Surface characteristics of Ti6Al4V alloy: effect of materials, passivation and autoclaving

The properties of passivated films for Ti6Al4V alloy prepared by various methods (as-polished, brazed at 970 degrees C for 2 h and brazed at 970 degrees C for 8 h) were investigated. Four passivations (non-treated, nitric acid passivation, 400 degrees C-treated in air, and aged in boiling water), with or without autoclaving treatments, were adopted for evaluating the changes of surface properties, including chemical composition, chemical structure, and oxide thickness. From X-ray photoelectron spectroscopic (XPS) analyses, surface elements of copper and nickel in brazed samples were undetected for non-treated, acid-passivated and boiling water-aged specimens, while they were found in the 400 degrees C-treated specimen. The relative contents of Ti2++Ti3+ to Ti4+ were determined by passivation treatments, but were not related to the experimental materials and autoclaving treatment. Passivation and autoclaving decreased the Ti to Ti4+ ratio by virtue of an increase in oxide thickness. Of the four types of passivation treatment, the 400 degrees C thermal treatment exhibited the lowest content of suboxides and metallic elements and the thickest oxide by XPS analysis; however, this treatment may cause a desorption of the basic OH group in the hydration layer on the surface of titanium alloy.

A comparison of the corrosion behaviour and surface characteristics of vacuum-brazed and heat-treated Ti6Al4V alloy

The corrosion characteristics of the brazed Ti6Al4V specimens were analysed and compared with respect to the conventionally heat-treated specimens by an electrochemical corrosion test. The object of this research was to explore the potentiality of the brazed titanium for biomaterials. The characteristics of the 1300 degrees C heat-treated and the 970 degrees C brazed specimens, with passivation and sterilization treatment, were evaluated by measurement of corrosion potential, Ecorr, corrosion current densities, Icorr, polarization resistance of the reacted surface films, Rp, in a potentiodynamic test. The experimental results show that the corrosion rates of the heat-treated and the brazed samples are similar at Ecorr, and the value of Ecorr for the brazed sample is noble to the heat-treated samples. The passive current density of the brazed specimen is either lower or higher than the heat-treated specimen, depending on the polarization potential. By Auger electron spectroscopic and high-resolution X-ray photoelectron spectroscopic analysis on specimens from the potentiostatic test, the elements of copper and nickel in the brazing filler were not detected while less alumina was found in the reacted film of the brazed specimens when compared with the heat-treated specimens. The implication of the results is discussed.

Removal of the olfactory bulbs delays photic reentrainment of circadian activity rhythms and modifies the reproductive axis in male Octodon degus

The diurnal rodent, Octodon degus, exhibits robust sex differences in several circadian measures, including circadian period (tau) and reentrainment rates to photic and nonphotic (social) zeitgebers. The neural substrates underlying such physiological differences remain unknown. In female degus, olfactory bulbectomies (BX) inhibit socially-facilitated reentrainment, but do not alter photic reentrainment, entrained measures, or tau in constant darkness (DD). This experiment investigated the effects of BX in male degus on (i) photic reentrainment rates of circadian rhythms following a 6-h phase advance of the light-dark (LD) cycle; (ii) photic entrainment; (iii) tau of free-running activity rhythms in DD; and (iv) body weight, paired testis weight, and the reproductive hormones, testosterone, androstenedione and follicle stimulating hormone (FSH). BX significantly delayed photic reentrainment rates. They did not, however, modify tau, the phase of activity onset or offset, amplitude or duration (alpha) of the activity rhythm, mean daily locomotor activity levels, or body weight. FSH, testosterone and androstenedione were unaffected by BX, whereas paired testis weights were significantly greater in BX degus compared with shams. Thus, the olfactory bulbs influence photic reentrainment of circadian rhythms and modestly affect the reproductive axis in male degus. Our results suggest that the olfactory bulbs may be a neural source of observed sex differences in photic reentrainment in degus, and highlight interspecies variation in the olfactory bulbs' effects on entrained and free-running circadian rhythms and on reproduction.

Role of transesophageal echocardiography in the evaluation of patients with clinical pacemaker syndrome

OBJECTIVES

The goal of this study was to investigate the possible role of transesophageal echocardiography in the evaluation of patients with clinical pacemaker syndrome.

