Diagnosis and management of left ventricular diastolic dysfunction in the hypertensive patient

The progression of hypertensive involvement toward heart failure includes myocardial fibrosis and changes of left ventricular (LV) geometry. In the presence of these abnormalities, diastolic abnormalities occur and are defined as LV diastolic dysfunction (DD). They include alterations of both relaxation and filling, precede alterations of chamber systolic function and can induce symptoms of heart failure even when ejection fraction is normal. The prevalence of heart failure with normal ejection fraction (HFNEF) increased over time whereas the rate of death from this disorder remained unchanged. In this view, diagnosis, prognosis, and therapeutic management of DD and HFNEF in hypertensive patients is a growing public health problem. DD may be asymptomatic and identified occasionally during a Doppler-echocardiographic examination. This tool has gained, therefore, important clinical position for diagnosis of DD. Comprehensive assessment of diastolic function should be done not by a simple classification of DD progression but by estimating the degree of LV filling pressure (FP), a true determinant of symptoms and prognosis. This can be obtained by different ultrasound maneuvers/tools but the ratio between transmitral E velocity and pulsed tissue Doppler-derived early diastolic velocity (E/e' ratio) is the most feasible and accurate. The identification of left atrial enlargement may be useful in uncertain cases. The recommended management of DD in hypertensive patients should correspond to blood pressure (BP) lowering and to the attempt of reducing LV mass and normalizing LV geometry. Prospective studies with well-defined entry criteria are needed to establish whether this approach could reflect a better prognosis.

Osteonecrosis of the jaw related to sunitinib

CASE REPORT

A 59-year-old male patient was referred to the hospital with exposed bone measuring 10 mm in diameter in the posterior, left-side region of the lower jaw. Two months previous, the first molar had been extracted. The patient had contracted renal cell carcinoma and had been treated by nephrectomy in 2003. Soft tissue metastases occurred. After initial therapy with interferon and vinblastine, a relapse occurred and the therapy was changed to sorafenib, followed by sunitinib. Osteonecrosis of the lower jaw appeared 1 year after initial and exclusive therapy with sunitinib.

CONCLUSIONS

Bisphosphonates had never been applied. With increasing application of multi-kinase inhibitors, complications due to osteonecrosis could occur more frequently.

Computer-Aided Patient-Specific Coronary Artery Graft Design Improvements Using CFD Coupled Shape Optimizer

This study aims to (i) demonstrate the efficacy of a new surgical planning framework for complex cardiovascular reconstructions, (ii) develop a computational fluid dynamics (CFD) coupled multi-dimensional shape optimization method to aid patient-specific coronary artery by-pass graft (CABG) design and, (iii) compare the hemodynamic efficiency of the sequential CABG, i.e., raising a daughter parallel branch from the parent CABG in patient-specific 3D settings. Hemodynamic efficiency of patient-specific complete revascularization scenarios for right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCX) bypasses were investigated in comparison to the stenosis condition. Multivariate 2D constraint optimization was applied on the left internal mammary artery (LIMA) graft, which was parameterized based on actual surgical settings extracted from 2D CT slices. The objective function was set to minimize the local variation of wall shear stress (WSS) and other hemodynamic indices (energy dissipation, flow deviation angle, average WSS, and vorticity) that correlate with performance of the graft and risk of re-stenosis at the anastomosis zone. Once the optimized 2D graft shape was obtained, it was translated to 3D using an in-house "sketch-based" interactive anatomical editing tool. The final graft design was evaluated using an experimentally validated second-order non-Newtonian CFD solver incorporating resistance based outlet boundary conditions. 3D patient-specific simulations for the healthy coronary anatomy produced realistic coronary flows. All revascularization techniques restored coronary perfusions to the healthy baseline. Multi-scale evaluation of the optimized LIMA graft enabled significant wall shear stress gradient (WSSG) relief (~34%). In comparison to original LIMA graft, sequential graft also lowered the WSSG by 15% proximal to LAD and diagonal bifurcation. The proposed sketch-based surgical planning paradigm evaluated the selected coronary bypass surgery procedures based on acute hemodynamic readjustments of aorta-CA flow. This methodology may provide a rational to aid surgical decision making in time-critical, patient-specific CA bypass operations before in vivo execution.

Infection, vascularization, remodelling--are stem cells the answers for bone diseases of the jaws?

Osteonecrosis after craniofacial radiation (ORN), osteomyelitis and bisphosphonates related necrosis of the jaw (BRONJ) are the predominant bone diseases in Cranio- and Maxillofacial surgery. Although various hypothesis for the pathophysiological mechanisms including infection, altered vascularisation or remodelling exist, the treatment is still a challenge for clinicians. As the classical pharmacological or surgical treatment protocols have only limited success, stem cells might be a promising treatment option, indicated by recently published data.

Coronary vasoconstrictor responses are attenuated in young women as compared with age-matched men

Recent work in humans suggests coronary vasoconstriction occurs with static handgrip with a time course that suggests a sympathetic constrictor mechanism. These findings are consistent with animal studies that suggest this effect helps maintain transmural myocardial perfusion. It is known that oestrogen can attenuate sympathetic responsiveness, however it is not known if sympathetic constrictor responses vary in men and women. To examine this issue we studied young men (n = 12; 28 ± 1 years) and women (n = 14; 30 ± 1 years). Coronary blood flow velocity (CBV; Duplex Ultrasound), heart rate (ECG) and blood pressure (BP; Finapres) were measured during static handgrip (20 s) at 10% and 70% of maximum voluntary contraction. Measurements were also obtained during graded lower body negative pressure (LBNP; activates baroreflex-mediated sympathetic system) and the cold pressor test (CPT; a non-specific sympathetic stimulus). A coronary vascular resistance index (CVR) was calculated as diastolic BP/CBV. Increases in CVR with handgrip were greater in men vs. women (1.25 ± 0.49 vs. 0.26 ± 0.38 units; P < 0.04) and CBV tended to fall in men but not in women (−0.9 ± 0.9 vs. 1.7 ± 0.8 cm s−1; P < 0.01). Changes in CBV with handgrip were linked to the myocardial oxygen consumption in women but not in men. CBV reductions were greater in men vs. women during graded LBNP (P < 0.04). Men and women had similar coronary responses to CPT (P = n.s.). We conclude that coronary vasoconstrictor tone is greater in men than women during static handgrip and LBNP.

