Treatment of Obesity with Thyroid hormones in Europe. Data from the THESIS* Collaboration.

PURPOSE: The use of thyroid hormones (TH) to treat obesity is unsupported by evidence as reflected in international guidelines. We explored views about this practice, and associations with respondent characteristics among European thyroid specialists. METHODS: Specialists from 28 countries were invited to a survey via professional organisations. The relevant question was whether "Thyroid hormones may be indicated in biochemically euthyroid patients with obesity resistant to lifestyle interventions". RESULTS: Of 17,232 invitations 5695 responses were received (33% valid response rate; 65% women; 90% endocrinologists). Of these, 290 (5.1%) stated that TH may be indicated as treatment for obesity in euthyroid patients. This view was commoner among non-endocrinologists (8.7% vs. 4.7%, p < 0.01), private practice (6.5% vs. 4.5%, p < 0.01), and varied geographically (Eastern Europe, 7.3%; Southern Europe, 4.8%; Western Europe, 2.7%; and Northern Europe, 2.5%). Respondents from Northern and Western Europe were less likely to use TH than those from Eastern Europe (p < 0.01). Gross national income (GNI) correlated inversely with this view (OR 0.97, CI: 0.96-0.97; p < 0.001). Having national guidelines on hypothyroidism correlated negatively with treating obesity with TH (OR 0.71, CI: 0.55-0.91). CONCLUSIONS: Despite the lack of evidence, and contrary to guidelines' recommendations, about 5% of respondents stated that TH may be indicated as a treatment for obesity in euthyroid patients resistant to life-style interventions. This opinion was associated with (i) respondent characteristics: being non-endocrinologist, working in private practice, treating a small number of hypothyroid patients annually and (ii) national characteristics: prevalence of obesity, Eastern Europe, low GNI and lack of national hypothyroidism guidelines.

Boosting the photocatalytic properties of NaTaO3 by coupling with AgBr.

AgBr/NaTaO3 composites, with different molar % of NaTaO3 (Br/NTO(X%)), have been synthesized by simple precipitation methods; bare NaTaO3 was synthesized by hydrothermal procedure, while AgBr was synthesized by a precipitation procedure using cetyl-tri-methyl-ammonium bromide (CTAB) and AgNO3. Samples have been characterized by X-ray diffraction (XRD), N2 adsorption, UV-vis diffuse reflectance spectroscopy (DRS), Fourier-transform infrared spectroscopy (FT-IR), Transmission electron microscopy (TEM) and X-ray photoelectron spectroscopy (XPS). Photocatalytic activity of the as-prepared photo-catalysts was evaluated through photocatalytic degradation of rhodamine B (RhB), methyl orange (MO) and caffeic acid (CAFA) under UV and visible illumination. Single AgBr material and Br/NTO(X%) composites displayed the ability to absorb light in the visible region, while NaTaO3 is only photoactive under UV irradiation. Based on the position of conduction and valence bands of AgBr and NaTaO3, the heterojunction between these two photo-catalysts corresponds to a type II junction. In the case of photocatalytic degradation of RhB and CAFA, Br/NTO(x%) composites have highest photocatalytic activity than that obtained by both parental materials under the same operational conditions. AgBr and Br/NTO(x%) composites achieve a fast degradation of MO, together with a considerable adsorption capacity, attributed to the presence of a remaining amount of residual CTAB on the AgBr surface. In summary, coupling AgBr with NaTaO3 improves the photocatalytic activity under both UV and visible illumination with respect to the parental components, but the performance of the composites is highly dependent on the type of substrate to be degraded and the illumination conditions.

Inspiratory muscle training as adjuvant therapy in obstructive sleep apnea: a randomized controlled trial.

