from 65.7% in GP1 and 75.3% in CP to 80% in GP2 versus 8.9% in AP (p < 0.05). There was a slow increase of tissue ingrowth until the sixth postoperative week (GP1 74.4%, GP2 85.0%, and CP 91.3% versus AP 19.6% [p < 0.01]). Thickness of the internal layer varied from 0.11 to 0.21 mm at 2 weeks in all grafts studied and from 1.02 mm (AP) and 1.28 mm (GP2) to 1.39 mm (GP1), versus 0.41 mm in the CP (p < 0.01) after 6 months of implantation. CONCLUSIONS: The type of coating significantly influences the healing properties of knitted polyester prostheses. When used for thoracic aortic replacement in pigs, AP coating clearly results in inferior healing compared with GP1/GP2 or CP impregnation, with digestion of the coating material and tissue ingrowth used as parameters. The thinnest internal layer was found in the CP prostheses, reflecting superior healing properties of this coating in the model studied.

[Long-term follow-up of anti-tachycardia surgery in patients with ventricular tachycardia]. / Langzeitverlauf nach antitachykarder Operation bei Patienten mit Kammertachykardien.

From March 1980 to May 1992 mapping guided surgery was performed in 132 patients with drug-refractory recurrent ventricular tachycardia. There were 121 patients (group I) with coronary disease and 11 patients (group II) had noncoronary ventricular tachycardia. Patients in group I underwent subendocardial resection and cryoablation was performed in group II patients. Perioperative mortality (< 30 days after surgery) was 8% (10/132 patients). During the mean follow-up of 41 +/- 24 months, 37/122 patients (30%) died, 35/111 patients in group I (32%) and 2/11 patients in group II (18%) (p = 0.29). In group I, sudden death occurred in 8/111 patients (7%) and cardiac death in 23/111 patients (21%); in group II, 1/11 patients (9%) died from sudden and 1/11 patients (9%) from cardiac death. Nonfatal recurrences occurred significantly more frequently in group II (6/11 patients, 55%) than in group I (16/111 patients, 14%) (p < 0.01). During the follow-up functional class of heart failure improved in 69 patients (57%), remained constant in 27 patients (22%) and decreased in the remaining 26 patients (21%). The surgical approach to control ventricular tachycardia has low rates of sudden death and nonfatal recurrences in patients with drug-refractory ischemic ventricular tachycardia. Patients with noncoronary disease had a high incidence of nonfatal ventricular tachycardia after surgery and should be considered for other therapeutic approaches in the future.

Ventricular tachycardia surgery in 1992: did the automatic defibrillator change this approach?

The role of ventricular tachycardia (VT) surgery has been changed since the automatic implantable cardioverter defibrillator (ICD) is available. We studied the follow-up of 131 patients who underwent mapping guided surgery due to recurrent VT refractory to antiarrhythmic drug treatment. There were 65 patients operated upon between 1980-1985 (group I) and 66 patients between 1986-1991 (group II). Ten patients (8%) died perioperatively (< 3 weeks after surgery) [7/65 patients, 11%, in group I and 3/66 patients, 5%, in group II (P = 0.15)]. During a mean follow-up of 41 +/- 24 months, 38 of 121 patients died (31%), significantly more patients in group I (24/58 patients, 41%) than in group II (14/63 patients, 22%) (P < 0.05). In group I, there was a higher incidence of sudden (7/58 patients, 12%) or cardiac death (15/58 patients, 26%) than in group II (sudden death 4/63 patients, 6%, cardiac death 7/63 patients, 11%) (P < 0.05). There was a similar incidence of VT recurrences between group I (9/65 patients, 14%) and group II (9/66 patients, 14%). Our data show that the indication for VT surgery has changed since the ICD is available because of better patient selection.

[Artificial intravascular oxygenation (IVOX). Application to the treatment of postoperative respiratory failure]. / Artifizielle intravaskuläre Oxygenierung (IVOX). Zur Therapie des postoperativen Lungenversagens.

Very recently, the concept of artificial intracorporeal oxygenation of blood for patients suffering from respiratory failure has been introduced into clinical practice through development of a totally implantable intravascular oxygenator (IVOX). We report on the use of such a device in a patient who developed severe respiratory insufficiency secondary to prolonged hypovolaemic shock and pneumonia following successful repair of a ruptured abdominal aortic aneurysm in September, 1990. Postoperatively, severe hypoxaemia occurred (AaDO2 548-602 torr) despite extensive mechanical ventilatory support. There was no obvious chance to overcome this situation by conventional therapeutic measures and the decision was made to institute IVOX therapy. Hypoxaemia was resolved immediately and both FiO2 and tidal volume could be reduced within hours. The patient's respiratory condition continued to improve over the next days leading to termination of IVOX therapy after 71 hours. However, the necessity of long-term ventilatory support secondary to recurrent pneumonia and sepsis, multiple abdominal reoperations for ischemic colitis and retroperitoneal abscess prolonged his recovery. He was discharged from the hospital after four months and is alive and well now 14 months after his operation. He is the first long-term survivor after IVOX therapy in Europe. IVOX may be successfully used in selected patients while the indications and it's potential role in the therapy of severe respiratory failure still need to be defined.