Iatrogenic mandibular fracture associated with third molar removal

Third molar extraction is one of the most common procedures performed in oral and maxillofacial surgery units. It is sometimes accompanied by complications such as alveolar osteitis, secondary infection, hemorrhage, dysesthesia and, most severely, iatrogenic fracture. This article describes two mandibular angle fractures that occurred in two patients during the surgical extraction of one erupted and one unerupted third molar, including a brief review of the literature.

Detection of severe left anterior descending coronary artery stenosis by transthoracic evaluation of resting coronary flow velocity dynamics

In the presence of severe stenosis, coronary artery flow may be reduced at rest. Recent advances in echocardiography have made non-invasive sampling of velocities in the left anterior descending coronary artery (LAD) possible. The aim of our study was to evaluate feasibility and capability of transthoracic Doppler to detect severe stenosis of the LAD. The study population consisted of 42 subjects with suspected coronary artery disease scheduled for coronary angiography. All had complete transthoracic echocardiography and Doppler sampling of LAD velocities. Quantitative coronary angiography was performed within 24 hours of the echocardiogram. Correlations between LAD velocity profile, measurements and calculations, and the angiographic results were performed. Six subjects had LAD occlusion, 10 had severe (>80% diameter) LAD stenosis, and 26 had normal or non-occlusive LAD disease. In all six subjects with LAD occlusion, distal LAD velocities were not detectable, while in the other 36 subjects, LAD velocities were recorded indicating the vessels were patent. In the 10 subjects with severe LAD stenosis, the diastolic/systolic velocity ratio was <1.5, while in those with non-significant LAD disease, the diastolic/systolic velocity ratio was >1.5 (P<0.005). Diastolic LAD flow was 21.8±13 mL/min in the presence of severe stenosis as compared to 48.5±20 mL/min in subjects without severe stenosis (P<0.0013). LAD velocities had high sensitivity and specificity for the prediction of severe angiographic stenosis. Thus transthoracic Doppler measurement of LAD velocities is feasible and can predict the presence of severe LAD stenosis or occlusion.

Circadian variation in coronary flow velocity reserve and its relation to α1-sympathetic activity in humans

BACKGROUND

The circadian change in coronary microvascular function has not been directly assessed in human beings. Recent advances in transthoracic Doppler echocardiography (TTDE) provide noninvasive, physiological assessment of coronary flow velocity reserve (CFVR).

METHODS

This study consisted of 20 young healthy subjects (24 ± 2 years, 20 men) who underwent CFVR examinations at 3 different times; early morning (6AM), late morning (11AM) and late evening (10PM). The flow velocity in the distal portion of the left anterior descending coronary artery was measured with TTDE at baseline and during adenosine infusion to calculate CFVR. These examinations were repeated with the intake of α1-blocker (prazosin 1mg) on the other day.

RESULTS

CFVR showed a circadian variation with an increase from the early morning to the late morning, following a decrease to the late evening thereafter (4.4 ± 0.9 at 6AM; 5.2 ± 1.3 at 11AM; 4.2 ± 1.1 at 10PM, p<0.001). In the study with α1-blocker, CFVR was comparable between the early morning and the late morning, whereas CFVR in the late evening was lower than those in other 2 time points (5.0 ± 1.1 at 6AM; 4.9 ± 0.9 at 11AM; 4.3 ± 0.9 at 10PM, p<0.001).

CONCLUSIONS

This study demonstrates that CFVR has a circadian variation in humans, with an increase from the late evening to the late morning. Adding α1-blocker ameliorated CFVR only in the early morning, indicating that α1-sympathetic activity plays a heterogeneous and important role in the circadian change of CFVR in humans.

Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil

A retrospective study was performed to assess maxillofacial fractures in patients treated at a public hospital from 2002 to 2006. The data collected included age, gender, etiology, type of injury, treatment modalities and period of treatment. Causes were grouped into seven categories: road traffic collisions, sports accidents, occupational accidents, gunshot fractures, falls, violence and other causes. The analyses involved descriptive statistics, the Chi-squared Test and the Fisher Exact Test. Records from 132 patients sustaining 185 maxillofacial fractures were evaluated. The mandible (54.6%) was the most commonly fractured bone in the facial skeleton, followed by the zygoma (27.6%). The mean age of the patients was 37.7 years, and the male:female ratio was 4.3:1. Most fractures occurred in adults with ages ranging from 18 to 39 years. A significant statistical relation was found between the age and the etiology of the trauma (p < 0.05), and between the number of fractured sites and the age of the patient (p < 0.05). Considering the age groups, accidents were the most frequent cause of maxillofacial fractures in the age group between 18 to 39 years, and interpersonal violence was the most frequent cause of maxillofacial fractures in the age group between 40 to 59 years. Treatment was performed on the same day as the diagnosis in 44.7% of the patients. Open surgery with internal stable fixation was indicated for most of the patients. Facial fractures occurred primarily among men under 30 years of age, and the most common sites of fractures in the face were the mandible and the zygomatic complex. Traffic road collisions were the main etiologic factor associated with maxillofacial trauma.

Coronary vasoreactivity is not altered in young people with type 1 diabetes

BACKGROUND AND AIM

Abnormal coronary microvascular circulation has been demonstrated in diabetes and is associated with increased rate of cardiovascular events. Our objective was to evaluate coronary vasoreactivity in young people with type 1 diabetes with and without microvascular complications.