The aim of this randomized controlled trial was to analyze the effects of an inspiratory muscle training (IMT) program on apnea and hypopnea index (AHI), inspiratory muscle strength, sleep quality, and daytime sleepiness in individuals with obstructive sleep apnea (OSA), whether or not they used continuous positive airway pressure (CPAP (+/-) therapy. The intervention group underwent IMT with a progressive resistive load of 40-70% of the maximum inspiratory pressure (PImax) for 30 breaths once a day for 12 weeks. The control group was submitted to a similar protocol, but with at a minimum load of 10 cmH2O. Changes in the AHI were the primary outcome. PImax was measured with a digital vacuometer, daytime somnolence was measured by the Epworth sleepiness scale (ESS), and the quality of sleep by the Pittsburgh Sleep Quality Index (PSQI). CPAP use was treated as a confounder and controlled by stratification resulting in 4 subgroups: IMT-/CPAP-, IMT-/CPAP+, IMT+/CPAP-, and IMT+/CPAP+. Sixty-five individuals were included in the final analysis. Significant variations were found in the 4 parameters measured throughout the study after the intervention in both CPAP- and CPAP+ participants: PImax was increased and AHI was reduced, whereas improvements were seen in both ESS and PSQI. The twelve-week IMT program increased inspiratory muscle strength, substantially reduced AHI, and had a positive impact on sleep quality and daytime sleepiness, whether or not participants were using CPAP. Our findings reinforce the role of an IMT program as an adjunct resource in OSA treatment.

Inspiratory muscle training as adjuvant therapy in obstructive sleep apnea: a randomized controlled trial

The aim of this randomized controlled trial was to analyze the effects of an inspiratory muscle training (IMT) program on apnea and hypopnea index (AHI), inspiratory muscle strength, sleep quality, and daytime sleepiness in individuals with obstructive sleep apnea (OSA), whether or not they used continuous positive airway pressure (CPAP (+/−) therapy. The intervention group underwent IMT with a progressive resistive load of 40-70% of the maximum inspiratory pressure (PImax) for 30 breaths once a day for 12 weeks. The control group was submitted to a similar protocol, but with at a minimum load of 10 cmH2O. Changes in the AHI were the primary outcome. PImax was measured with a digital vacuometer, daytime somnolence was measured by the Epworth sleepiness scale (ESS), and the quality of sleep by the Pittsburgh Sleep Quality Index (PSQI). CPAP use was treated as a confounder and controlled by stratification resulting in 4 subgroups: IMT−/CPAP−, IMT−/CPAP+, IMT+/CPAP−, and IMT+/CPAP+. Sixty-five individuals were included in the final analysis. Significant variations were found in the 4 parameters measured throughout the study after the intervention in both CPAP− and CPAP+ participants: PImax was increased and AHI was reduced, whereas improvements were seen in both ESS and PSQI. The twelve-week IMT program increased inspiratory muscle strength, substantially reduced AHI, and had a positive impact on sleep quality and daytime sleepiness, whether or not participants were using CPAP. Our findings reinforce the role of an IMT program as an adjunct resource in OSA treatment.

Polyaniline coated tungsten trioxide as an effective adsorbent for the removal of orange G dye from aqueous media.

In this work, the core-shell PANI@WO3 composite was obtained from the reaction of aniline monomer polymerization with WO3 particles; sodium persulfate was used as an oxidant. Various analytical techniques such as scanning electron microscopy (SEM-EDS), X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), Brunauer-Emmett-Teller (BET), and X-ray photoelectron spectroscopy (XPS) were used to characterize the as-prepared PANI@WO3 adsorbent, which well confirmed that the WO3 particles were coated by polyaniline polymer. The PANI@WO3 composite was tested as an adsorbent to remove reactive orange G (OG) for the first time. pH, adsorbent dose, contact time, initial dye concentration, and temperature were systematically investigated in order to study their effect on the adsorption process. The experimental findings showed that the PANI@WO3 composite has considerable potential to remove an aqueous OG dye. Langmuir and Freundlich's models were used to analyze the equilibrium isotherms of OG dye adsorption on the PANI@WO3 composite. As a result, the best correlation of the experimental data was provided by the Langmuir model, and the maximum capacity of adsorption was 226.50 mg g-1. From a thermodynamic point of view, the OG dye adsorption process occurred spontaneously and endothermically. Importantly, PANI@WO3 still exhibited an excellent adsorption capability after four regeneration cycles, indicating the potential reusability of the PANI@WO3 composite. These results indicate that the as prepared PANI@WO3 composite could be employed as an efficient adsorbent and was much better than the parent material adsorption of OG dye.

