Lower-normal TSH is associated with better metabolic risk factors: A cross-sectional study on Spanish men

BACKGROUND AND AIMS

Subclinical thyroid conditions, defined by normal thyroxin (T4) but abnormal thyroid-stimulating hormone (TSH) levels, may be associated with cardiovascular and metabolic risk. More recently, TSH levels within the normal range have been suggested to be associated with metabolic syndrome and cardiovascular risk. This work studies the linearity of the relationship between metabolic syndrome and TSH across the euthyroid range.

METHODS AND RESULTS

We studied 3533 male participants of the Aragon Workers' Health Study (AWHS) with normal TSH and free T4 levels, across quintiles of these variables, after adjusting for age, alcohol intake, and smoking. Compared with the lowest TSH quintile, the odds ratios for metabolic syndrome at the higher quintiles, which indicate lower thyroid function, were 1.34 (1.04, 1.73), 1.56 (1.21, 2.01), 1.57 (1.22, 2.03), and 1.71 (1.32, 2.21). The lowest free T4 quintile also showed an odds ratio of 1.49 (1.16, 1.90) with respect to the highest quintile. In addition, spline models showed departures from linearity: the risk of metabolic syndrome mostly increases at TSH values below the median (sample half-closest to subclinical hyperthyroidism). Interestingly, glucose also increases with TSH primarily below the median TSH, diastolic blood pressure shows similar changes across the entire TSH range, whereas body mass index, triglycerides, and high-density lipoprotein (HDL)-cholesterol change only at the highest normal TSH values, which are associated with lower free T4 concentration.

CONCLUSIONS

TSH and free T4 within the normal range are associated with the metabolic syndrome. The sample half-below the TSH median (with probably higher functional thyroid status) exhibited better metabolic and cardiovascular profiles.

Efficacy of primary systemic chemotherapy regimen containing anthracyclines with/without taxanes in comparison to CMF in women with early breast cancer

Neoadjuvant chemotherapy is the treatment of choice for locally-advanced breast cancer and leads to down staging and improved breast-conserving therapy (BCT) rates. While its efficacy is well established, considerably less is known about the most effective regimen. We have performed a retrospective analysis of 132 breast cancer patients who had undergone neoadjuvant chemotherapy at our institution. Patients had either received a) anthracyclines ("A", n=35), b) anthracyclines and taxanes ("AT", n=55), or c) neither of the two compounds ("NoA/T", n=42). Clinical response, pathological response and survival were evaluated in each arm. While all three regimens resulted in significant tumor regression, AT was most effective with a mean tumor shrinkage of 39% (ultrasound) and 41% (mammography) (Kruskal-Wallis, p=0.004, and p=0.027). Breast conservation was achieved in 75% by AT, in 49% by A, and in 19% by NoA/T (Kruskal-Wallis, p<0.001). The treatment groups did not differ in respect to pathological complete response (pCR) (chi2-test, p=0.068), although higher cumulative anthracycline doses were predictive of pCR in multivariate analyses (p=0.022). While the mammographic but not the ultrasound-determined tumor diameter determined whether a woman underwent BCT, only an ultrasound-determined size reduction was predictive for disease-free survival (DFS) and overall survival (OS) (log rank, p=0.0093, and p=0.044, respectively). Other parameters that affected BCT rates were age (p= 0.003), year of diagnosis (p=<0.001), presence of multifocal disease (p= 0.032) and the cumulative anthracycline dose (p= <0.001). While the combination of anthracyclines and taxanes is most effective in achieving clinical remission and BCT, the cumulative anthracycline dose appears most important for achieving pCR.

Efficacy of primary systemic chemotherapy regimen containing anthracyclines with/without taxanes in comparison to CMF in women with early breast cancer