METHODS AND RESULTS

Twenty-five type 1 diabetic patients without microvascular complications (DC-), 23 with microvascular complications (DC+), and 18 control subjects (C) were studied. Coronary vasoreactivity was assessed by means of coronary flow reserve (CFR). Blood flow velocity in the left anterior descending coronary artery was measured at rest and after high-dose dipyridamole using transthoracic color-guided pulsed Doppler echocardiography. CFR was defined as the ratio of hyperaemic to resting diastolic peak flow velocities. The three groups had similar cardiac function parameters, and also systolic and diastolic blood pressure at rest, which remained unchanged during dipyridamole infusion. Resting coronary flow velocity was comparable in C, DC-, and DC+ (p=ns). Dipyridamole infusion produced a threefold increase in coronary diastolic peak velocity, which reached similar values in C (0.69±0.16 m/s), DC- (0.69±0.18 m/s), and DC+ (0.66±0.11 m/s). Mean CFR ratio was similar in C (3.33±0.66), DC- (3.30±0.51), and DC+ (3.24±0.60). At multiple linear regression analysis, no association was found between CFR and age, sex, HbA(1c), duration of diabetes, and complications.

CONCLUSION

Coronary vasodilatory function is preserved in young D patients, even those with early microvascular complications, suggesting that coronary vasoreactivity deteriorates at more advanced stages of microvascular complications and/or in the presence of other cardiovascular risk factors.

Facial fractures in the elderly: a retrospective study in a hospital in Belo Horizonte, Brazil

BACKGROUND

An increasing incidence of maxillofacial trauma in the elderly has been noted, as a consequence of increased longevity, resulting in a higher percentage of elderly people in the population.

METHODS

A retrospective study was undertaken to assess facial fractures in elderly presenting during the period 2000 to 2002 in Belo Horizonte, Brazil. The data collected included age, gender, etiology, date of trauma, maxillofacial trauma, anatomic site of fracture, and treatment. The statistical analysis involved evaluation of measures of central tendency and variability and calculation of proportions.

RESULTS

It encountered 165 facial fractures in 122 elderly aged 60 years or older. The majority of fractures were sustained by elderly in the age group 60 years to 69 years. Falls was the major cause of trauma followed by car accidents. The mandible was found to be the most common fractured bone in the facial skeleton, followed by the zygomatic complex. A conservative approach was accomplished in the most of cases.

CONCLUSION

Gender was associated with the presence or absence of fractures and with the etiology. There was no association between age and fractures. No association was found between etiology and age for women and men. The proportion of fractures of the zygomatic arch, mandible body, and parasymphysis treated surgically were statistically higher than the same proportion among the cases of other fractures. The fractures of the nose were more often treated conservatively than other fractures.

Eagle's syndrome - A case report and review of the literature

Eagle's syndrome (ES) occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. The symptoms related to this condition can be confused with those attributed to a wide variety of facial neuralgias. ES can be diagnosed radiologically and by physical examination. The treatment of ES is primarily surgical. The styloid process can be shortened through an intraoral or external approach. In this paper a case of ES exhibiting unilateral symptoms with bilateral elongation of styloid process is reported and the literature is reviewed.

Role of cardiovascular imaging in systemic autoimmune diseases

Systemic autoimmune diseases are characterized by an excess of cardiovascular (CV) morbidity and mortality compared to the general population, mainly due to chronic inflammation that promotes the development of endothelial dysfunction and enhanced atherosclerosis. Early diagnosis of silent CV involvement is mandatory to improve the long term prognosis of these patients and CV imaging provides valuable information as a reliable diagnostic tool. Transthoracic echocardiography, with several applications (e.g. coronary flow reserve evaluation, tissue Doppler imaging, speckle tracking and the transesophageal approach), represents a first line evaluation, in association with biomarkers of endothelial dysfunction, such as asymmetric dimethylarginine. Nuclear medicine provides useful information on myocardial perfusion. The aim of this editorial is to provide a brief but complete review of the diagnostic tools available for screening and follow up of CV involvement in systemic autoimmune diseases.

Recovery of distal coronary flow reserve in LAD and LCx after Y-Graft intervention assessed by transthoracic echocardiography

BACKGROUND

Y- graft (Y-G) is a graft formed by the Left Internal Mammary Artery (LIMA) connected to the Left Anterior Descending Artery (LAD) and by a free Right Internal Mammary Artery (RIMA) connected to LIMA and to a Marginal artery of Left Circumflex Artery (LCx). Aim of the work was to study the flow of this graft during a six months follow-up to assess whether the graft was able to meet the request of all the left coronary circulation, and to assess whether it could be done by evaluation of coronary flow reserve (CFR).

METHODS

In 13 consecutive patients submitted to Y-G (13 men), CFR was measured in distal LAD and in distal LCx from 1 week after , every two months, up to six months after operation (a total of 8 tests for each patient) by means of transthoracic echocardiography (TTE) and Adenosine infusion (140 mcg/kg/min for 3-6 min). A Sequoia 256, Acuson-Siemens, was used. Contrast was used when necessary (Levovist 300 mg/ml solution at a rate of 0,5-1 ml/min). Max coronary flow diastolic velocity post-/pre-test > or =2 was considered normal CFR.

RESULTS

Coronary arteriography revealed patency of both branches of Y-G after six months. Accuracy of TTE was 100% for LAD and 85% for LCx. Feasibility was 100% for LAD and 85% for LCx. CFR improved from baseline in LAD (2.21 +/- 0.5 to 2.6 +/- 0.5, p = 0.03) and in LCx (1.7 +/- 1 to 2.12 +/- 1, p = 0.05). CFR was under normal at baseline in 30% of patients vs 8% after six months in LAD (p = 0.027), and in 69% of patients vs 30% after six months in LCx (p = 0.066).

CONCLUSION

CFR in Y-G is sometimes reduced in both left territories postoperatively but it improves at six months follow-up. A follow-up can be done non-invasively by TTE and CFR evaluation.