Facile synthesis and characterization of a novel 1,2,4,5-benzene tetracarboxylic acid doped polyaniline@zinc phosphate nanocomposite for highly efficient removal of hazardous hexavalent chromium ions from water.

The present study describes the preparation of a novel 1,2,4,5-benzene tetracarboxylic acid doped polyaniline@zinc phosphate (BTCA-PANI@ZnP) nanocomposite via a facile two-step procedure. Thereafter, the as-prepared composite material adsorption characteristics for Cr(VI) ions removal were evaluated under batch adsorption. Kinetic approach studies for Cr(VI) removal, clearly demonstrated that the results of the adsorption process followed the pseudo second order and Langmuir models. The thermodynamic study indicated a spontaneous and endothermic process. Furthermore, higher monolayer adsorption was determined to be 933.88 mg g-1. In addition, the capability study regarding Cr(VI) ions adsorption over BTCA-PANI@ZnP nanocomposite clearly revealed that our method is suitable for large scale application. X-ray photoelectron spectroscopy (XPS) analysis confirmed Cr(VI) adsorption on the BTCA-PANI@ZnP surface, followed by its subsequent reduction to Cr(III). Thus, the occurrence of external mass transfer, electrostatic attraction and reduction phenomenon were considered as main mechanistic pathways of Cr(VI) ions removal. The superior adsorption performance of the material, the multi-dimensional characteristics of the surface and the involvement of multiple removal mechanisms clearly demonstrated the potential applicability of the BTCA-PANI@ZnP material as an effective alternative for the removal of Cr(VI) ions from wastewater.

Risk assessment and avoidance in juvenile golden hamsters exposed to repeated stress.

Juvenile hamsters are typically less vulnerable to social subjugation than adults, although they will avoid aggressive individuals in some situations. The purpose of this study was to determine the extent to which social subjugation stimulates fear- or anxiety-like behavior in juvenile hamsters in both social and non-social contexts. Social context testing was conducted in a Y-maze while the non-social context apparatus consisted of an open field arena and a lat-maze. In the Y-maze, subjects were exposed to an unfamiliar aggressive adult hamster. Compared with non-subjugated controls, subjugated juveniles spent significantly more time in the area furthest from the aggressive adult stimulus. In addition, socially stressed animals were more likely to avoid the arm of the maze containing the social stimulus. When they did walk in the arm containing the social stimulus, subjugated individuals were more likely to ambulate slowly. Subjugated hamsters also performed fewer olfactory investigations in the proximity of the unfamiliar aggressive individual. Despite these behavioral differences detected between groups during testing in a social context, we observed no differences between groups in the open field and lat-maze. This suggests that the effects of subjugation observed in the Y-maze are specific to exposure to a social context and that social subjugation in juvenile hamsters does not result in a generalized state of fear. Instead, subjugated juveniles learned to avoid adult males and were otherwise behaviorally similar to non-subjugated controls.

Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement?

OBJECTIVES: Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution. METHODS: Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006). RESULTS: Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis. CONCLUSIONS: Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.

Unguarded mitral orifice associated with discordant atrioventricular connection, double-outlet right ventricle, and pulmonary atresia.

We report a case of unguarded mitral valve orifice in a newborn boy that was associated with mirror-image cardiac sidedness, ambiguous abdominal sidedness, discordant atrioventricular connection, double-outlet right ventricle, and pulmonary atresia.

Protective effect of early and late administration of pralidoxime against organophosphate muscle necrosis.

The objective of the present investigation was to study the protection afforded by a single administration of pralidoxime against the muscle necrosis induced by the organophosphate compound metamidophos at different times after intoxication. The fiber necrosis of the diaphragm muscle was quantified by a morphometric technique, comparing the area fraction occupied by necrotic muscle fibers in animals that received pralidoxime at different times after intoxication, i.e., 0, 1, 3, 6, and 12 h. Pralidoxime administration protected metamidophos-induced muscle necrosis in all groups studied except for the 12-h group. The earlier the administration of pralidoxime the greater the protection against muscle necrosis. This protection was not accompanied by complete reactivation of plasma cholinesterase activity. Results support the current opinion that pralidoxime should be administered as soon as possible after organophosphate intoxication, because in addition to reversing the muscarinic effects, early administration of pralidoxime also prevents muscle necrosis--which could impair muscular function and respiratory condition. The time difference between recovery of plasma cholinesterase activity and muscle necrosis protection indicates that this method is not completely trustworthy for patient follow-up, since some improvement may occur in spite of the low plasma cholinesterase activity.