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Background: Neoadjuvant chemotherapy is the treatment of choice for locally-advanced breast cancer and leads to down staging and improved BCT rates. While its efficacy is well established, considerably less is known about the most effective regimen. Methods: We have performed a retrospective analysis of 132 breast cancer patients who had undergone neoadjuvant chemotherapy at our institution. Patients had either received a) anthracyclines (“A”, n=35), b) anthracyclines and taxanes (“AT”, n=55), or c) neither of the two compounds (“NoA/T”, n=42). Clinical response, pathological response and survival were evaluated in each arm. Results: While all three regimen resulted in significant tumor regression, AT was most effective with a mean tumor shrinkage of 39% (ultrasound) and 41% (mammography) (Kruskal-Wallis, p=0.004, and p=0.027). Breast conservation was achieved in 75% by AT, in 49% by A, and in 19% by NoA/T (Kruskal-Wallis, p<0.001). The treatment groups did not differ in respect to pCR (χ2-test, p=0.068), although higher cumulative anthracycline doses were predictive of pCR in multivariate analyses (p=0.022). While the mammographic and not the ultrasound-determined tumor diameter determined whether a woman underwent BCT, only an ultrasound-determined size reduction was predictive for DFS and OS (log rank, p=0.0093, and p=0.044, respectively). Other parameters that affected BCT rates were age (p= 0.003), year of diagnosis (p=<0.001), presence of multifocal disease (p= 0.032) and the cumulative anthracycline dose (p= <0.001). Conclusions: While the combination of anthracyclines and taxanes is most effective in achieving clinical remission and BCT, the cumulative anthracycline dose appears most important for achieving pCR.

No significant financial relationships to disclose.

A description of cattle movements in two departments of Buenos Aires province, Argentina

We present a descriptive analysis of cattle movement information retrieved from the Argentinean animal movement database for two departments in the province of Buenos Aires during 2004. For each quarter of the year (January to March, April to June, July to September, and October to December) we report the number of on- and off-farm movement events for the purpose of finishing. Our analyses show that the distribution of the number of finishing-related movement events per farm was skewed, with the majority of farms reporting at least 1 and less than 5% of farms of reporting greater than 15 finishing related movement events throughout the year. The frequency of finishing-related movement events varied over time, with a 1.2-1.8-fold increase in reported movement events from April to September, compared with the rest of the year. These analyses indicate that cattle movement patterns in these departments are dependent on the relative mix of constituent cattle enterprise types. Departments with a mixture of breeding and finishing enterprises behave as potential recipients and distributors of infectious disease, whereas departments comprised of primarily finishing enterprises are predominantly recipients of infectious disease, rather than distributors. Data integrity audits of the Argentinean animal movement database, on a regular or intermittent basis, should allow the presence of bias in these data to be quantified in greater detail.

Conventional stepwise vs. vital capacity rapid inhalation induction at two concentrations of sevoflurane

BACKGROUND AND OBJECTIVE

A multicentre study was conducted to compare three methods of inhalation induction with sevoflurane in adult premedicated patients.

METHODS

One-hundred-and-twenty-five adult patients of ASA I-II were scheduled for short elective surgical procedures (< 90 min) under general anaesthesia with spontaneous ventilation of the lungs via a laryngeal mask airway. Patients were randomly assigned to one of three groups: conventional stepwise inhalation induction group (Group C) or vital capacity rapid inhalation induction groups at 4.5% (Group VC4.5) or at 8% sevoflurane (Group VC8). Before anaesthetic induction, fentanyl 1 micro kg(-1) was given and the face mask applied with the anaesthetic breathing system primed with sevoflurane 4.5% or 8% in the respective vital capacity groups. Loss of eyelash reflex, time to cessation of finger tapping, laryngeal mask insertion, side-effects and adequacy of induction were recorded.

RESULTS

The time to loss of eyelash reflex was significantly shorter in both vital capacity groups vs. the control group: VC8: 68 +/- 7 s; and VC4.5: 94 +/- 6.5 s vs. C: 118 +/- 6.4s (P < 0.0001). Significant differences were found in all pairwise comparisons for time to cessation of tapping: Group VC8 (62 +/- 7 s), Group VC4.5 (85 +/- 6 s) and Group C (116 +/- 6 s; P < 0.0001). The time to laryngeal mask insertion was significantly shorter in the Group VC8 (176 +/- 13 s) compared with the other two groups, Group VC4.5 (219 +/- 13 s) and Group C (216 +/- 9 s). There were no significant differences in the incidence of side-effects between the three groups.

CONCLUSIONS

Inhalation induction of anaesthesia with sevoflurane with the three techniques tested is safe, reliable and well accepted by the patients. The vital capacity rapid inhalation group primed with sevoflurane 8% was the fastest method with no relevant side-effects.