Coronary flow reserve by transthoracic echocardiography predicts epicardial intimal thickening in cardiac allograft vasculopathy

Cardiac allograft vasculopathy (CAV) is the leading cause of morbidity and mortality in heart transplantation (HT). We sought to investigate the role of coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) in CAV diagnosis. CAV was defined as maximal intimal thickness (MIT) assessed by intravascular ultrasound (IVUS) > or =0.5 mm. CFR was assessed in the left anterior descending coronary artery in 22 HT recipients at 6 +/- 4 years post-HT. CAV was diagnosed in 10 patients (group A), 12 had normal coronaries (group B). The mean MIT was 0.7 +/- 0.1 mm (range 0.03-1.8). MIT was higher in group A (1.16 +/- 0.3 mm vs. 0.34 +/- 0.07 mm, p < 0.0001). CFR was 3.1 +/- 0.8 in all patients and lower in group A (2.5 +/- 0.6 vs. 3.7 +/- 0.3, p < 0.0001). CFR was inversely related with MIT (r =-0.774, p < 0.0001). A cut point of < or =2.9, identified as optimal by receiver operating characteristics analysis was 100% specific and 80% sensitive (PPV = 100%, NPV = 89%, Accuracy = 91%). CFR assessment by CE-TTE is a novel noninvasive diagnostic tool in the detection of CAV defined as MIT > or =0.5 mm. CFR by CE-TTE may reduce the need for routine IVUS in HT.

Review of floor of mouth dysontogenic cysts

OBJECTIVES

We report the common surgical approaches, incidence of sinus tracts, and recurrence rates of floor of mouth dysontogenic (epidermoid, dermoid, and teratoid) cysts in the pediatric population.

METHODS

Data were derived from PubMed, Medline, Embase, Google Scholar, and manual searches. Three cases from the senior author's (J.P.M.) practice were included. All English-language studies consisting of floor of mouth dysontogenic cysts were included. Case reports of tongue dysontogenic cysts, mandibular dysontogenic cysts, maxillary dysontogenic cysts, and dysontogenic cysts in the neck below the hyoid bone were excluded.

RESULTS

There are 198 case reports, including those presented here, of floor of mouth dysontogenic cysts. They are more common in male patients (55.1%), and the most common location is in the sublingual space (104 or 52.5%). Most floor of mouth dysontogenic cysts can be excised by an intraoral approach. There are 5 reported cases in the literature of recurrent dysontogenic cysts and 11 cases of multiple floor of mouth dysontogenic cysts.

CONCLUSIONS

Floor of mouth dysontogenic cysts most commonly present in the sublingual space, and most can be excised by an intraoral approach. Multiple dysontogenic cysts often require a combination of intraoral and extraoral approaches. Recurrence of a dysontogenic cyst may be secondary to a tract not identified at the time of surgery.

Surgical excision of intra-oral dermoid cyst under local anaesthesia: a review of nine cases

OBJECTIVE

The purpose of this article is to highlight the effectiveness of local anaesthesia in the surgical excision of intral-oral dermoid cyst in the absence of available modern and efficient general anaesthetic options as experienced in our environment.

PATIENTS AND METHODS

A retrospective review of nine patients with intra-oral dermoid cysts seen at the oral and maxillofacial surgery units of three specialist hospitals in eastern Nigeria was carried out between 1996 and 2007. We used simple clinical findings and the aspiration technique for our provisional diagnosis and treated our patients by using local anaesthesia, which contains 2% lignocaine hydrochloride in 1: 80,000 adrenaline.

RESULTS

Out of the nine cases seen, the male-to-female ratio was 2:1, representing six male and three female. The age range was 13-22 years, with a mean age of 19 years. The use of local anaesthesia was uneventful and despite the limited options of treatment and the absence of advanced imaging techniques we achieved total success and good results in all nine patients.

CONCLUSION

The anaesthetic difficulties and uncertainties associated with the management of intral-oral dermoid cysts especially in an environment that lack modern general anaesthetic options can be avoided by the use of local anaesthesia. This may, therefore, be an effective alternative to difficult and sometime expensive general anaesthetic methods used in developed countries and could be emulated by oral and maxillofacial surgeons in poorer countries.

Facial fractures in children and adolescents: a retrospective study of 3 years in a hospital in Belo Horizonte, Brazil

AIM

The purpose of this study was to review the etiology, incidence and treatment of selected oral and maxillofacial fractures in children in Belo Horizonte, Brazil, during a period of 3 years.

MATERIALS AND METHODS

The data collected for this study included age, gender, etiology, date of trauma, associated maxillofacial trauma, anatomic site of fracture and treatment. The analysis involved descriptive statistics and chi-squared test, Bonferroni test, Kolmogorov-Smirnov, Kruskal-Wallis and Mann-Whiney tests and analysis of variance.

RESULTS AND CONCLUSIONS

This study examined 566 facial fractures in 464 children of 18 years of age or less. The majority of fractures were observed in children within the age group of 13-18 years of age. Bicycle accidents were the major cause of trauma, followed by falls. The mandible was found to be the most common fractured bone in the facial skeleton, followed by the nose. A conservative approach was applied in most cases.

Osteoradionecrosis: an update

Osteoradionecrosis (ORN) of the mandible is the most serious and severe side effect of combined treatment of head and neck tumors. A new theory for the pathogenesis of ORN has been proposed relating it to a fibro-atrophic mechanism including free radical formation, endothelial dysfunction, inflammation, microvascular thrombosis leading to bone and tissue necrosis. Risk factors mainly include radiation related risk factors, surgery and, tobacco and alcohol abuse. Removing of diseased teeth after and even probably after radiotherapy is generally considered the main risk factor in ORN. Conversely, steroid use before or after radiation may have a protective effect related to the inhibition of the initial inflammatory phase of ORN. Prevention of ORN is still based on the preventive extractions of decayed or periodontally compromised teeth before radiotherapy. Based on the current understanding of ORN pathophysiology, new preventive and therapeutic protocols have been suggested for mild to moderate stages. Free tissue surgical transfers is the treatment of choice of severe, extensive and long established ORN.

"Passive exercise" using whole body periodic acceleration: effects on coronary microcirculation

BACKGROUND

The whole body periodic acceleration (WBPA) system has recently been developed as a "passive exercise" device by providing increased pulsatile shear stress for improvement of endothelial function. This study aimed to investigate the short-term effect of WBPA on coronary flow reserve (CFR) through transthoracic Doppler echocardiography (TTDE) in healthy subjects and patients with coronary artery disease (CAD).