The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients.

OBJECTIVES: We assessed the operative and late mortality and the present clinical status of 216 patients with tricuspid atresia who had a nonfenestrated Fontan procedure performed at the Mayo Clinic in the 25-year period 1973 to 1998. BACKGROUND: The Fontan operation eliminates the systemic hypoxemia and ventricular volume overload characteristic of prior forms of palliation. However, it originally did so at the cost of systemic venous and right atrial hypertension, and the long-term effects of this "price" were unknown when the procedure was initially proposed. METHODS: We reviewed the clinical records of the 216 patients retrospectively. These were arbitrarily grouped into early (1973 through 1980), middle (1981 through 1987) and late (1988 through 1997) surgical eras. Patient outcome was also analyzed according to age at surgery. Operative and late mortality rates were determined and present clinical status was ascertained in 167 of 171 surviving patients. RESULTS: Overall survival was 79%. Operative mortality steadily declined and was 2% (one of 58 patients) during the most recent decade. Late survival also continues to improve. Age at operation had no effect on operative mortality, and late mortality was significantly increased only in patients who were operated on at age 18 years or older. Eighty-nine percent of surviving patients are currently in New York Heart Association class I or II. CONCLUSIONS: The initial 25-year experience with the nonfenestrated Fontan procedure for tricuspid atresia has been gratifying, with most survivors now leading lives of good quality into adulthood. These results justify continued application of this procedure for children born with tricuspid atresia.

Thrombosis of intracardiac or extracardiac conduits after modified Fontan operation in patients with azygous continuation of the inferior vena cava.

BACKGROUND: The Fontan procedure in patients with azygous continuation of the inferior vena cava, requires a cavo-pulmonary anastomosis, and deviation of the hepatic venous drainage to the pulmonary arteries using an intra- or extracardiac conduit. METHODS: We report thrombosis of two pericardial conduits and one Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) graft used for deviation of hepatic venous blood to the pulmonary arterial tree in 3 patients aged 11, 24, and 28 years. Two of the conduits (pericardial) were intraatrial. The Gore-Tex graft was placed in an extracardiac position. The two pericardial conduits obstructed completely. RESULTS: One patient died at reoperation. In the 2nd patient, the conduit was excised and the hepatic veins were allowed to drain into the atrium. In the 3rd patient, partial thrombosis of the Gore-Tex conduit was noted 30 months after operation. The thrombus resolved with oral anticoagulation. CONCLUSIONS: Conduits carrying only hepatic venous blood flow may have a higher risk of thrombosis. Anticoagulation or alternative methods of directing hepatic blood flow to the pulmonary circulation must be considered in these patients.

Early and late results of operations for defects associated with corrected transposition and other anomalies with atrioventricular discordance in a pediatric population.

OBJECTIVES: The purpose of this study was to determine the early and late results for children having operations for defects associated with corrected transposition of the great arteries and other anomalies with atrioventricular discordance. METHODS: Data on 111 children operated on from July 1, 1971, through January 31, 1996, including clinic records, operative reports, and follow-up visits and questionnaires, were analyzed with particular reference to variables associated with early and late mortality, reoperations, ventricular function, and status of the atrioventricular valves. RESULTS: Complex associated anomalies were common and included double-outlet right ventricle (n = 43) and situs abnormalities (n = 38). Overall early mortality was 16%; for the 29 patients operated on after 1986, early mortality was 3%. Early survival was adversely affected by patch repair of ventricular septal defect and early operative interval. Follow-up of the 93 early survivors extended to 26.5 years (mean 11.4 years). Overall survival was 77% (+/-4%) at 5 years and 67% (+/-5%) at 10 years. Late survival was adversely affected by prior operations, more severe preoperative functional class, and cardiac rhythm other than sinus. Reoperation was required for 38 (41%) patients, most commonly for conduit replacement (n = 22) or repair/replacement of the systemic ventricle atrioventricular valve (n = 13). CONCLUSIONS: These results can serve as a basis for comparison with newer surgical alternatives proposed for corrected transposition of the great arteries.