MNU induction of neoplasia in a platyfish model

Interspecific hybrid crosses between members of the fish genus Xiphophorus have been used for over 70 years to study the genetic aspects of melanoma formation. In the well-established "Gordon-Kosswig" cross, the platyfish X. maculatus is outcrossed to the swordtail X. helleri, and the resulting backcross segregants spontaneously develop melanoma. We recently produced a distinct cross between X. maculatus and another platyfish species, X. couchianus. X. maculatus strain Jp 163 A is homozygous for several X-linked pigment pattern genes, including the Spotted dorsal (Sd), Dorsal red (Dr), and Anal fin spot (Af). Af is a sex-limited trait, coding exclusively for melanophores distributed on the modified anal fin or "gonopodium" in the adult male fish. Within F1 and BC1 hybrids (to X. couchianus), the Sd pigment pattern is phenotypically suppressed, whereas Dr and Af are enhanced. We exposed BC1 hybrids to the direct-acting carcinogen N-methyl-N-nitrosourea (MNU). Treatment led to the development of schwannomas, fibrosarcomas, and retinoblastomas. In addition, numerous MNU-treated males that inherited Af developed a pronounced melanotic phenotype, with melanin-containing cells oftentimes totally covering the gonopodium and extending further to grow within the ventral regions of the fish. Genetic linkage analysis of the BC1 hybrids revealed a significant (p < 0.01) association between CDKN2X genotype and the phenotypic degree of melanization. Such an association is consistent with a locus within linkage group V playing a role in the development of melanosis and delineates three genetic preconditions and a carcinogenic scheme resulting in melanosis of the ventral regions of hybrid fish. The overall study further alludes to the potential of using Xiphophorus fish to study carcinogenic mechanisms for tumors other than melanoma (schwannoma, fibrosarcoma, and retinoblastoma) and should enable extensive pathologic and molecular genetic studies of derived neoplastic abnormalities.

[Congenital mitral stenosis. Experience in 1991-2001]

OBJECTIVE

To describe ten years of experience with congenital mitral stenosis.

METHOD

All cases with congenital mitral stenosis from January 1991 to 2001 were analized.

RESULTS

16 patients with congenital mitral stenosis were found, mean age 3 +/- 3.08 years. TYPES OF OBSTRUCTIONS: Mitral commisures combined with tendinous cords fusion (45%), parachute mitral valve 37%, supravalvar mitral ring in one, fusion between papillary muscle and leaflets in one, and double mitral orifice in one. Hemodynamic (in mmHg) findings: wedge pressure 18.4 +/- 4, pulmonary artery systolic 61 +/- 21, diastolic 34 +/- 15, mean 47 +/- 18 mmHg, mean transvalvar gradient (MTG) 12.9 +/- 7.3, PRU 5.5 +/- 3.8. Four patients received medical treatment. Surgical results: Six patients underwent mitral repair, and four were subjected to mitral valve replacement (two with previous mitral repair). Global mortality was 2 (12.5%). Follow-up was 3.5 +/- 3 years. There was a significant difference when the initial MTG 22.6 +/- 11.5 mmHg before surgical repair was compared with the final MTG 4.75 +/- 1.5 (P < 0.05), also when initial MTG 12 +/- 2.3 before mitral valve replacement was compared with the final MTG 6 +/- 1.15 mmHg (P < 0.05).

CONCLUSION

Most patients are candidates for mitral surgical repair, however at mid term one third will require mitral valve replacement.

[Atrioventricular discordance. Clinico-surgical experience 1990-2000]

OBJECTIVE

To know the incidence of ventriculoarterial connections combined with atrioventricular discordance, associated lesions and surgical results, including the first case with anatomical correction.

METHOD

All patients with atrioventricular discordance by echocardiography from 1990 to March 2000 were analyzed.

RESULTS

Thirty six patients with atrioventricular discordance were found. Ages ranged from 0.1 to 46 years, with a mean 9.2 years (SD 5.9 years). Atrial chambers were situs solitus in 88.9%, inversus in 11.2%. The ventriculoarterial connections were discordant in 28 (77.7%), double outlet right ventricle in 4 (11.1%) (one of them was a "criss cross" heart), single outlet (pulmonary atresia) in 4 (11.1%), and double outlet left ventricle in 1 (2.7%). Associated lesions: Ventricular septal defect with pulmonary stenosis or atresia was present in 21 (58%), ventricular septal defect with no pulmonary obstruction was observed in 10 (28%). Five had tricuspid regurgitation with right ventricular disfunction, (two adults). Surgical results: 22 (61%) required 28 surgical procedures: 8 (36%) were palliative and 19 (86%) were corrective, one of them was our first anatomical correction. Operative mortality in all was 40.1%, postoperative atrioventricular block was observed in 9 (40.1%).