METHODS

This study consisted of 15 healthy subjects and 20 patients with CAD who underwent CFR examination before and immediately after WBPA. The flow velocity in the distal portion of the left anterior descending coronary artery (LAD) was measured with TTDE at baseline and during adenosine infusion. Coronary flow reserve was calculated as the ratio of hyperemic to basal mean diastolic flow velocity.

RESULTS

The WBPA treatment was completed in all 35 subjects without complications. There were no significant differences in heart rate and systolic blood pressure before and after WBPA. Whole body periodic acceleration increased CFR from 3.3 +/- 1.0 to 3.7 +/- 1.1 in the 35 subjects (P < .001). Coronary angiography showed significant LAD narrowing in 8 of the 20 CAD patients, but WBPA increased CFR from 2.4 +/- 0.4 to 2.7 +/- 0.5 in them as well (P < .01).

CONCLUSIONS

This study demonstrates that WBPA improves CFR in healthy subjects and patients with CAD.

Influence of abnormal glucose metabolism on coronary microvascular function after a recent myocardial infarction

OBJECTIVES

This study sought to assess the association between abnormal glucose metabolism and abnormal coronary flow reserve (CFR) in patients with a recent acute myocardial infarction (AMI).

BACKGROUND

Mortality and morbidity after AMI is high among patients with abnormal glucose metabolism, which may be related to abnormal microcirculation.

METHODS

We studied 183 patients with a first AMI. In 161 patients with no history of diabetes mellitus (DM), an oral glucose tolerance test was performed, and patients were categorized according to World Health Organization criteria for whole blood glucose into 3 groups. After coronary angiography and revascularization, a comprehensive transthoracic echocardiogram and noninvasive assessment of CFR was performed in the distal part of left descending artery, as an indicator of microvascular function. Adenosine was administered by intravenous infusion (140 microg/kg/min) to obtain the hyperemic flow profiles. The CFR was defined as the ratio of hyperemic to baseline peak diastolic coronary flow velocities.

RESULTS

Median CFR was 1.9 (interquartile range [IQR] 1.4 to 2.4], and 109 (60%) patients had a CFR <or=2. The lowest CFR was seen in patients with a history of DM (1.4 [IQR 1.4 to 1.7], n = 22) and in patients with newly diagnosed DM (1.6 [IQR 1.3 to 2], n = 39), whereas CFR did not differ in patients with abnormal glucose tolerance (2.1 [IQR 1.4 to 2.6], n = 58) and in patients with normal glucose tolerance (2.2 [IQR 1.7 to 2.6], n = 62). In a stepwise logistic regression model adjusting for age, sex, site and size of AMI, heart rate, risk factors of the metabolic syndrome, degree of angiographic evidence of coronary artery disease, and medical therapy, newly diagnosed DM (odds ratio: 3.0) and a history of DM (odds ratio: 9.9) remained significant predictors of CFR <2, whereas impaired glucose tolerance was not.

CONCLUSIONS

CFR is decreased in patients with known or newly diagnosed DM even after adjustment of possible confounders, whereas CFR in patients with impaired glucose tolerance seems less affected. (Coronary Flow Reserve and Glucometabolic State [CFRGS]; NCT00845468).

Facial trauma in the largest city in Latin America, São Paulo, 15 years after the enactment of the compulsory seat belt law

Traffic accidents are a reality throughout Brazil. The face is one of the anatomic parts most affected by these accidents, especially when a seat belt is not used. These accidents are costly for the public health system and have a significant impact on society and the lives of families involved. The compulsory use of seat belts in Brazil, especially in São Paulo, has decreased the rate of facial trauma. This suggests that the public health policies and measures adopted by the Brazilian authorities have benefited the population 15 years after the enactment of the law of compulsory seat belts in the city of São Paulo.

Transthoracic echocardiography for imaging of the different coronary artery segments: a feasibility study

Background

Transthoracic echocardiography (TTE) may be used for direct inspection of various parts of the main coronary arteries for detection of coronary stenoses and occlusions. We aimed to assess the feasibility of TTE to visualise the complete segments of the left main (LM), left descending (LAD), circumflex (Cx) and right (RCA) coronary arteries.

Methods

One hundred and eleven patients scheduled for diagnostic coronary angiography because of chest pain or acute coronary syndrome had a TTE study to map the passage of the main coronary arteries. LAD, Cx and RCA were each divided into proximal, middle and distal segments. If any part of the individual segment of a coronary artery with antegrade blood flow was not visualised, the segment was labeled as not satisfactorily seen.

Results

Complete imaging of the LM was achieved in 98% of the patients. With antegrade directed coronary artery flow, the proximal, middle and distal segments of LAD were completely seen in 96%, 95% and 91% of patients, respectively. Adding the completely seen segments with antegrade coronary flow and segments with retrograde coronary flow, the proximal, middle and distal segments of LAD were adequately visualised in 96%, 96% and 93% of patients, respectively. With antegrade directed coronary artery flow, the proximal, middle and distal segments of Cx were completely seen in 88%, 61% and 3% and in RCA in 40%, 28% and 54% of patients. Retrograde coronary artery flow was correctly identified as verified by coronary angiography in seven coronary segments, mainly in the posterior descending artery (labeled as the distal segment of RCA) and distal LAD.

Conclusions

TTE is a feasible method for complete demonstration of coronary flow in the LM, the proximal Cx and the different segments of LAD, but less suitable for the RCA and mid and distal segments of the Cx. (ClinicalTrials.gov number NTC00281346.)

Epidermoid cyst of the floor of the mouth: two case reports

Introduction

Epidermoid cysts that appear in the midline floor of the mouth are, usually, a result of entrapped ectodermal tissue of the first and second branchial arches, which fuse during the third and fourth weeks in utero. The incidence in the floor of the mouth of the oral cavity is rare and development sites are the sublingual, submaxillary and submandibular spaces.