BACKGROUND

Several reports on transthoracic echocardiographic features of ventricular pacing were described; however, no previous study of transesophageal echocardiography has been undertaken in patients at the severe end of pacemaker syndrome who need reprogramming of dual-chamber pacing for symptom relief.

METHODS

Twelve patients with ventricular-inhibited pacemakers (VVI) with clinical symptomatic pacemaker syndrome (group I) and 10 patients with VVI without pacemaker syndrome (group II) were prospectively studied. The two groups were pacemaker dependent and had persistent ventriculoatrial conduction. Transesophageal echocardiographic parameters were assessed in group II and within 6 hours before reprogramming to the DDD mode in group I. Follow-up transesophageal echocardiographic study was performed 28+/-5 days after reprogramming in group I.

RESULTS

All patients in group I had subjective improvements of symptoms after DDD reprogramming. The atrial reverse flow velocities of pulmonary veins in group I before reprogramming were significantly higher in group II (39.3+/-11.4 versus 15.7+/-13.5 cm/sec, p < 0.0001). Spontaneous echo contrast in the descending aorta was detected in all patients from group I before reprogramming. The prevalence of significant mitral regurgitation (> or = moderate) was significantly higher in group I before reprogramming than in group II (67% versus 8%, p = 0.01). Significant mitral regurgitation and spontaneous echo contrast in the descending aorta in group I disappeared after reprogramming to the DDD mode.

CONCLUSIONS

Transesophageal echocardiography provides physiologic, pacemaker-related hemodynamic changes in paced patients. Significantly higher atrial reverse flow velocities of pulmonary veins, increased frequency of spontaneous echo contrast in the descending aorta, and significant mitral regurgitation are peculiar echocardiographic findings in patients with VVI with clinical pacemaker syndrome.

Estradiol phase shifts circannual body mass rhythms of male ground squirrels

Gonadectomized male golden-mantled ground squirrels (Spermophilus lateralis) were implanted with estradiol benzoate (EB)-filled or empty capsules. Body mass was monitored before, during, and for at least 1 yr after hormone treatment. EB treatment during the mass-gain phase of the annual cycle significantly decelerated increases in body mass; the period of the circannual rhythm (CAR) of body mass was 54 days longer in EB- than blank-treated squirrels. Hormone treatment during the mass-loss phase accelerated mass loss; although this effect only approached statistical significance, some phase markers of the CAR were significantly advanced in subsequent cycles. We conclude that, as in females, estradiol affects the waveform of the CAR of males differently at different phases of the circannual cycle. Sexual differentiation does not eliminate responsiveness of CARs of squirrels to estradiol; sex differences, if any, are subtle rather than absolute and, in this respect, differ from circadian rhythms.

In vitro and in vivo mechanical evaluations of plasma-sprayed hydroxyapatite coatings on titanium implants: the effect of coating characteristics

This study was undertaken to evaluate the effect of coating characteristics on the mechanical strengths of the plasma-sprayed HA-coated Ti-6Al-4V implant system both in vitro and in vivo. Two types of HA coatings (HACs) with quite different microstructures, concentrations of impurity-phases, and indices-of-crystallinity were used. In vitro testings were done by measuring the bonding-strength at the Ti-6Al-4V-HAC interface, with HACs that had and had not been immersed in a pH-buffered, serum-added simulated body fluid (SBF). The shear-strength at the HAC-bone interface was investigated in a canine transcortical femoral model after 12 and 24 weeks of implantation. The results showed a bonding degradation of approximately 32% or higher of the original strength after 4 weeks of immersion in SBF, and this predominantly depended on the constructed microstructure of the HACs. After the push-out measurements, it was demonstrated that the HACs with higher bonding-strength in vitro would correspondingly result in significantly higher shear-strength at each implant period in vivo. Nevertheless, there were no substantial histological variations between the two types of HACs evaluated. The most important point elucidated in this study was that, among coating characteristics, the microstructure was the key factor in influencing the mechanical stability of the HACs both in vitro and in vivo. As a consequence, a denser HAC was needed to ensure mechanical stability at both interfaces.