Late results of the Rastelli operation for transposition of the great arteries.

The Rastelli operation, first performed in 1968, was developed for repair of transposition of the great arteries with associated ventricular septal defect and severe pulmonary stenosis. This operation includes placement of an intracardiac baffle to direct left ventricular blood to the aorta and an extracardiac valved conduit to establish continuity between the right ventricle and the pulmonary arteries. Over the last 3 decades, the Rastelli operation has been performed with a progressive decline in early mortality, and it remains the preferred repair for transposition, ventricular septal defect, and severe fixed valvular or subvalvular pulmonary stenosis. This chapter examines the late results of our 33-year experience with the Rastelli operation and describes our operative technique.

Valvular heart operation in patients with previous mediastinal radiation therapy.

BACKGROUND: The outcome of valvular heart operations in patients with previous mediastinal radiation therapy was studied. METHODS: This is a single center retrospective study of 60 patients (37 females, 23 males) with a mean age of 62 +/- 15 years (28 to 88 years old) operated on from January 1976 to December 1998. Valvular heart operations performed included aortic valve replacements (n = 26), mitral valve procedures (n = 16), tricuspid valve procedures (n = 6), and multiple valve procedures (n = 12). A total of 264 clinical, hemodynamic, electrocardiographic and echocardiographic variables were analyzed. RESULTS: Total follow-up was 199 patient-years with a mean of 3.3 +/- 3.1 years and a range of 0 to 12.4 years old. Early mortality was 7 patients (12%). Early mortality in patients with constrictive pericarditis was 40% (4 of 10) compared with 6% (3 of 50) in patients without constrictive pericarditis. By univariate analysis, early mortality was associated with constrictive pericarditis (p = 0.011), reduced preoperative ejection fraction (p = 0.015), and longer cardiopulmonary bypass times (p = 0.037). A total of 14 patients (23%) required permanent pacemaker placement before (n = 7), during (n = 1), or early (n = 6) after valvular heart operations. There were 19 late deaths (malignancies, 7; heart failures, 5; other cardiac, 4; and other noncardiac, 3). Overall survival and freedom from late cardiac death and cardiac reoperation at 5 years for hospital survivors were 66% +/- 8%, 82% +/- 7%, and 93% +/- 4%, respectively. By univariate analysis, late cardiac death was associated with low ejection fraction (p = 0.002), New York Heart Association (NYHA) functional class IV (p = 0.004), preoperative congestive heart failure (p = 0.02), and preoperative atrial fibrillation (p = 0.038). Eighty-five percent of the discharged patients were in NYHA functional class I or II at follow-up. CONCLUSIONS: Early results of valve replacement after mediastinal radiation therapy were good except in the presence of constrictive pericarditis. Long-term outcome was limited by malignancy and heart failure. Early surgical intervention is recommended before the development of risk factors for late death, namely, severe symptoms, left ventricular dysfunction, and atrial fibrillation.

Late pulmonary valve replacement after repair of tetralogy of Fallot.