It was present two cases of epidermoid cyst of the floor of the mouth and discussed the different surgical approaches for this lesion.

Cases presentation

Two cases of midline epidermoid cysts of the floor of the mouth are presented, evaluating the different surgical approaches. The preoperative assessment was made using ultrasonography and computed tomography in both cases. Regarding surgical techniques used, a transcutaneous approach was adopted when the cysts were under the geniohyoid muscle and a midline incision of the oral mucosa along the lingual frenulum was used for sublingual cysts. During the postoperative course, there were no complications, except for mild edema in one case. Follow-up ranged between 5 months and 4 years; no recurrence or malignant changes were observed.

Conclusions

Surgery of epidermoid cyst of the floor of the mouth is the treatment of choice. Access depends on the lesion's location in relation to the mylohyoid or geniohyoid muscles. If the cyst is located over the mylohyoid, surgery is carried out only through the oral cavity, whereas the extraoral incision was necessary only when the cysts were under the geniohyoid muscle.

Optimization of flow reserve measurement using SPECT technology to evaluate the determinants of coronary microvascular dysfunction in diabetes

PURPOSE

The aim of this study was to validate a new method to measure regional myocardial perfusion reserve (MPR) with technetium-labelled tracers in patients with type 2 diabetes mellitus (DM2).

METHODS

A total of 40 consecutive DM2 patients without history of coronary artery disease (CAD) and 7 control subjects were recruited. Dipyridamole myocardial blood flow index (MBF) was assessed by measuring first transit counts in the pulmonary artery and myocardial count rate from gated SPECT images using (99m)Tc-labelled tracers. The corresponding MBF index was estimated 2 h later according to the same procedure. Regional myocardial perfusion reserve (MPR) was defined as the ratio between dipyridamole and baseline MBF using a 17-segment left ventricular (LV) model. Coronary flow reserve (CFR) was estimated by transthoracic contrast echo Doppler monitoring of flow velocity in the left anterior descending coronary artery (LAD) during the same session.

RESULTS

Estimated MPR was higher in control subjects than in patients (3.36 +/- 0.66 vs 1.91 +/- 0.61, respectively, p < 0.01). In patients, LAD CFR and LAD MPR were 2.01 +/- 0.78 vs 1.93 +/- 0.63, respectively (p = ns). The agreement between the two techniques was documented by their close correlation (r = 0.92, p < 0.001) and confirmed by the Bland-Altman analysis. Reversible perfusion defects occurred in 13 patients (32%) who showed similar MPR values as the remaining 27 (2.10 +/- 0.71 vs 1.83 +/- 0.71, respectively, p = ns). Finally, MPR was closely correlated with age (r = -0.50, p < 0.01) and time elapsed from the diagnosis of DM2 (r = -0.51, p < 0.01).

CONCLUSION

LV regional MPR can be accurately estimated with the broadly available single photon technology. Application of this method to DM2 patients documents the presence of a microvascular dysfunction homogeneously distributed throughout the LV walls and most frequently not associated with reversible perfusion defects.

Incidence and patterns of mandibular condyle fractures

PURPOSE

The aim of the present study was to retrospectively evaluate the epidemiologic characteristics of the prevalence, type, and treatment modalities of condylar fractures of the mandible.

PATIENTS AND METHODS

Data were collected from patients during an 8-year period (1999 to 2007). The data recorded included demographic data, etiology, diagnosis, type, dislocation, use of protective devices, state of the dentition, associated facial and general trauma, soft tissue lesions, treatment methods, and the interval between trauma and treatment. Data analysis included a descriptive analysis, chi(2) test, Fisher's exact test, t test, and Kruskal-Wallis test.

RESULTS

During the 8-year period, 209 unilateral fractures and 54 bilateral fractures were treated, with a male/female ratio of 3.05:1 and a mean age of 28.4 years, for a total of 317 condylar fractures. Male gender was significantly associated with the presence of a condylar fracture (P < .05). The most common cause of condylar fractures was road traffic accidents (57.8%). Of the 317 fractures, 300 were classified as simple fractures, and 249 fractures were not displaced. Protective devices significantly decreased the number of condylar fractures occurring from road traffic accidents (P < .05). Symphysis fractures were significantly associated with both unilateral and bilateral fractures of the mandibular condyle (P < .05). Subcondylar displaced fractures were significantly associated with surgical treatment (P < .05).

CONCLUSIONS

Young adults were involved in most of the accidents. Road traffic accidents were the main cause of condylar fractures. The mandatory use of safety helmets and seatbelts and education of those using the road are essential to decrease the number of facial fractures.

Effect of human peripheral monocyte subsets on coronary flow reserve in infarct-related artery in patients with primary anterior acute myocardial infarction

1. In the present study, we investigated the relationships between relative levels of specific peripheral monocyte subsets and coronary flow velocity reserve (CFVR) during the subacute phase in patients with acute myocardial infarction (AMI). 2. The study was performed on 29 patients with primary anterior AMI who had been successfully treated using primary percutaneous coronary intervention. Two monocyte subsets (CD14(+)CD16(-) and CD14(+)CD16(+)) were measured by flow cytometry. Transthoracic Doppler echocardiography was used to measure CFVR on Days 4 and 7 after the onset of AMI onset. We defined DeltaCFVR as the difference in CFVR values between Days 4 and 7. The extent of myocardial salvage on Day 7 after AMI was evaluated by cardiovascular magnetic resonance (CMR) imaging as the difference between the area of myocardium at risk and the area of necrotic myocardium. 3. There was a significant negative correlation between DeltaCFVR and peak CD14(+)CD16(-) monocyte counts in AMI patients, whereas no significant association was found between CD14(+)CD16(+) monocyte counts and DeltaCFVR. There was a significant positive correlation between DeltaCFVR and the extent of myocardial salvage. 4. In conclusion, peak levels of CD14(+)CD16(-) monocytes following primary anterior AMI were closely related to the extent of microvascular injury.

