Effect of levosimendan on right ventricular systolic and diastolic functions in patients with ischaemic heart failure.

OBJECTIVES: Levosimendan is a novel positive inotropic calcium sensitiser agent used in acute left heart failure. In this study, the effect of levosimendan on the right ventricular systolic and diastolic functions was evaluated by tissue Doppler comparing them with dobutamine in patients with ischaemic heart failure. METHODS: Patients having an acute decompensated heart failure with ischaemic cardiomyopathy and left ventricular ejection fraction <40% were included in the study. Before and 24-h after treatment, peak systolic (Sa), peak early (Ea), peak late (Aa) diastolic annular velocities and Ea/Aa ratio from tricuspid lateral annulus by tissue Doppler and systolic pulmonary artery pressure (SPAP) were measured. RESULTS: Sa, Ea and the Ea/Aa ratio were significantly increased in the levosimendan group whereas SPAP was significantly reduced. In the dobutamine group, no significant differences were observed in the Sa, Ea, Aa and Ea/Aa ratio in spite of a significant reduction in SPAP. Decrease in SPAP was greater in the levosimendan group (p=0.002). CONCLUSION: Levosimendan improves right ventricular systolic and diastolic functions.

Transbrachial coil occlusion of unligated thoracic side branch of arterial graft of internal mammary artery leading to silent ischemia in a diabetic patient.

There is not an established consensus on the treatment of coronary steal syndrome caused by unligated thoracic side branches of internal mammary artery. Occlusion of thoracic side branch is not recommended without objective evidence of ischemia. This case report presents transbrachial coil occlusion of thoracic side branch of left internal mammary artery causing silent ischemia in a diabetic patient with atypical chest pain and palpitation.

The efficacy of telmisartan compared with perindopril in patients with mild-to-moderate hypertension.

In this study, efficacy of the angiotensin II type 1 receptor blocker telmisartan given as monotherapy was compared with that of perindopril monotherapy in patients with mild-to-moderate hypertension. After a 2-week, single-blind, placebo run-in period, 60 patients were randomised to double-blind, once-daily treatment with telmisartan 80 mg or perindopril 4 mg for 6 weeks. Clinic and ambulatory blood pressure measurements and clinical laboratory evaluation were performed at the end of the placebo run-in and active treatment phases. Both telmisartan and perindopril significantly (p < 0.0001) reduced clinic systolic blood pressure (SBP) and diastolic blood pressure (DBP) compared with baseline values. Also, both drugs significantly (p < 0.0001) reduced 24-h mean ambulatory SBP and DBP compared with baseline. Comparison of the mean hourly antihypertensive activities showed that the reduction in mean ambulatory DBP for the last 8 h of the dosing interval was significantly greater (p < 0.05) in telmisartan-treated patients. A 24-h mean DBP of <85 mmHg was observed in 66.6% of the telmisartan-treated patients but in only 46.6% of the perindopril-treated patients (p < 0.05). It is concluded that telmisartan and perindopril both produce significant reductions in clinic SBP and DBP, but the mean reduction in ambulatory DBP during the last 8 h of the dosing interval is greater in patients treated with telmisartan.

Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture.

Four patients who developed combined tendon and overlying skin defects following operative repair of ruptured Achilles tendon were presented. Three patients had an infected wound. The average interval from the first operation for repairing the ruptured Achilles tendon and the reconstructive procedure was 46.2 days (range, 5-65 days). All patients were treated with a one-stage operation including radical debridement, reconstruction of the Achilles tendon defects using vascularized or nonvascularized tendon grafts, transfer of peroneus brevis for augmentation, and skin coverage with a free flap. The patients recovered uneventfully. The average follow-up period was 39.2 months (range, 18-79 months). In all patients, an evaluation of the clinical outcome, the performance of the calf muscles using a computerized dynamometer, and structural changes of the reconstructed Achilles tendon using magnetic resonance (MR) imaging were made. The clinical outcome was excellent in three patients and good in one. In isokinetic testing (Cybex-Norm), strength was found to be normal in one patient and abnormal in three patients. MR images revealed an intratendinous area of homogenous and normal intensity signal, and a significant increase in thickness and width in all levels of the reconstructed Achilles tendon. The authors conclude that it is possible to obtain satisfactory function in patients with complex wounds in the region of the Achilles tendon.