CONCLUSION

Right ventricular dysfunction is not uncommon. Surgical results revealed high mortality and high pacemaker requirement for atrioventricular block.

Direct communication between right pulmonary artery and left atrium

A case of direct communication between right pulmonary artery and left atrium is reported. The diagnosis was made before surgical correction. A surgical ligation of the fistula resolved the cyanosis of the patient. Selective angiocardiogram of the right pulmonary artery 4 months after surgery revealed no residual shunt. This very rare malformation should be considered in the clinical setting of unexplained cyanosis. This is the number 50 case reported in the literature.

[Percutaneous treatment of multiple heart defects]

We describe our experience in 6 cases with multiple congenital heart defects treated by percutaneous intervention. Their age ranged from 2.3 to 10 years (mean 6.1), with follow-up from 1 to 84 months (mean 28.8). Two cases had coarctation of the aorta (AC) and persistent ductus arteriosus (PDA). Two patients had pulmonary valve stenosis (PVS) and PDA, one case with aortic stenosis (AE) and PDA and one case with AC, mitral stenosis and subaortic stenosis (Shone's Syndrome). Ductus arteriosus was occluded in all patients with Gianturco coils or Rashkind occluder. The valvular gradient post balloon decreased in cases with AC from 46 to 9 mmHg, with PVS from 110 to 10 mmHg and with AE from 40 to 14 mmHg. In a 8 year old boy with Shone's syndrome, we performed angioplasty of aortic coarctation, mitral valvuloplasty with Inoue catheter. He was referred to surgery for subaortic repair stenosis. All are asymptomatic at follow-up. In conclusion; percutaneous intervention is possible in patients with multiple congenital heart defects.

[Urapidil in anesthesiology: pharmacology and indications]

This review aims to describe the pharmacological bases for using urapidil, a recently introduced hipotensor, and to survey the literature on its therapeutic possibilities. The anesthesiologist often sees hypertension during surgery and must apply hypotensive treatment to prevent complications. Urapidil works mainly by antagonizing postsynaptic alpha-1-adrenergic receptors and stimulating 5-HT1A receptors, a double mechanism that provides vasodilation with moderate decrease in blood pressure without reflex tachycardia. Adverse side effects are rare and clinically unimportant. Onset is rapid after intravenous administration and duration of action is short; dose can be easily adjusted based on response and patient requirements. While urapidil has been used successfully in a variety of diseases and surgical procedures, its pharmacological characteristics make it particularly useful in patients at high cardiovascular risk or undergoing neurosurgery, in which results are good. Although the oral form is not sold in Spain, it is used in other countries to treat chronic high blood pressure. Urapidil is a hypotensor with a wide range of indications (critical hypertension, prophylaxis for hypertensive peaks and treatment of hypertension during surgery) and few side effects.

[Comparison of lidocaine and urapidil for prevention of hemodynamic response to tracheal intubation in patients in general good health]

OBJECTIVE

To compare the efficacy of endovenous administration of 0.5 mg/kg-1 of urapidil to 1 mg/kg-1 of lidocaine for attenuating hemodynamic response to laryngoscopy and tracheal intubation.

PATIENTS AND METHODS

Study of 40 ASA I and II patients with normal blood pressure undergoing elective surgery under general anesthesia with orotracheal intubation. The patients were randomly assigned to two groups to receive either 0.5 mg/kg-1 of urapidil or 1 mg/kg-1 five minutes before anesthetic induction. Anesthesia was provided with 0.04 mg/kg-1 of midazolam, 2 micrograms/kg-1 of fentanyl, 2 mg/kg-1 of propofol, 0.1 mg/kg-1 of vecuronium before proceeding to orotracheal intubation, after electromyographic determination of neuromuscular response with T1 less than 5%, and laryngoscopy. Heart rate, systolic, diastolic and mean pressures, and the product of heart rate and mean arterial pressure (HR x MAP) were recorded at the following times: baseline (before administering either lidocaine or urapidil), after induction, after laryngoscopy and intubation, and 3 minutes and 5 minutes after intubation.