Imaging myocardial angiogenesis

Imaging myocardial angiogenesis presents a major technical challenge because the ideal spatial resolution required is substantially higher than that available with standard X-ray angiography and nuclear medicine imaging. Moreover, these clinical imaging methods are currently inadequate (because of insufficient resolution) for clinical trials of angiogenic agents for the treatment of ischemic heart disease. Specialized techniques in MRI, ultrasonography, echocardiography and CT that are under development might provide improved means of imaging myocardial angiogenesis. Molecular imaging technologies are also being developed to improve resolution and to provide a better mechanistic insight into angiogenic therapies for ischemic heart diseases. This Review examines advanced methods for imaging angiogenesis. These technologies might soon permit data to be obtained directly from scientific studies and clinical trials.

Usefulness of coronary flow reserve measured by echocardiography to improve the identification of significant left anterior descending coronary artery stenosis assessed by multidetector computed tomography

Multidetector computed tomography (MDCT) detects coronary artery disease. However, an overestimation of coronary artery stenosis and artifacts can prevent accurate identification of significant coronary narrowing. The combination of MDCT with coronary flow reserve (CFR), the hyperemic/baseline peak flow velocity ratio, measured by transthoracic Doppler echocardiography might be helpful. We studied 144 consecutive patients with CFR and quantitative coronary angiography, obtained using both MDCT and invasive coronary angiography (reference method). It was hypothesized that the CFR might provide an incremental value to MDCT in detecting significant (> or =70%) left anterior descending (LAD) coronary artery stenosis. A CFR cutoff of <2 was used to discriminate significant stenosis. CFR was feasible in 141 (98%) of 144 patients, and MDCT was feasible in 131 (91%) of 144 patients (p <0.02). In a univariate model, the prediction of significant LAD stenosis was slightly, but significantly (p <0.0001), better with CFR (sensitivity 90%, specificity 96%, positive predictive value 84%, negative predictive value 97%, and diagnostic accuracy 94%, chi-square = 97.5) than with MDCT (sensitivity 80%, specificity 93%, positive predictive value 71%, negative predictive value 95%, diagnostic accuracy 90%, chi-square = 63.2). When the findings from transthoracic Doppler echocardiography and MDCT agreed, the diagnostic accuracy increased (96%; chi-square = 86.1, p <0.0001). In a multivariate prediction of significant LAD stenosis using a logistic neural network, CFR overshadowed MDCT, and the area under the receiver operating curve was 0.99. Of the 13 patients missed by MDCT, the diagnostic accuracy of transthoracic Doppler echocardiography to predict significant LAD stenosis was 100%. Thus, CFR could improve the diagnostic accuracy of MDCT to detect significant LAD stenosis.

Non-invasive coronary flow reserve after successful primary angioplasty for acute anterior myocardial infarction is an independent predictor of left ventricular recovery and in-hospital cardiac events

BACKGROUND

The prediction of left ventricular (LV) recovery and adverse cardiac events after reperfused acute myocardial infarction (AMI) is challenging. The aim of this study was to assess the usefulness of noninvasive coronary flow reserve (CFR) to predict LV recovery and in-hospital adverse cardiac events after AMI by comparison with other available tools.

METHODS

Fifty-five consecutive patients (mean age, 59 +/- 13 years; 33% women) with first reperfused ST-elevation anterior AMIs and sustained Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow underwent prospectively, < 24 hours after successful primary coronary angioplasty, standard echocardiography and noninvasive CFR assessment in the distal part of the left anterior descending coronary artery, using intravenous adenosine infusion, while in a stable hemodynamic situation. CFR was defined as peak hyperemic left anterior descending coronary artery flow velocity divided by baseline flow velocity. LV ejection fraction (LVEF) was measured using the biplane Simpson's rule. A no-reflow pattern was defined as diastolic deceleration time of basal diastolic coronary flow velocity < 600 ms and/or systolic flow reversal and recovery of LV function as an absolute increase of LVEF >or= 10% at 3-month follow-up. Adverse events were defined as the composite of death, recurrent AMI, and acute heart failure.

RESULTS

In the whole population, the mean LVEF was 46 +/- 5% at baseline and 55 +/- 9% at follow-up. Patients without LV recovery had more severely impaired CFR compared with those with LV recovery (2.1 +/- 0.55 vs 1.46 +/- 0.2, P < .001), as did patients with adverse events compared with those without events (P = .01). Furthermore, CFR was significantly correlated with 3-month LVEF and regional wall motion score (both P values < .01). On multivariate analysis, CFR was an independent predictor of global and regional LV function at follow-up (both P values <or= .01) and of in-hospital cardiac events (P = .02). Receiver-operating characteristic curve analysis demonstrated that a cutoff value of 1.7 for CFR yielded sensitivity of 76% and specificity of 96% to predict LV recovery at follow-up (P < .01).

CONCLUSION

Noninvasive CFR determined < 24 hours after AMI was an independent predictor of LV recovery at 3-month follow-up and of in-hospital adverse cardiac events.

Determinants of coronary flow reserve in heart transplantation: a study performed with contrast-enhanced echocardiography

BACKGROUND

Determination of coronary flow reserve (CFR) is increasingly being used in cardiac allograft vasculopathy (CAV). We aimed to identify determinants of CFR in heart transplantation (HT).

METHODS

CFR was measured by transthoracic echocardiography in 119 HT recipients (97 men, 22 women; 50 +/- 12 years of age at HT and 8 +/- 5 years post-HT). CFR was expressed as the ratio of hyperemic (adenosine infusion at a rate of 0.14 mg/kg) to basal diastolic flow velocity. Rejection scores (RS) on endomyocardial biopsy were calculated. Angiographic CAV was analyzed using a qualitative grading system. The coronary tree was divided into 17 traits and a CAV severity/diffusion index (SDI) was calculated for each patient, summing the scores assigned to all lesions.

RESULTS

Upon multivariate analysis, CFR was related to CAV (p = 0.001), interventricular septum thickness (p = 0.01), ischemic heart disease pre-HT (p = 0.02) and SDI and SDI/segment number (p < 0.0001 and p = 0.003, respectively). In patients without CAV, CFR was related only to RS for severe grades (p = 0.01).

