A quantitative sonoelastography evaluation of ocular and periocular elasticity after intravitreal ranibizumab injection.

PURPOSE: We evaluated changes in ocular and periocular elasticity by ultrasound (US) elastography in intravitreal ranibizumab-treated eyes and the healthy fellow eyes of patients with neovascular AMD. METHODS: The study was performed on 52 eyes of 26 volunteers who ranged in age from 59 to 89 (mean 72±7.78) years old. The study group consisted of the patients with neovascular AMD treated with intravitreal ranibizumab. The fellow eyes (without choroidal neovascularization) of the study group were selected as the control group. All patients were examined with sonoelastography before intravitreal injection and at 1day, 1week, and 1month after intravitreal injection. All images were acquired with a Toshiba Aplio 500 ultrasound system (Tokyo, Japan) including software with a combined autocorrelation method and a multifrequency linear probe. The elastography values of the anterior vitreous (AV), posterior vitreous (PV), retina-choroid-sclera complex (RCS), retrobulbar fat tissue (RF), optic nerve head (ONH) and retrobulbar optic nerve (RON) were measured in each eye. RESULTS: There were 13 male (50%) and 13 female (50%) participants in our study. Anterior vitreous, posterior vitreous, RCS, retrobulbar fat tissue, ONH, and RON US elastography values were similar in both groups (P˃0.05 for all). On the other hand, there was a positive correlation between the difference between baseline and 1-month PV sonoelastography values and age (r=0.47, P=0.035). CONCLUSION: A single dose intravitreal Ranibizumab (Lucentis®, Genentech, USA) injection does not alter the elasticity of ocular and periocular structures.

Sub-optimal drug treatment of diabetes and cardiovascular risk in diabetic patients in Turkey. A countrywide survey.

OBJECTIVES: The present study is a snapshot of how diabetic patients are treated for diabetes and coexisting cardiovascular risk factors in Turkey. We also addressed the question of what percentage of these patients are treated appropriately according to the current guidelines. Next step will be to determine which pharmacological treatment strategies affect mortality and morbidity in these patients and whether there are regional differences in these outcomes. METHODS: To get a representative picture, Turkey was splitted into four parts with different ethnic and socioeconomic features then centers were randomized within each of these parts. Number of the centers in a region were calculated according to the population of that region. 305 physicians in 11 cities participated in data collection during a period of 3 months. Consecutive 2226 diabetic patients patients who were above 55 years of age were included. Detailed information was obtained about the demographic features and the cardiovascular risk factor and diabetes status of the patients together with relevant drug treatment. Laboratory analyses were done locally and recorded if performed during the last 3 months. RESULTS: Most patients were treated with oral antidiabetic monotherapy regardless of diabetes duration, metabolic control and complication and cardiovascular risk factor status. There was a trend among physicians except for endocrinologists to underprescribe insulin. Monotherapy also was the main mode of treatment for hypertension. Angiotensin converting enzyme inhibitors were generally not used as first line treatment contrary to the recommendations and angiotensin converting enzyme inhibitors and angiotensin receptor blockers are not prescribed for renoprotection in microalbuminuric patients. Statins, fibrates, metformin and aspirin were largely underused. CONCLUSION: The present study indicates that diabetic patients are undertreated in Turkey. Therefore every effort should be spent to implement current guidelines in diabetic patients in order to prevent macro and microvascular complications of diabetes.

The relationship between QT dispersion and left and right ventricular diastolic dysfunction in patients with myocardial infarction.