Relation of systemic arterial pulse pressure to coronary atherosclerosis in patients with mitral stenosis

The relation of a wide systemic arterial pulse pressure to coronary atherosclerosis has not been fully defined. One hundred fifty-nine patients > 40 years old with symptomatic mitral stenosis (MS) who received routine coronary angiography were classified into 2 groups according to the presence of > or = 50% diameter narrowing of > or = 1 coronary artery (n = 48) or no significant disease (n = 111). Pulse pressure was determined both by noninvasive sphygmomanometer and invasive catheterization methods. There were no significant differences in risk factors of coronary artery disease (CAD) or the severity of MS between the 2 groups. From multivariate logistic regression analysis, independent predictors of development of CAD in MS were age (standardized coefficient beta = 1.3437, p = 0.0025), gender (beta = 0.0107, p = 0.0105), mean blood pressure (beta = 1.1839, p = 0.0105), and pulse pressure (beta = 1.3157, p = 0.0008). A wide pulse pressure (> or = 60 mm Hg) correlated with the presence of angiographically significant CAD with a sensitivity and specificity of 88% and 77%. The negative predictive value was 93%. Pulse pressure assessed by sphygmomanometry provided important clinical information. A wide pulse pressure in patients with MS was associated with a high incidence of CAD.

The induction of Fos-like proteins in the suprachiasmatic nuclei and intergeniculate leaflet by light pulses in degus (Octodon degus) and rats

In nocturnal rodents, exposure to light results in an increase in Fos expression in two regions that receive direct retinal input: the suprachiasmatic nuclei (SCN) of the hypothalamus and the intergeniculate leaflet (IGL) of the thalamus. The induction of Fos within the SCN of nocturnal rodents is phase dependent, with light presented during the subjective night increasing Fos expression and light presented during the subjective day having little effect. By contrast, Fos expression increases in the IGL when light is presented during the subjective day or night. It is unclear whether Fos is part of the pathway mediating light-induced phase shifts in diurnal rodents. In the present study, the ability of light to induce immunostaining for Fos in the SCN and IGL was compared in diurnal rodents, Octodon degus (degus), and nocturnal rats. Degus and rats were either maintained in constant darkness or exposed to a 1-h light pulse at circadian time (CT) 4 or 16. Degus exhibit robust phase shifts at each of those circadian hours, whereas rats demonstrate phase shifts only at CT 16. In degus, exposure to a 1-h light pulse at CT 16 resulted in an increase in the number of Fos-immunopositive (Fos+) cells in the ventrolateral SCN. By contrast, a 1-h light pulse at CT 4 resulted in a decrease in the number of Fos+ cells in the dorsomedial portion of the SCN. In rats, a light pulse presented at CT 16 resulted in an increase in Fos+ cells throughout the SCN, and a pulse at CT 4 had no effect on Fos staining. Both degus and rats showed increases in Fos expression in the IGL after light exposure at CTs 4 and 16. The authors conclude that light pulses presented at times that produce phase shifts in activity rhythms also alter Fos expression in the SCN and IGL of degus. Although these effects of light exposure on Fos expression are not identical in diurnal and nocturnal rodents, it is likely that Fos and other immediate early genes are part of the pathway mediating the effects of light in both diurnal and nocturnal rodents.

Pathophysiological mechanism of seasonal affective disorder

Despite the long history in medicine, the pathophysiological mechanism(s) of seasonal affective disorder (SAD) remain largely unknown. By employing a meta-analytic methodology, the authors of this study attempted to verify the validity of different pathophysiological mechanism(s) proposed for SAD. The findings showed that for phototherapy of medium light intensity, a combination of morning-evening therapy regime yielded the best therapeutic effect, and the antidepressant effect of the morning-evening light regime was superior to a single pulse of light administered at other times of day. Furthermore, the data showed that the antidepressant effect of a single pulse of light was similar for morning, midday, and evening light. These findings supported the photon-count hypothesis and refuted the proposed photoperiod, melatonin, and phase-shifting models of SAD.