CONCLUSIONS

Left ventricular hypertrophy, CAV and its severity/diffusion independently contribute to reduced CFR. In patients without angiographic CAV, CFR was only independently related to RS. Because a high rejection burden is associated with increased risk of CAV, CFR reduction may be an early marker of CAV. Microvascular dysfunction may contribute to the late morbidity and mortality seen in HT.

The coronary flow velocity reserve measured by stress transoesophageal echocardiography evaluates the success of coronary interventions – Results of a 5-year follow-up

OBJECTIVES

The aim of the present study was to examine the long-term prognostic value of coronary flow velocity reserve (CFR) evaluated by means of stress transoesophageal echocardiography (STEE) in patients who have undergone percutaneous coronary intervention (PCI).

DESIGN

The study comprised 31 patients with significant LAD stenosis who underwent LAD-PCI. In consequence of their clinical signs, 11 subjects required rePCI or coronary artery bypass graft (CABG) operation within six months. The clinical status of the remaining 20 cases improved during the follow-up. STEE examinations were performed before LAD-PCI and after it.

RESULTS

The CFR of patients in a stable clinical condition improved during the follow-up, while the CFR of those who required rePCI or CABG remained unchanged. From this patient population, two subjects died during the 5-year follow-up.

CONCLUSIONS

Most of the patients who displayed an improved CFR after PCI suffered no major clinical events during the 5-year follow-up; in contrast, in those who a priori had a low CFR and did not show any improvement after PCI, major events did occur during this period.

Association between serum uric acid levels and coronary flow reserve in hypertensive patients without concomitant risk factors

BACKGROUND

Hyperuricemia is associated with hypertension, vascular disease and cardiovascular (CV) disease. However, the role of serum uric acid (SUA) level as an independent risk factor for CV and renal morbidity in hypertension remains controversial. Accordingly, we aimed to determine whether SUA levels are independently and specifically associated with coronary flow reserve (CFR) impairment in hypertensive patients.

METHODS

We examined 80 never treated and newly diagnosed hypertensive individuals. The hypertensive individuals were divided into two groups based on CFR values.

RESULTS

Subjects with altered CFR (<2) had significantly higher SUA levels compared with those with normal CFR (> or = 2) (346.0 +/- 98.1 vs 260.7 +/- 75.6 micromol/l, p<0.0001). After adjusting for potential confounders, including age, sex, body mass index, blood pressure, lipids and creatinine, we found that SUA levels were independently associated with CFR impairment (beta = -0.417, p<0.0001). We also found that SUA levels were a good predictor of low CFR at the receiver-operating characteristic curve. Area under the curve was 76% (95% CI 0.64-0.88), and SUA levels were significantly predictive of low CFR (p<0.0001).

CONCLUSIONS

These results support a role for SUA level as an independent marker of target organ damage in hypertension.

Coronary flow reserve in dipper and non‐dipper hypertensive patients

BACKGROUND

Failure to decrease blood pressure (BP) normally during night-time, which is called non-dipping, in hypertensive individuals is associated with higher cardiovascular morbidity and mortality. In addition, non-dipping BP leads to structural changes in the left ventricle; however, the effect of non-dipping BP on coronary flow reserve (CFR) has not been studied yet.

METHODS

In this study, we measured CFR of 22 subjects with non-dipper hypertension, and 15 subjects with dipper hypertension using transthoracic second-harmonic Doppler echocardiography (Acuson Sequoia C256. None of the subjects had any systemic disease or coronary risk factor except hypertension.

RESULTS

Age, gender, body mass index, lipids and echocardiographic findings including left ventricular mass index were similar between the groups. Office BP recordings were similar between non-dipper and dipper groups (147.9+/-6.1/93.9+/-4.3 vs 144.0+/-8.0/93.0+/-3.7). Daytime and 24-h ambulatory BP measurements were similar within the groups, but night-time BPs were significantly greater in non-dipper group than those were in dipper group. Left ventricular diastolic and systolic functions, and both baseline and hyperemic peak diastolic coronary velocity as well as CFR, were similar between the non-dipper and dipper groups (CFR: 2.47+/-0.59 vs 2.39+/-0.47).

CONCLUSION

CFR were similar in patients with non-dipper and dipper hypertension in the absence of excessive left ventricular hypertrophy and other cardiovascular risk factors.

Detection, location, and severity assessment of left anterior descending coronary artery stenoses by means of contrast-enhanced transthoracic harmonic echo Doppler

AIMS

Contrast-enhanced second harmonic Doppler (ED) is a new ultrasound modality that increases the feasibility of recording blood flow velocity (BFV) in the left anterior descending coronary artery (LAD) using a transthoracic approach. Blood flow velocity convective acceleration is a reliable marker of coronary stenosis and can be used to assess the percentage area reduction at the stenosis site by applying the continuity equation. To detect, locate, and assess the severity of significant stenosis throughout the LAD by means of an ED recording of BFV acceleration at the stenosis site.

METHODS AND RESULTS

Fifty-three consecutive patients undergoing coronary angiography (CA) underwent a colour-guided pulsed-wave ED recording of BFV in the proximal/mid and distal portions of the LAD, and maximal and reference BFV was obtained in each of the two arterial segments. Maximal velocity was much higher in the diseased segments (>or=50% lumen narrowing) than in the normal segments (143 +/- 84 vs. 38 +/- 20 cm/s; P < 0.001); as the reference velocity was similar (37 +/- 13 vs. 31 +/- 12; P = 0.03), the percentage increase in velocity was also higher (290 +/- 233 vs. 20 +/- 37%; P < 0.001). Using a cut-off value of an 82% increase in velocity, sensitivity and specificity vs. CA was, respectively, 86 and 95%. The reduction in the percentage area of stenosis calculated using the continuity equation agreed with that determined by means of quantitative CA (r = 0.7).

CONCLUSION

Blood flow velocity evaluation in the LAD by means of transthoracic ED is feasible and reliable in detecting, locating, and assessing the severity of LAD stenosis.