Ruptured aneurysm of sinus of valsalva with ventricular septal defect: the role of transesophageal echocardiography in diagnosis.

We present a case of ruptured aneurysm of sinus of valsalva (ASV) along with subaortic ventricular septal defect (VSD). Transesophageal echocardiographic examination in addition to transthoracic echocardiography provides more powerful information about ASVs and coexistent cardiac malformations. This may be additional value for the cardiac surgeon planning resection of the lesion.

Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation and time factor.

We retrospectively analyzed the blood pressure (BP) and cardiothoracic index (CTi) of 67 hemodialysis patients with hypertension who could be followed up for at least 8 months. A new treatment policy was adopted, aimed at strict volume control. Dietary salt restriction was strongly emphasized. Ultrafiltration (UF) was applied during regular dialysis sessions and sometimes in additional sessions, as long as BP and CTi remained at greater than normal values. All antihypertensive drugs were discontinued at the beginning of treatment. Average BP decreased from 173 +/- 17/102 +/- 9 to 139 +/- 18/86 +/- 11 mm Hg after 6 months and to 118 +/- 12/73 +/- 6 mm Hg after 36 months. Corresponding values for CTi were 52% +/- 4%, 47% +/- 3%, and 42% +/- 4%, respectively. Conventional relatively short dialysis (three times weekly for at least 4 hours) can achieve normal BPs with prolonged effort in most patients, whereas improvement in heart condition facilitates this.

A rare cause of right atrial mass: thrombus formation and infection complicating a ventriculoatrial shunt for hydrocephalus.

BACKGROUND: Thrombus formation around the intracardiac end of the catheter, thromboembolism, and infection are the most important and life-threatening complications of ventriculoatrial shunts. In this article we report a patient with a large right atrial mass that was diagnosed by 2-D echocardiogram and removed via standard median sternotomy and cardiopulmonary bypass. CASE DESCRIPTION: A 63-year-old man who had a right ventriculoatrial shunt was admitted to our department in a septic clinical condition. His hemoglobin was 10.7 grams, white blood cell count was 22,900/mm3, and sedimentation rate was 50 mm/hr. Blood cultures grew coagulase negative staphylococcus. The echocardiogram showed a right atrial mass at the tip of the shunt catheter. The mass had a cystic and "glove-like" appearance and had a pendulous motion in the right atrium. After combined antibiotic therapy for 10 days, symptoms were relieved but echocardiographic findings did not change. A surgical approach was chosen because of the unchanged size of the mass and the risk of pulmonary embolism. First, the distal part of the ventriculoatrial shunt was separated from its pump and a new ventriculoperitoneal shunt was placed. After this, a standard median sternotomy, cardiopulmonary bypass and right atriotomy was performed. The tip of the shunt catheter with the attached pedunculated mass was removed. CONCLUSION: There are few cases of a large right atrial thrombus secondary to a ventriculoatrial shunt in the literature. Because of these serious complications of ventriculoatrial shunting, careful 2-D transthoracic echocardiographic examination should be mandatory for patients with ventriculoatrial shunts.

Effectiveness and safety of alternate-day simvastatin and fenofibrate on mixed hyperlipidemia.

This randomized prospective clinical study evaluated the lipid-lowering effects and safety of a new combination regimen in patients with mixed hyperlipidemia. The data show that alternate-day simvastatin and fenofibrate therapy was as effective as the standard daily combination of the same drugs at the same doses, and it was safer, less expensive, and more tolerable.

Dilated uremic cardiomyopathy in a dialysis patient cured by persistent ultrafiltration.