Rhythm chronotypes in a diurnal rodent, Octodon degus

Interindividual variations in entrained human circadian rhythms and their relationship to differences in ease of adjustment to phase shifts have been well described. Humans classified as morning type (MT) display phase-advanced temperature minimum, onset of daily activity, and onset of sleep, whereas evening type (ET) individuals demonstrate the opposite pattern with a later phase angle of entrainment for these measures. We examined 15 variables of circadian activity and temperature for diurnal Octodon degus (n = 49; 28 male, 21 female), and noted similar chronotype variations as described for humans. Individuals with extreme MT and ET chronotypes were identified as those who differed from the entire population mean by one or more standard deviations. Compared with MTs (n = 5) and intermediate chronotypes (ITs, n = 34), ETs (n = 10) displayed a significant delay in the phase of temperature minimum, rise in temperature above the daily mean, and decline in activity and temperature below the daily mean, and had longer elevated activity and temperature durations and higher levels of mean daily activity and activity amplitude. MTs also displayed a significant phase advance in the morning temperature rise compared with ITs and ETs. This is the first description of variation in entrained circadian rhythms similar to that described for humans in both an outbred animal population and a diurnal rodent.

Left atrial spontaneous echo contrast in patients with permanent pacemakers

OBJECTIVE

To determine the relations between left atrial appendage function, spontaneous echo contrast, and thromboembolism in patients with different modes of permanent pacemakers.

PATIENTS AND METHODS

88 patients with pacemaker implantation and 25 healthy controls in sinus rhythm had transoesophageal echocardiographic examination of the left atrial appendage. Left atrial size, appendage area, peak filling and emptying velocities of the atrial appendage, and the presence or absence of spontaneous echo contrast and thromboembolism were determined. The results in 63 patients with ventricular pacing (group 1, subdivided into subgroup 1A: 42 patients with sinus rhythm, and subgroup 1B: 21 patients with atrial fibrillation) were compared with those in 25 patients with synchronous pacing (group 2), and 25 normal control subjects (group 3).

RESULTS

Patients with ventricular pacing had two distinct appendage flow patterns: well defined biphasic filling and emptying waves in subgroup 1A, and irregular very low filling and emptying waves in subgroup 1B. The ejection fraction of the left atrial appendage in subgroup 1A was significantly better than that in subgroup 1B (mean (SD) 40.6 (12.0)% v 7.6 (5.0)%, P < 0.0001). The spontaneous echo contrast was observed in 90% of subgroup 1B patients but in only 19% in subgroup 1A (P < 0.05) and was not found in groups 2 and 3 (P < 0.0001). There was a trend for increased prevalence of spontaneous echo contrast in subgroup 1A v group 2 (P = 0.053). Thrombi were detected in two cases, and cardiogenic embolism occurred in one case in subgroup 1B. All patients with spontaneous echo contrast had ventricular pacing. Multivariate analysis showed that atrial fibrillation was associated with occurrence of spontaneous echo contrast in patients with ventricular pacing (P = 0.005).

CONCLUSIONS

The left atrial appendage ejection fraction was lower with ventricular pacing than with synchronous pacing. With ventricular pacing there was a trend towards increased prevalence of left atrial spontaneous echo contrast in patients in sinus rhythm, and a significantly increased prevalence in patients with atrial fibrillation.

Spectral properties of phototherapy for seasonal affective disorder: a meta-analysis

The general therapeutic effect of light on seasonal affective disorder (SAD) has been widely acknowledged. However, the antidepressant effect of light does not seem to be the same for different spectra of light. In this study, the authors attempted to study the spectral properties of phototherapy for SAD using a meta-analytical procedure. The findings suggested that light of short to medium wavelengths (blue/green/yellow) seem to be essential for the therapeutic effect of light on SAD. Red wavelengths were relatively ineffective. It was then postulated that SAD may be predisposed and/or precipitated by the inefficiency of the S and M cones in the retina. Furthermore, ultraviolet (UV) waves did not seem to be essential for SAD symptom alleviation by artificial light. Therefore, these potentially harmful UV waves should be blocked in any clinical application of phototherapy for SAD.

Olfactory bulbectomy impedes social but not photic reentrainment of circadian rhythms in female Octodon degus