RESULTS

ASA classification, age, sex and weight were similar in the two groups. Heart rate immediately after intubation, and after 3 and 5 minutes was significantly lower in the lidocaine group. Likewise HR x MAP immediately after intubation and 3 minutes later was significantly lower in the patients who received lidocaine.

CONCLUSIONS

In healthy ASA I and II patients with normal blood pressure, a dose of 1 mg/kg-1 of lidocaine provided better protection against the hemodynamic response to laryngoscopy and tracheal intubation than does 0.5 mg/kg-1 of urapidil.

[Compromized postadenoidectomy respiration in a child with obstructive sleep apnea syndrome]

A two-year-old boy with a history of slow growth, snoring during sleep and adenoid hypertrophy underwent adenoidectomy and transtympanic drainage under general anesthesia. Immediately after extubation, severe inspiratory stridor and shallow labored breathing began and persisted over a period of two hours, in spite of corticoid administration and oxygen therapy. The signs receded partially when the patient was seated and with a mandibular traction maneuver. As symptoms persisted, foreign body obstruction was ruled out by examination of the cavum and upper airway under general anesthesia and with orotracheal intubation. The patient was transferred to the pediatric intensive care unit, where he remained intubated for 18 hours. After extubation, stridor and shallow labored breathing reappeared but gradually receded as the residual effects of sedation disappeared. The parents mentioned symptoms suggestive of obstructive sleep apnea syndrome (OSAS) occurring since the boy was 6 months old and that had worsened in recent months. OSAS in children is characterized by intermittent obstruction of the upper airway during sleep, causing snoring and periods of apnea/hypopnea that lead to hypoxemia and hypercapnia. The most frequent cause is hypertrophy of the adenoid and tonsils, and the treatment of choice is adenotonsillectomy, although the risk of postoperative respiratory distress in such children is high. It is important to rule out OSAS in children who are candidates for adenotonsillectomy so that such patients are not scheduled for ambulatory surgery, but rather given adequate postoperative monitoring and treatment.

[Stents in aortic coarctation. Immediate results]

From September 1996 to March 1997 we implanted stents Palmaz (P-308 Johnson & Johnson) in six patients with aortic coarctation. Age ranged from 13 to 30 years (mean = 20), 3 female and 3 male. We implanted the stent without predilation. Balloon diameter was 12 mm in two cases and 15 mm in four cases for complete expansion we used 14 to 20 mm balloon diameter in five instances and in one case we used a dual balloon 15 + 15 mm. The gradient pre-stent ranged from 30 to 65 mmHg (mean = 44) and decreased to 0 mmHg in five cases and in one patient the residual gradient was 4 mmHg. Systolic aortic pressure pre-stent was 135 mmHg and decreased to 117 mmHg. There were no significant complications. In conclusion, we have demonstrated the feasibility of balloon-expandable stent implantation as a method of alleviation the obstruction in coarctation of the aorta in this group of patients. It is an excellent alternative to surgical treatment and it is better than balloon angioplasty that results in marked improvement in the angiographic appearance of the thoracic aorta. It eliminates the gradient, has minimum morbidity and no mortality, no aneurysm formation. Late restenosis and possible aneurysm formation remains an unlikely complication in view of the ample luminal diameter and the high velocity of flow.

[Stents: experience at the Cardiology Hospital of the 21st century National Medical Center]

From february 1995 to february 1997 we implanted 157 stents in 105 patients. Age ranged from 38 to 81 years (mean 58), there were 83 males and 22 females. In 62.8% cases we implanted one stent and in 39 (37.2%) cases 2 to 6. Eighty three were Palmaz/Schatz (P/S), 27 ACT-ONE, 18 Wiktor (W), 9 Gianturco Rubin (GR), 8 Wallstent, 6 XT-Bard and 6 microstent. Indication were de novo in 23.8%, 87.5% post failure PTCA and in 13.3% late PTCA restenosis. Implant was successful al 96.1% of the patients. The first 32 patients received oral anticoagulation, the last 72 received aspirin and ticlopidine only.