OBJECTIVE: The purpose of this study was to investigate the relation between electrical dispersion and impairment of ventricular filling in patients with acute myocardial infarction (MI). METHODS: Thirty patients with recent myocardial infarction (17 patients with anterior and 13 patients with inferior MI) were included in the study. QT dispersion (QTd) was defined as maximum minus minimum QT interval durations. Flow propagation velocity measured by color m-mode echocardiography was used to determine diastolic function. RESULTS: There was a positive correlation between isovolumic relaxation time and QTd, as well as negative correlation existed between left ventricular flow propagation velocity (LVFPV) and QTd. The QTd was greater and LVFPV was lower in patients with anterior myocardial infarction as compared with those with inferior MI. CONCLUSION: There is an association between electrical dispersion and left ventricular filling abnormalities in patients with acute myocardial infarction.

Long- and short-term effects of transmyocardial laser revascularization in acute myocardial ischemia.

BACKGROUND AND OBJECTIVE: This study examined the effect of transmyocardial laser revascularization (TMLR) on infarct size and global and regional left ventricular (LV) function. STUDY DESIGN/MATERIALS AND METHODS: Acute ischemia was induced in 24 dogs by ligating the left anterior descending artery. TMLR was done through a left thoracotomy in 12 dogs. The 12 control dogs had ligation only. Global and regional LV function were measured before ligation, then at 6 hours or 3 months after ligation. We calculated the volumetric ratio of damaged myocardium to myocardium at risk (Vd/Vr). RESULTS: At 6 hours, global compensation despite regional dyskinesia was universal; Vd/Vr was the same in control and TMLR dogs. At 3 months, global function during stress was significantly higher in TMLR dogs than in control dogs (P < .05); regional contractions were synergic only in TMLR dogs; mean Vd/Vr was significantly lower in TMLR dogs. CONCLUSION: TMLR limits infarct expansion and improves long-term global and regional function after acute ischemia.

Transmyocardial laser revascularization: clinical experience with twelve-month follow-up.

We are investigating a new technique for myocardial revascularization in which an 800 W carbon dioxide laser is used to drill 1 mm diameter channels into a beating heart after left thoracotomy. Clotting occludes the channels on the subepicardium, and in the long-term setting, blood from the left ventricular cavity flows through these channels to perfuse the ischemic subendocardium. To test the efficacy of this technique in a preliminary clinical trial, we used it as sole therapy for 21 consecutive patients. All patients had hibernating myocardium, reduced coronary flow reserve, or both, had distal diffuse coronary artery disease, and had angina refractory to normal therapy. Eight patients were excluded from follow-up because of death (n=5), rerevascularization (n=2), or diaphragmatic paralysis resulting in postoperative respiratory incapacity (n=1). In the remaining 13 patients available for follow-up, the mean angina class (Canadian Cardiovascular Society) was 3.7 +/- 0.4 before operation and 1.8 +/- 0.6 12 months after operation (p < 0.01). Mean resting left ventricular ejection fraction was 48% +/- 10% before operation and 50% +/- 8% at 12-month follow-up. At 12 months, resting mean subendocardial/subepicardial perfusion ratio had increased by 20% +/- 9% in septal regions treated by laser but decreased by 2% +/- 5% in untreated regions (n=11, p <.001). These results suggest that revascularization by this laser technique positively affects subregional myocardial perfusion and may result in clinical benefits for patients with reversible myocardial ischemia. Studies to date have not demonstrated significant changes in global and regional ventricular contractile function.

Myocardial revascularization with laser. Preliminary findings.