Recent studies demonstrated that nonphotic (social) cues markedly accelerate reentrainment to large phase shifts of the light-dark (LD) cycles in female Octodon degus and that such changes are likely effected by chemosensory stimuli. This experiment investigated the effects of olfactory bulbectomies on (1) socially facilitated reentrainment rates of circadian rhythms following a 6-h phase advance of the LD cycle, (2) photic reentrainment rates of circadian rhythms following a 6-h advance of the LD cycle, (3) photic entrainment, and (4) the circadian period (tau) of activity rhythms in constant darkness (DD). olfactory bulbectomies (BX) blocked socially facilitated reentrainment rates but did not alter reentrainment rates of circadian rhythms to photic cues alone. In addition, BX lowered mean daily locomotor activity levels and decreased the amplitude of the activity rhythm in degus housed in entrained (LD 12:12) conditions but did not alter the phase of activity onset or offset, duration (alpha) of activity, or mean daily core body temperature. Bulbectomies also failed to modify tau of free-running activity rhythms. This experiment confirms that the olfactory bulbs and chemosensory cues are necessary for socially facilitated reentrainment. In contrast to their effects in nocturnal rodents, BX do not produce significant circadian photic changes in diurnal degus. This is the first experiment to determine that chemosensory stimuli modulate the circadian system in a diurnal rodent.

Individual variation in reentrainment after phase shifts of light-dark cycle in a diurnal rodent Octodon degus

The rate and pattern of activity and temperature reentrainment was determined after 3-, 6-, and 9-h phase advances and phase delays in two groups of Octodon degus for whom phase response curves (PRCs) to light and dark pulses and free-running periods (tau) in constant darkness and constant light had previously been determined [T.M. Lee and S. E. Labyak. Am. J. Physiol. 273 (Regulatory Integrative Comp. Physiol. 42): R278-R286, 1997.]. We predicted that individuals with light-pulse PRCs containing both significant phase delay and phase advance regions would phase delay more rapidly than individuals lacking significant phase delays after light pulses. We also expected that animals without a phase delay region in the light-pulse PRC would demonstrate more temporary circadian abnormalities during the period of reentrainment (periods of masking, bimodal patterns of activity, and abnormal phase relationships between activity and temperature). Degus with light-pulse PRCs containing both a significant phase-delay and -advance region reentrained significantly faster and with fewer disrupted patterns of entrainment after 6- and 9-h phase delays than degus without phase-delay regions in the PRC. The rate of reentrainment after phase advances did not differ between animals with the two types of PRC except for temperature after a 6-h phase shift. Because animals with and without phase-delay regions in the light-pulse PRC had equivalent tau s, the interindividual variation in reentrainment is best explained by the fundamental differences in the light-pulse PRCs. The variation of rate and pattern of reentrainment for both groups of animals were reasonably predicted or explained by knowledge of the light-pulse and dark-pulse PRCs.

Social cues modulate free-running circadian activity rhythms in the diurnal rodent, Octodon degus

Two experiments assessed the effects of social cues and daily disturbance on the circadian locomotor activity rhythms of Octodon degus housed in constant darkness. In experiment 1, females in free-running conditions were housed alone or with entrained female partners ("donors") in cages on either side of a mesh barrier. Donors were removed daily and entrained to 1 h of light, and as a control, the cages of singly housed animals were rustled daily coincident with donor removal and replacement. None of the animals housed alone entrained to daily disturbances presented during the active phase, and seven of eight degus failed to show changes in the circadian period (tau) or phase of their rhythms. In contrast, although the presence of entrained donors did not elicit full entrainment of free-running rhythms, five of six animals demonstrated partial entrainment for 5-12 days (of 30 days), four of six altered phase of activity onset, and six of six lengthened tau of circadian rhythms. In experiment 2, females whose free-running circadian activity rhythms were at least 10 h out of phase were housed together in pairs. None of the pairs demonstrated mutual synchronization of their activity rhythms, although 8 of 12 degus modified phase of activity onset and 9 of 12 animals altered tau. We conclude social information in the absence of light, is sufficient for partial entrainment and for changes in tau and phase of free-running rhythms in this diurnal rodent.

Intramedullary implant of plasma-sprayed hydroxyapatite coating: an interface study

An intramedullary implant model in the canine femora was developed to evaluate the mechanical and histological responses between cancellous bone and plasma-sprayed hydroxyapatite coatings (HACs) on ti-6A1-4V implants, with 12- and 24-week follow-ups. HACs of different thicknesses were investigated. Results of the mechanical testings revealed that after 24 weeks of implantation, the mean shear strength (2.49 +/- 0.12 MPa) of the 50 microns HACs was significantly higher (p < 0.05) than that of the 200 microns HACs (1.44 +/- 0.19 MPa). However, using backscattered electron images (BEIs) throughout all the implant periods, no substantial histological variations in the extent of new bone apposition between the two HACs were observed. Occasionally, solution-mediated disintegration of the 50 microns HAC was found 24 weeks postimplantation. Histomorphometric studies from the BEIs demonstrated that for both HACs the percentage of the direct HAC-cancellous bone contact was approximately 50% at 12 weeks and 75% at 24 weeks. After the mechanical tests, the 200 microns HACs had fracture sites either inside the coating layers or at the HAC-titanium interfaces, which might explain why the mechanical performance of the 200 microns HACs was inferior to that of the 50 microns HACs even though both HACs had the same histological behaviors.