A patient is presented who after 2 years of hemodialysis showed all of the features of congestive cardiomyopathy to a very severe degree: dilation of all cardiac compartments, increased left ventricular mass, low ejection fraction, diastolic disturbances, third- to fourth-degree mitral and tricuspid regurgitation, ascites, and low blood pressure. All of these abnormalities gradually but completely disappeared during 5 months of persistent ultrafiltration during or between dialysis sessions. It was concluded that chronic fluid overload was a major factor in the cardiac disease of this patient. Unrecognized hidden fluid overload has long been known (but also neglected), and its prevention deserves top priority in chronic dialysis patients.

Reconstruction of soft tissue and bone defects in lower extremity with free flaps.

This article reports our experiences treating soft tissue and bone defects in the lower extremity with free flaps. One of the most common causes for lower extremity wounds are high-energy injuries. These kinds of injuries contain soft tissue and bone defects beyond neurovascular complications. The rate of infection and nonunion is very high in these injuries. Between 1988 and 1996, we applied 33 flaps to 28 patients. The numbers and kinds of the free flaps are as follows: 12 latissimus dorsi, nine radial forearm, seven lateral arm, three vascularised fibula grafts with skin, one gracilis, and one medial plantar flap. Three free flaps were lost (12%). The success rate is 88%. The advantage of free flaps is that they allow the reconstruction of the large defects in one-session operations. Thus, they decrease the rate of infection and increase that of nonunion. The patient returns to his active life at an earlier stage.

[Heterotopic replantation]. / Heterotope Replantationen.

In multidigital amputations, it is sometimes better to replant an amputated finger to a different proximal part if a better function can be expected in this position. In our clinical material between October 1991 and March 1994, heterotopic replantation was performed in twelve digits in eleven patients. Three fingers were replanted to the thumb, three to the index, four to the middle, and two to the ring fingers. The functional results were satisfying. The total active range of motion was on an average 24% of a normal finger. Static two-point discrimination was 8.5 mm on an average, and the values for the Semmes-Weinstein test ranged between 3.61 and 6.5. A heterotopic replantation is of special value for primary thumb reconstruction.

Eight years experience in crush and avulsion type finger amputation.

Between July 1986 and July 1994, we studied 125 total finger amputations due to crush and avulsion type injuries at the Izmir Hand and Microsurgery Hospital. Of the 125 fingers replanted, 88 were successful, for a general survival rate of 70.4%. In the period between 1986 and 1991, we performed end-to-end anastomoses and achieved a survival rate of 48.3% (Group I). Between 1991 and 1994, with the application of a primary interpositional vein graft for the required indications in this type of injury, the general survival rate increased to 77.1% (Group II; P < 0.05). We conclude that the significant increase in the survival rate in Group II is related to both the increased experience of the surgical team and the application of the primary interpositional vein graft.

Rolling belt injuries in children.

The rolling belts on agricultural machinery attract children who unconsciously grab them. The injuries produced include friction burns, injuries to flexor tendons, digital nerves and arteries, skin in zone 2 and fractures. Subtotal or total amputation may occur. We present the results of such injuries to 44 fingers in 16 children aged 1 to 9. The functional results are not satisfactory. In order to grade the results we have devised a classification to this injury. The survival rate for all fingers was 71%, but in the fingers with circulatory problems the survival rate was 50%. On functional assessment seven patients had a good result, seven moderate, and two fair.

Replantations and their functional results: the Turkish experience.

The development of microsurgery with regard to replantation of severed extremities has in Turkey been a relatively recent although rapid process. The first revascularization was performed by our team in Izmir in 1986. By 1988 a 24-hr emergency replantation service was available and a special surgery branch hospital in hand and microsurgery was established in 1991. This hospital was the first of its kind in Turkey and one of the few in the world. Here we present our replantation series comprising 83 patients treated between July, 1986, and December, 1990. From a total of 83 patients, 136 extremities were involved, with only 24 of 136 lost; a success rate of 82%. Functional results were rated as excellent or good in 49 cases.