COMPLICATIONS

4.7% acute thrombosis, 0.9% sub-acute thrombosis, three of them (2.5%) developed myocardial infarction, 0.9% emergency surgical treatment, 2.8% vascular complications and death in 2.8%. During follow-up (1 to 18 months, mean 7.7) we repeated angiography and 35 patients two to 14 months (m = 5.6), 12 of them had restenosis, during dilation two cases had dissection of the main left coronary artery and were send to surgery, the others were dilated without complications. One case had restenosis of the stent with obstructive lesions in other vessels and was send to elective surgery. The reminded patients are symptom free and had negative stress test. We conclude that this technology is an excellent alternative to percutaneous myocardial revascularization. Larger trials with long term follow-up is necessary to determine the true incidence of restenosis with the different types of stents.

[Severe airway obstruction in 4 cases of postoperative obstructive hematoma]

Obstructive hematoma is a rare postoperative complication of surgery on the floor of the mouth or the anterior region of the neck and throat. The insidious development of symptoms, including agitation, which may be attributed to other causes, or their late appearance in hospital wards staffed by personnel unaccustomed to treating airway complications, means that the risk of hypoxia or respiratory failure is high. We describe four patients in whom the clinical picture began with agitation and dyspnea. Once the diagnosis was established, and after decompression of the surgical wound, tracheal intubation proved impossible in two patients, who required emergency tracheostomy. Two patients died from lack oxygen. Our review of the literature and experience have led to the following recommendations that may prevent avoidable deaths: a) the caregivers directly responsible for these patients should receive specific training; b) long-term monitoring and observation should take place in recovery units where early signs and symptoms can be detected and treated immediately; c) tracheostomy or 24-hour intubation should be considered when surgery in this anatomic region is highly invasive; d) consider that postoperative agitation in these patients is a symptom of hypoxia unless another cause is demonstrated; and e) the zone must be decompressed rapidly by opening the surgical wound and safeguarding the airway whenever obstructive hematomas present.

[Usefulness of intracoronary ultrasound in percutaneous transluminal coronary angioplasty]

From February 1995 to April 1996 we performed intracoronary ultrasound (ICUS) in 32 patients who had percutaneous transluminal coronary angioplasty (PTCA). Eccentric plaques were found in 53% (n = 17) and concentric in 47% (n = 15). We found that 59.3% (n = 19) were soft, hard 21.8% (n = 7) and calcified plaques in 19% (n = 6). More than 40% of the plaques had some degree of calcium and most of them had dissection post PTCA ICUS deferred the procedure in 25% (n = 8) of cases. Seven of them were patients with late control post PTCA and no significant obstruction and a patient was found not to be a good candidate for PTCA. In 24 lesions we found morphology changes post PTCA: 41.6% type A, 12.5% type B, 45.8% type C, 8.3% type D, 90.9% type E1 and 9.1% type E2. Dissection was present in 54.1% post PTCA, ICUS information indicated other interventions (prolonged insufflations or stents). Two cases with acute coronary syndromes had smooth and fibrous plaques with excellent response to PTCA. Residual percentage stenosis post PTCA for quantitative coronary angiography was 23.7% and with ICUS 52.4%.

COMPLICATIONS

there were three cases with coronary spasm that responded well to nitroglycerin. In conclusion, ICUS provides information to evaluate results of PTCA. It also identifies complications and in some cases can improve results.

[Transcatheter closure of ductus arteriosus with coils. Immediate results. Initial experience in Mexico]

From March to May 1996 we performed transcatheter closure of patent ductus arteriosus with spring coils in 4 patients. Age ranged from 5 month to 11 years (mean 4.3 years). One of them had two previous Rashkind occluders with persistant shunt and other case had pulmonary valve stenosis, in this case we performed pulmonary valvuloplasty and after that closure of ductus arteriosus. Mean pulmonary arterial pressure was 10 to 38 mmHg (mean 18), QP/QS was 1.2 to 5.0 (mean 3.2). Immediate total occlusion occurred in two cases and the other had trivial shunt by doppler echocardiography. No complications were detected. In conclusion we believe that this device is another no surgical alternative to treat persistant ductus arteriosus. It is effective, it has a low cost, and all the patients are candidates. The procedure carries minimum risk and has no mortality.