Free-running rhythms and light- and dark-pulse phase response curves for diurnal Octodon degus (Rodentia)

Only rarely have precise, short-duration light pulses been used to generate phase response curves (PRCs) in diurnal mammals as done for nocturnal mammals, and a dark-pulse PRC has never been generated for a diurnal mammal. In addition, the relationship between free-running rhythms in different light intensities and PRCs has not been explored in diurnal mammals. We examined these relationships in Octodon degus, a diurnal hystricomorph rodent. Male degus lengthened the circadian period (tau) and duration of daily activity (alpha) after an increase in light intensity from 0 (DD) to 250 lx, and tau was furthered lengthened when light intensity increased from 580 to 5,800 lx. To generate a light-pulse PRC, degus were housed in DD and exposed to 20-min light pulses (250 lx) and phase shifts recorded across the circadian day. Two different PRCs were generated in response to 20-min light pulses. The majority of animals produced significant phase delays between circadian time (CT) 0 and CT 6, phase advances between CT 13 and CT 22, and a nonsignificant response period between CT 8 and CT 13. Two animals produced a PRC devoid of significant phase delays, producing only significant phase advances between CT 17 and CT 24. To generate a dark-pulse PRC, animals were moved to LL (580 lx) and exposed to 1-h dark pulses. After dark pulses degus produced significant phase delays between CT 20 and CT 8, advances from CT 10 to CT 17, and nonsignificant responses between CT 18 and CT 20. This is the first report of a PRC to dark-pulse stimuli for a diurnal mammal. Thus light- and dark-pulse PRCs can be generated in a comparable way to those of nocturnal rodents, and we conclude that nocturnal and diurnal rodents use similar photic signals to produce somewhat different PRCs.

Effects of dobutamine on aortic valve indexes in asymptomatic patients with bileaflet mechanical prostheses in the aortic valve position

We investigated the effects of alternating transvalvular flow rate on Doppler-derived aortic valve resistance and valve area in asymptomatic patients with mechanical aortic valve replacement under dobutamine infusion. The Gorlin-derived aortic valve area and continuity equation-derived aortic valve area seem to be less flow dependent; valve resistance tends to be flow dependent.

Exaggerated luminal loss a few minutes after successful percutaneous transluminal coronary angioplasty in patients with recent myocardial infarction compared with stable angina: an intracoronary ultrasound study

This study investigates the mechanisms of exaggerated acute luminal loss after successful coronary angioplasty in patients with recent myocardial infarction compared with stable angina by angiography and intracoronary ultrasound (ICUS). We studied 15 consecutive patients (group 1) who, after a successful thrombolysis for myocardial infarction, underwent delayed (8 +/- 2 days after the myocardial infarction) successful balloon coronary angioplasty. Group 1 patients were individually matched with 15 stable angina patients (group 2). The percentage of stenosis and acute luminal loss were measured by quantitative coronary analysis. The ultrasound characteristics of lumen pathology were described as soft, hard, calcified, eccentric, concentric, thrombotic, and dissection lesions. Matching by stenosis location, reference diameter, sex, and age resulted in 2 comparable groups of 15 lesions with identical baseline characteristics. Immediately after percutaneous transluminal coronary angioplasty (PTCA), the minimal luminal diameter increased from 0.5 +/- 0.3 mm to 2.4 +/- 0.3 mm and from 0.5 +/- 0.2 mm to 2.4 +/- 0.3 mm in groups 1 and 2, respectively. Similar balloon sizes were used in both groups. The acute luminal loss (the difference between the maximal dilated balloon diameter and the minimal luminal diameter) immediately after PTCA was 0.4 +/- 0.2 mm and 0.3 +/- 0.3 mm (14 +/- 8% and 10 +/- 11% of balloon size) (P = not significant [NS]) in groups 1 and 2, respectively. After ICUS (mean 24 min after the last balloon deflation), the acute luminal loss was 0.9 +/- 0.3 mm and 0.5 +/- 0.4 mm (29 +/- 11% and 17 +/- 8% of balloon size) (P = 0.01) in groups 1 and 2, respectively. There was a significantly higher prevalence of intracoronary thrombus formation as detected by ICUS in group 1 compared with group 2 (80% vs. 20%; P < 0.001). In matched groups of successfully treated coronary angioplasty, patients with recent myocardial infarction had a similar magnitude of acute gained luminal loss immediately after the procedure. However, an exaggerated luminal loss a few minutes after the last balloon deflation in patients with recent myocardial infarction was noted because of mural thrombus formation compared with patients with stable angina.