Prevention of graft infection by bonding of gentamycin to Dacron prostheses.

To increase the efficacy of perioperative antibiotic prophylaxis in vascular surgery an experimental study including topical application of the gentamicin derivative EMD 46/217 and fibrin sealant as antibiotic carrier to Dacron prostheses was initiated. In vitro treatment of Dacron with gentamicin and fibrin was followed by constant antibiotic release for 3 weeks. In a subsequent animal study Dacron grafts were implanted in the aorta of 10 pigs after direct contamination with Staphylococcus aureus solution. One graft was pretreated with the antibiotic/fibrin compound, a second with the antibiotic alone. Grafts 3 (no pretreatment) and 4 (fibrin alone) served as controls. After 1 week the grafts and their corresponding implantation sites were excised for measurement of antibiotic content and for culture. The antibiotic content of grafts with the antibiotic/fibrin compound was 25.0 +/- 7.2 micrograms/gm wet weight, whereas Dacron pretreated with the antibiotic alone contained no measurable drug amounts except for one specimen (0.5 microgram/gm) (antibiotic/fibrin vs antibiotic, p less than .0005). The corresponding implantation sites to antibiotic/fibrin grafts contained 1.07 +/- 0.54 microgram/gm antibiotic, whereas in only 2/10 implantation sites of antibiotic grafts low antibiotic levels were found (0.05 and 0.2 microgram/gm) (antibiotic/fibrin vs antibiotic, p less than 0.005). All control grafts and 9/10 antibiotic grafts were infected. By contrast, only five were contaminated, and 5 of 10 remained sterile after culture (antibiotic/fibrin vs antibiotic, p less than 0.05). This finding correlates with the antibiotic content in the Dacron. It is concluded that pretreatment of prosthetic Dacron grafts with the antibiotic/fibrin compound results in binding of sufficient amounts of antibiotic for at least 1 week.(ABSTRACT TRUNCATED AT 250 WORDS)

Collagen-presealed or uncoated aortic bifurcation Dacron prostheses: a 5-year clinical follow-up study.

A total of 70 patients undergoing replacement of the aortic bifurcation between October 1983 and June 1985, were studied 5 years postoperatively for graft patency. In 35 cases a collagen-coated knitted Dacron prosthesis (group I) was implanted, while an identical, but uncoated, Dacron graft was used in a second group of 35 patients (group II). Distribution of vascular risk factors were similar in both patient groups. The underlying disease was aortoiliac occlusive disease in 24 patients of group I and in 33 of group II. Aortoiliac aneurysmal disease was present in 10 patients of group I and in 2 patients of group II. One patient of group I was suffering from Takayasu's disease of the descending type. At follow-up, all grafts were patent in group I, while in group II 8 distal limb occlusions occurred between 6 and 46 months postoperatively. This represents a 5-year limb patency rate of 100% for collagen-presealed grafts versus 88.6% for uncoated prostheses (p less than 0.01). A higher incidence of distal anastomotic aneurysms was found in group I (7/70 limbs) compared to group II (1/70 limbs) (p less than 0.05). It is concluded that long-term patency of knitted Dacron prostheses in aortic bifurcation replacement is not reduced by presealing with collagen. It appears that this type of coating may actually enhance long-term patency after reconstruction of the aortoiliac axis. The higher rate of distal anastomotic aneurysm formation in patients with presealed grafts, however, could not be correlated with a failure of the sealant material or with the underlying disease of the patients involved.

Total arterial revascularization of the heart using both mammary arteries and the right gastroepiploic artery.

From April 1988 to April 1989, nine patients (seven men and two women) with coronary three-vessel disease and disabling angina underwent elective myocardial revascularization. None of the patients had available veins because of previous bypass procedures (three) or extensive varicosis (six). On standard cardiopulmonary bypass and cardioplegic arrest the right and the left mammary arteries (RIMA, LIMA) and the right gastroepiploic artery (RGEA) were anastomosed each to a major coronary branch (none of them as free graft) in each patient. All patients survived the operation but one, who died 2 weeks after the operation of a bilateral pneumonia. Autopsy revealed patent anastomoses. One patient had to be reexplored for bleeding. Two patients required temporary inotropic support. There was no perioperative myocardial infarction. All survivors were discharged home in an average of 18.7 days after the operation, are free from angina, and all have negative stress tests (mean follow-up 7.7 months) but one with severe coronary atherosclerosis who experiences slight exertional angina despite good patency of the grafts. Five patients were recatheterized after a mean interval of 5.4 months after operation revealing in all cases patent anastomoses. Total revascularization of the heart with arterial grafts is feasible, safe, and it could become the method of choice if patency persists in the long run.

Acute hypercalcemic crisis after an open heart operation.

Acute hyperparathyroidism developed in a previously normocalcemic 64-year-old woman during the first week after a coronary operation. Prolonged QT interval in the electrocardiogram and hypercalcemia were documented on the fourth postoperative day. Neck exploration on the fifth postoperative day revealed a lower right parathyroid adenoma. Parathyroidectomy resulted in rapid and dramatic improvement of the clinical picture and normalization of laboratory values.