[Intravascular ultrasound. Initial experience and review of the literature]

From February 1995 to February 1996, 52 patients underwent intravascular ultrasound (IVUS) imaging: three with aortic coarctation (AoCo), one with persistent ductus arteriosus (PDA), 5 with rheumatic heart disease (RHD) and normal coronary arteries by angiography, one with muscular bridge in anterior descending artery, 20 with percutaneous transluminal coronary angioplasty PTCA (Group I), one of them with eximer laser and 22 stents (Group II). In patients with AoCo was possible to observe obstruction mechanism and the effect of dilation. In patient with PDA we measured the diameter of ductus. In patients with RHD we found early atherosclerosis in four cases, no detected by angiography. In Group I, we found soft plaque in 8, fibrous/mixed in 7 and calcified plaque with the calcium located superficially near the lumen in 5, concentric in 6 and 14 eccentric plaques. In this group the objective was observational in most of the cases, except when the imaging was characteristic of mayor dissection or small final lumen. In 10 cases we observed fracture or dissection of the plaque, in some with small flaps into the lumen. In the last two cases, IVUS was used to optimize results after PTCA in one, in the other we postponed the procedure because the characteristics of the lesion (severe superficial calcification). The patient who underwent eximer laser, IVUS demonstrated irregular and small lumen and was followed by PTCA. In Group II, IVUS was used to optimize deployment of stents. We did not have any case with subacute thrombosis.

COMPLICATIONS

Only four cases had angina with ischemic ECG changes during the procedure, but reverted after catheter pullback and intracoronary nitroglycerin. In summary, IVUS gives information about mechanism of obstruction, its complications and results of PTCA. Also detect early atherosclerotic disease not observed by angiography. Optimize deployment of stents and avoids cumarinic anticoagulation in most of the patients. Rational selection of device or deferral of the procedure is possible if we know the characteristics of the plaque before intervention. Utility in other cardiovascular diseases is limited at this time. It's a safe procedure, the morbidity is low and in our experience, without mortality. In the future this new technology will bring useful information in other types of coronary arteries diseases.

[Angioplasty and percutaneous valvuloplasty in congenital and acquired cardiopathies. Short- and long-term results]

Percutaneous transluminal balloon catheterization was performed in 38 patients, age 2 to 38 years (mean 13) between October, 1985 and May, 1987. Nineteen with pulmonary valve stenosis (PVS), three with small atrial septal defect (ASD) and one with ventricular septal defect (VSD); six with aortic valve stenosis (AVS); eight with Coarctation of the aorta (CoAo), in two with VSD and one with small ductus arteriosus; and four with rheumatic mitral stenosis (RMS). In PVS the peak systolic gradient (PSG) decreased significantly immediately after the procedure (92 +/- 40 vs 20 +/- 19 mmHg P less than 0.01). Nine patients were evaluated three months and seven one year later and no significant change occurred (19 +/- 11 and 20 +/- 19 mm Hg). The right ventricular systolic pressure (RVSP) and the ratio RVSP/left ventricular systolic pressure (LVSP) decreased immediately after the procedure (114 +/- 37 vs 69 +/- 36 mmHg P less than 0.15, and 0.98 +/- 0.29 vs 0.62 +/- 0.36, P less than 0.15). Three months later the RVSP and ratio RVSP/LVSP decreased more (57 +/- 16 mmHg, P less than 0.05, and 0.47 +/- 0.18, P less than 0.05) and one year later (54 +/- 27 mm Hg, P less than 0.05 and 0.46 +/- 0.24, P less than 0.05). In one case we repeated de dilatation one year later for restenosis. In CoAo PSG decreased immediately after dilation (59 +/- 21 vs 26 +/- 18 mmHg, P less than 0.1). Three months later the gradient was 38 +/- 20 mmHg. One patient was sent to surgery for significant residual gradient and one was dilated again 4 months after the first dilatation. One case was evaluated at cardiac catheterization one year later with gradient of 28 mmHg and blood pressure and femoral pulses were normal. In AVS PSG decrease immediately in all (91 +/- 25 vs 37 +/- 22 mmHg, P less than 0.02). Recatheterization in 4 patients three months later showed improvement in two. Two cases were sent to surgery for significant residual gradient. In these two patients we did not performed a dilatation because one had thrombosis in the puncture site and in the other we suspect subvalvular obstruction. The other two patients have shown clinical, echocardiographic and radiographic improvement.(ABSTRACT TRUNCATED AT 400 WORDS)

[Rhabdomyoma in a newborn infant. Echocardiographic diagnosis]

With the 2D echocardiography, is easier the diagnosis of intracardiac tumors nowadays. We present a case of a newborn girl with a rhabdomyoma intra-myocardiac and intracavitary. We discuss the clinical manifestations, surgical indications and the association with tuberous sclerosis.