Percutaneous transvenous mitral balloon valvuloplasty alone in patients with combined aortic and mitral stenosis

To investigate the feasibility of percutaneous transvenous balloon dilatation of the mitral valve in patients with combined aortic and mitral stenosis, 12 patients were studied by echocardiography and catheterization before and after mitral valvuloplasty. Aortic stenosis was defined from prevalvuloplasty catheterization study as a transaortic pressure gradient of more than 25 mm Hg. All 12 patients underwent transvenous balloon mitral valvuloplasty successfully. Immediately after the procedure, all patients experienced improvement in clinical symptoms and in hemodynamic variables. Mitral valve areas were significantly increased from 0.78 +/- 0.18 to 1.73 +/- 0.21 cm2 (P < 0.0001) by planimetry method. Cardiac output was significantly increased from 3.6 +/- 0.1 to 4.2 +/- 0.5 L/min (P = 0.01). Mean transaortic flow rate increased 33% (from 198 +/- 68 to 254 +/- 41 mL/s, P = 0.002). Mean pressure gradient across the aortic valve after mitral valvuloplasty was not significantly increased, from 34 +/- 7 to 37 +/- 13 mm Hg. Aortic valve areas, derived from the Gorlin formula, were significantly increased from 0.57 +/- 0.12 to 0.73 +/- 0.14 cm2 (P = 0.006) after mitral valvuloplasty. However, continuity equation-derived aortic valve area was independent of increasing flow rate after mitral valvuloplasty from 1.29 +/- 0.35 to 1.30 +/- 0.29 cm2. During follow-up with a mean of twenty four +/- fourteen months, 8 patients were in New York Heart association functional class I, 3 in class II, and 1 in class IV who received pericardiotomy owing to constrictive pericarditis without aortic valve replacement. In conclusion, mitral valvuloplasty alone may be safe and effective in alleviating symptoms in mitral stenosis patients with transaortic pressure gradient > 25 mm Hg. Continuity equation-derived aortic valve areas seem to be flow independent in evaluation of aortic stenosis and are important for decision making.

Role of transesophageal echocardiography in the management of metastatic tumors invading the left atrium

Two patients with metastatic tumors invading the left atrium are described. One is a 52-year-old woman with osteosarcoma; the other is a 77-year-old man with lung cancer. The first patient presented with severe dyspnea 1 year after treatment for a primary tumor. Cardiac metastasis was suspected, then documented by transesophageal echocardiography. The study of pulmonary vein flow showed decreased systolic forward and increased diastolic components of pulmonary venous flow. The second patient presented with chronic cough without dyspnea. Although a huge tumor invaded the left atrium, as in the first patient, a normal pattern of pulmonary vein flow with higher systolic than diastolic velocities was shown by transesophageal echocardiography. Thus, transesophageal echocardiography is not only a useful tool to diagnose left atrial metastatic tumors, but also the study of pulmonary venous flow patterns can delineate causes of dyspnea in patients with metastatic tumors invading the left atrium.

Effects of increasing flow rate on aortic stenotic indices: evidence from percutaneous transvenous balloon dilatation of the mitral valve in patients with combined aortic and mitral stenosis

OBJECTIVES

To investigate the effects of transvalvar flow rate on aortic valve resistance and valve area after percutaneous transvenous balloon dilatation of the mitral valve in a homogeneous group of patients with rheumatic heart disease.

DESIGN

Retrospective analysis of 12 patients with combined aortic and mitral stenosis who had undergone balloon dilatation of the mitral valve over a period of 9 years.

SETTING

Tertiary referral centre.