BACKGROUND: We assessed the transmyocardial laser revascularization (TMLR) as sole therapy in patients with symptomatic coronary artery disease refractory to interventional or medical treatment. METHODS AND RESULTS: Thirty-one patients were evaluated with positron emission tomography (PET), dobutamine echocardiography, 201Tl single-photon emission computed tomography (201Tl-SPECT), and multigated acquisition radionuclide ventriculography (MUGA). TMLR was performed in 21 patients who had demonstrable ischemia in viable myocardium. The mean Canadian Cardiovascular Society (CCS) angina class was 3.70 +/- 0.7 (4 patients with unstable angina). Untreated septal segments were used as controls. At 3 months, (n = 15 patients), the mean CCS angina class was to 2.43 +/- 0.9 (P < .05). On dobutamine echocardiography, the mean resting wall motion score index was improved by 16% in lased segments (P < .03 vs control), and mean LVEF at peak stress increased by 19% (P = NS vs baseline). On 201Tl-SPECT, perfusion of lased and nonlased segments did not change. On PET, the mean ratio of subendocardial to subepicardial perfusion (SEn/SEp) increased 14% over baseline (P < .001 vs control). At 6 months (n = 15 patients), the mean CCS angina class was 1.7 +/- 0.8 (P < .05). The mean resting wall motion score index was up by 13% in lased segments (P < .05 vs control). Resting LVEF was unchanged. Stress LVEF increased 21% (P = NS vs baseline). Myocardial perfusion remained unchanged by 201Tl-SPECT. On PET, 36% of the lased segments were better, and 25% were worse compared with baseline. The resting SEn/SEp by PET was up 21% (P < .001 vs control). All deaths (two perioperative and three late) occurred in patients with preoperative congestive heart failure. Two patients required repeat revascularization of new coronary lesions. CONCLUSIONS: These results suggest that TMLR improves anginal status, relative endocardial perfusion, and cardiac function in patients who do not have preoperative congestive heart failure.

Simultaneous evaluation of cardiac wall motion and myocardial ischemic injury by measurement of electrical impedance.

The authors devised a new method to simultaneously evaluate cardiac wall motion and myocardial ischemic injury by measurement of myocardial electrical impedance. This method is based on the principle that electrical properties of the myocardium are affected by intra- or extracellular structure. Impedance was assessed by measuring voltage while a constant alternating current (0.4 mA, 50 kHz) was being applied to the myocardium by way of an electrode that had two parallel 6 mm long needles. In five dogs, an electrode was placed in the left ventricular wall, adjacent to a pair of ultrasonic crystals that were used to estimate regional wall thickness. To change regional contractility and to induce ischemic injury, the left anterior descending coronary artery was ligated. The impedance waveforms were observed to be synchronized with cardiac contraction, and changes in impedence correlated well with changes in wall thickness. Dyskinetic movements in the ischemic myocardium could also be detected through assessment of the impedance waveform. During the first 2 hr, the average value of impedance increased significantly, from 254 +/- 38 omega-cm to 329 +/- 13 omega-cm (P < 0.005), and then decreased, indicating a correlation with the progression and irreversibility of ischemic injury. This simple technique may eventually allow us to simultaneously assess cardiac wall motion and myocardial ischemia in humans.

Transmyocardial laser revascularization. Anatomic evidence of long-term channel patency.

Transmyocardial laser revascularization, a new surgical technique, is being tested in patients with chronic obstructive coronary artery disease that is refractory to conventional revascularization techniques and to maximal medical therapy. During the operation, which is performed on the beating heart through a left thoracotomy, a high-energy CO2 laser is used to bore transmural channels (1 mm in diameter) into the left ventricle. Each high-energy laser pulse is delivered during end diastole and transects the heart within 10 to 60 msec. The operation is based on the theory that blood will flow directly from the left ventricle into the channels and then into the myocardial vascular plexus. Restoring perfusion should alleviate ischemia in potentially viable myocardium and improve ventricular function. Recently, one of our patients died 3 months after transmyocardial laser revascularization of causes unrelated to the operation. Histologic analysis enabled us to obtain, for the 1st time, anatomic evidence of patent laser channels. Routine staining of cardiac tissue with hematoxylin and eosin revealed multiple patent channels, running perpendicular to and interconnecting with the native vasculature. Although reactive fibrous scar tissue had caused narrowing of the original laser tract, the channels had endothelialized and they contained red blood cells. These findings suggest that the laser channels were functional. We report this interesting case and briefly discuss the anatomic and physiologic phenomena involved in establishing camerosinusoidal blood flow by use of transmyocardial laser revascularization.