BACKGROUND: Pulmonary regurgitation appears to be well tolerated early after repair of tetralogy of Fallot; however, it may result in progressive right ventricular dilatation and dysfunction necessitating eventual valve replacement. Our objective was to review our experience with late pulmonary valve replacement after complete repair of tetralogy of Fallot. METHODS AND RESULTS: A total of 42 patients (16 female and 26 male) were operated on between July 1, 1974, and January 1, 1998. Mean age was 22 years (range 2-65 years). The mean interval between tetralogy repair and pulmonary valve replacement was 10.8 years (range 1.6 months-33 years). Mean follow-up was 7.8 +/- 6.0 years (maximum 23 years). Indications for pulmonary valve replacement included decreased exercise tolerance in 58%, right heart failure in 21%, arrhythmia in 14%, syncope in 10%, and progressive isolated right ventricular dilatation in 7%. Heterograft prostheses were used in 33 patients and homografts in 9. Five patients underwent isolated pulmonary valve replacement; concomitant procedures performed in 37 patients included tricuspid valve repair/replacement (n = 18), residual ventricular septal defect repair (n = 12), atrial septal defect closure (n = 4), pulmonary artery patch angioplasty (n = 17), and right ventricular outflow tract enlargement (n = 13). One patient died early (2%) of multiorgan failure. There were 6 late deaths, 3 of which were cardiac related. Survival was 95.1% +/- 3.4% and 76.4% +/- 8.9% at 5 and 10 years, respectively. Functional class of patients was improved significantly; preoperatively, 76% of patients were in New York Heart Association class III-IV, and after pulmonary valve replacement, 97% of surviving patients were in class I-II (P =.0001). Moderate to severe reduction in right ventricular function was noted on preoperative echocardiography in 59% and on late echocardiography in 18% (P =.03). Of the 5 patients who had supraventricular arrhythmias before pulmonary valve replacement, 1 had postoperative recurrence and the arrhythmia is controlled with antiarrhythmic therapy; the other 4 are in normal sinus rhythm at late follow-up. Eight patients subsequently underwent pulmonary valve re-replacement without early mortality at a mean interval of 9.0 +/- 4.2 years (range 3.8-16.8 years). Freedom from pulmonary valve re-replacement was 93.1% +/- 4.7% and 69.8% +/- 10.7% at 5 and 10 years, respectively. The only significant risk factor for re-replacement was young age at the time of the initial pulmonary valve replacement (P =.023). CONCLUSION: Late pulmonary valve replacement after tetralogy repair significantly improves right ventricular function, functional class, and atrial arrhythmias, and it can be performed with low mortality. Subsequent re-replacement may be necessary to maintain functional improvement.

Surgical treatment of persistent esophageal compression by an unusual form of right aortic arch.

A 32-year-old woman with dysphagia due to an unusual form of right aortic arch and anomalous left subclavian artery had successful repair after two previous failures. The definitive repair was accomplished by resection of the retroesophageal portion of the right aortic arch. The continuity of the aorta was established with a prosthetic graft. The operation was performed through a median sternotomy with cardiopulmonary bypass and circulatory arrest.

Surgical treatment of valvular heart disease in patients with acromegaly.

BACKGROUND AND AIM OF THE STUDY: Acromegaly is associated with heart disease in one-third of patients, and diastolic dysfunction may precede global systolic dysfunction. Patients with acromegalic heart disease may have valvular disease, but the role of surgery in such patients has not been established. The purpose of this study was to document the outcome of surgery in a series of these patients from one institution. METHODS: Among 951 patients with the diagnosis of acromegaly seen at our institution since 1972, 10 (eight men, two women) have undergone operation for valvular heart disease. Average patient age was 62.2 +/- 11.5 years; average body weight was 84 +/- 13 kg; average height was 178 +/- 12 cm. The mean duration of acromegaly was 15.2 +/- 12.7 years. At the time of heart surgery, seven patients had active disease, defined by elevation of growth hormone levels, while three had inactive disease. Treatment of pituitary adenomas before valvular surgery included surgical resection in three patients and external-beam radiation treatment in four. The preoperative ejection fraction was 42 +/- 19% (range: 20% to 66%). Valve lesions included aortic stenosis in four patients, aortic regurgitation in four, and mitral regurgitation in three (one patient had double valve disease). RESULTS: Valve replacement was performed in all patients with aortic disease (two bioprostheses, six mechanical), and three patients with mitral regurgitation had repair. Concomitant procedures performed in seven patients included coronary bypass (two), left ventricular aneurysmectomy (two), and ligation of the left atrial appendage, septal myectomy and defibrillator insertion (one each). Early complications included endocarditis, low cardiac output and arrhythmia in one patient each. There were no perioperative deaths. One patient underwent reoperation ten years later for a perivalvular leak. CONCLUSION: Valvular surgery can be performed safely in acromegalic patients, even those with active endocrinopathy.