PATIENTS

Twelve (8 women, 4 men; mean (SD) age 37 (9) of 227 consecutive patients with critical mitral stenosis undergoing transvenous balloon dilation of the mitral valve in the centre also had aortic stenosis, defined as a transaortic pressure gradient of more than 25 mm Hg measured at a catheterisation study before valvuloplasty.

INTERVENTIONS

Echocardiographic variables (mitral valve area measured by the pressure half-time method and planimetry, and the aortic valve area derived from the continuity equation) and haemodynamic measurements (cardiac output, left ventricular mean systolic pressure, aortic mean pressure, transaortic valve pressure gradient, mitral valve and aortic valve areas derived from the Gorlin formula, and aortic valve resistance) were assessed before and after transvenous balloon dilatation of the mitral valve. Follow up catheterisation to measure haemodynamic variables was performed one week after mitral valvuloplasty.

RESULTS

Mean transaortic flow rate increased 33% after mitral valvuloplasty (from 198 (68) to 254 (41) ml/s, P = 0.002). Aortic valve areas derived from the Gorlin formula were significantly increased from 0.57 (0.12) to 0.73 (0.14) cm2 (P = 0.006) after mitral valvuloplasty. However, aortic valve area and valve resistance derived from the continuity equation were independent of the increase in flow rate after mitral valvuloplasty (from 1.29 (0.35) to 1.30 (0.29) cm2 and from 317 (65) to 259 (75) dyn.s.cm-5, both P = NS).

CONCLUSION

The Gorlin-derived aortic valve area tends to be flow-dependent, and continuity equation-derived aortic valve area and catheterisation-derived valve resistance seem to be less flow-dependent. In patients with combined mitral and aortic stenosis, these flow-independent indices are important for decision-making.

Left atrial spontaneous echo contrast in asymptomatic patients with a mechanical valve prosthesis

BACKGROUND

Valve thromboembolism may be a fatal complication of mechanical valve prosthesis if detected late. Spontaneous echo contrast (SEC) is a well-documented prothrombotic phenomenon; here we report it in asymptomatic patients with a mechanical valve prosthesis.

METHODS

Ninety-two asymptomatic patients with a mechanical valve prosthesis for underlying rheumatic heart disease underwent transesophageal echocardiography. Appendage area, peak filling and emptying velocities of the left atrial appendage, and the presence or absence of SEC and thrombi were determined. The results of 56 patients without SEC or thrombi (group I) were compared with those of 24 patients with SEC and no thrombi (group II) and 12 patients with thrombi (group III).

RESULTS

Spontaneous echo contrast was present in 39% of the asymptomatic patients with a mechanical valve prosthesis. Although 12 patients had cardiac thrombi, including valve thrombi in 4, no patients presented symptoms. Anticoagulant therapy had no significant association with SEC and atrial thrombi. There was a significantly greater prevalence of atrial fibrillation and mitral prosthesis in groups II and III than in group I. Two patterns of left atrial appendage flow were identified: one was organized biphasic flow with peak filling velocities of 41.2 +/- 17.2 cm/s and emptying velocities of 40.5 +/- 17.5 cm/s. The other showed irregular, very low peak filling velocities (104 +/- 11.5 cm/s) and emptying velocities (12.3 +/- 13.1 cm/s). The former flow pattern was associated with sinus rhythm and the latter form was associated with atrial fibrillation.

CONCLUSIONS

There was a relatively high prevalence of SEC and thrombi in patients with a mechanical valve prosthesis. Patients with a valve prosthesis may not have clinical symptoms. Anticoagulation intensity was not associated with the occurrence of SEC and thrombi. Patients with the mitral valve prosthesis and atrial fibrillation were identified as a high-risk of subgroup for the development of SEC and thrombi.

Case report: reversible systolic heart failure and deep jaundice in hyperthyroidism

Systolic heart failure because of hyperthyroidism in patients without preexisting heart disease is not common. Thyrotoxic systolic heart failure is rarely diagnosed during life. Reports about thyrotoxicosis-related systolic heart failure have been diagnosed postmortem. However, antemortem diagnosis of this fatal disease has important clinical implications because if detected early, thyrotoxicosis-related systolic heart failure is reversible. Here is a report a patient with Graves' disease, systolic heart failure, and deep jaundice, which resolved after the treatment of antithyroid drugs.