mmHg In Cases Research Articles

Frequency of Bioprosthetic Valve Fracturing Utilization in an All-Comers Valve-in-Valve TAVR Cohort.

Introduction: Valve-in-valve TAVR (ViV-TAVR) is an established treatment for failing surgical aortic valves in patient at high surgical risk. Elevated transprosthetic gradients are common after ViV-TAVR. Previously, bench tests showed feasibility of bioprosthetic valve fracturing (VF) using high-pressure balloons. Small case series show reduced transprosthetic gradients using VF. We present our clinical experience and outcome of VF.Material and Methods: Consecutive ViV-TAVR patients were identified from our institutional TAVR database and utilization of bioprosthetic valve fracturing or intraprocedural postdilatation was reviewed. Surgical valves were categorized as responsive or not responsive to VF. Transprosthetic gradients were compared in procedures with VF and procedures with or without postdilatation.Results: In 67 consecutive ViV-TAVR procedures between January 2018 and September 2020, VF was attempted in 15 cases with eight being successful. Standard postdilatation was performed in 21 patients and 31 cases were without postdilatation. Mean transprosthetic gradients (MPG) decreased from 34.2 + 12.5 to 12.7 + 7.4 mmHg (p < 0.001) for all patients. MPG was 8.6 + 3.5 mmHg after VF, 12.9 + 8.5 mmHg after standard postdilatation (p = 0.18) and 13.4 + 6.8 mmHg in cases without postdilatation (p = 0.04). In small surgical valves with true inner diameter <21 mm MPG was 9.1 + 3.5 mmHg after VF, 14.2 + 8.9 after standard postdilatation (p = 0.068) and 16.2 + 9.2 mmHg without postdilatation (p = 0.152). Failed attempts with BVF occurred with the Perimount standard valve.Conclusion: Bioprosthetic valve fracturing results in lower mean transprosthetic gradients after ViV-TAVR. Responsiveness of BVF in Perimount surgical valves, long-term hemodynamic outcome, and potential survival benefits need further evaluation.

Implication of inhaled nitric oxide for the treatment of critically ill COVID-19 patients with pulmonary hypertension.

AimsThis study aims to analyse whether inhaled nitric oxide (iNO) was beneficial in the treatment of coronavirus disease 2019 (COVID‐19) patients with pulmonary hypertension.Methods and resultsFive critically ill COVID‐19 patients with pulmonary hypertension designated Cases 1–5 were retrospectively included. Clinical data before and after iNO treatment were serially collected and compared between patients with or without iNO treatment. The five cases experienced pulmonary artery systolic pressure (PASP) elevation (≥50 mmHg) at 30, 24, 33, 23, and 24 days after illness onset (d.a.o), respectively. Cases 1–3 received iNO treatment on the 24th, 13th, and 1st day after the first elevation of PASP, with concentrations varied from 10 to 20 ppm based on the changes of PASP and blood pressure for 10, 9, and 5 days, respectively. Upon iNO treatment, PASP of Cases 1 and 2 returned to normal on the 10th day and 1st day, and maintained between 50 and 58 mmHg in Case 3. Pa02/Fi02 increased from 88 to 124, 51 to 118, and 146 to 244, respectively. SPO2 increased from 91% to 97% for Case 1 and maintained a high level above 97% for Case 2. Cardiac function remained normal in the three patients after treatment. Moreover, Cases 1 and 3 survived from severe acute respiratory syndrome coronavirus 2 infection, while Case 2 finally died on the 36th day after the first elevation of PASP due to severe complications. Both cases who did not receive iNO treatment experienced a sudden decrease of PASP and Pa02/Fi02 due to right heart failure and then died.ConclusionsInhaled nitric oxide treatment was beneficial in reducing and stabilizing the PASP and might also reduce the risk of right heart failure in COVID‐19 with pulmonary hypertension.

Association of Serum C-reactive Protein in Preeclampsia and its Effect on Fetal Birth Weight – A Case Control Study

Objective(s): The aim of this study was to evaluate the association of serum C-reactive protein (CRP) in preeclampsia (PE) and its effect on fetal birth weight.Materials and methods: This case control study was conducted in Chittagong Medical College Hospital, Bangladesh, from July 2013 to June 2014. Study population was pregnant women of third trimester with preeclampsia (case group) and normal blood pressure (control group). The maternal serum C-reactive protein (CRP) levels were measured by immune turbidometric assay between 32 weeks to term. The women were divided into three groups: mild PE, severe PE (according to ACOG criteria) and normal healthy group. The value of CRP and its correlation with birth weight was compared between groups.Results: One hundred and fifty (150) pregnant women were analyzed. Among them 50 were case and 100 control. There was no difference between age of the patients of both groups. The mean systolic blood pressure was 148.40 ± 12.35 mm Hg in case and 122.15 ± 6.44 mmHg in control group. The mean diastolic blood pressure was 100.00 ± 9.74 mmHg in case and 74.05 ± 5.97 mmHg for the control. The systolic and diastolic blood pressure was significantly higher in preeclamptic group (P &lt; 0.000). C-reactive protein was 10.28 ± 7.25 mg/ mL in mild PE and 10.94 ± 6.32 mg/mL in severe PE and 3.45 ± 1.71 mg/mL in normotensive group, which was significantly higher in case than control group (P = 0.000). Preeclamptic women delivered at a significantly shorter gestational age than normal pregnant women. Mean gestational age during delivery for the case group and control group was 39.02 ± 1.6 and 39.58 ± 0.8 weeks respectively. Mean birth weight in PE (2.52 ± 0.42 kg) was significantly lower than normal pregnancies (2.88 ± 0.29 kg). The sensitivity and specificity of CRP were 68% and 98% respectively. Multiple regression analysis showed that there is a strong association between CRP levels and PE and birth weight.Conclusion: This small study showed that in case group CRP was raised in 68% cases which is much higher in comparison to healthy control group where CRP was high only in 2% cases. High CRP has association with low birth weight. Therefore, CRP may be used as cost effective investigation to identify the risk of preeclampsia and its effect on fetal birth weight.Bangladesh J Obstet Gynaecol, 2016; Vol. 31(2) : 75-80

Suture Trabeculotomy Ab Interno for Secondary Glaucoma Combined With Scleromalacia

To report 2 cases of secondary glaucoma combined with scleromalacia that were successfully treated with trabeculotomy ab interno. Retrospective case report : Trabeculotomy ab interno was used to treat secondary glaucoma combined with scleromalacia, which occurred due to refractory scleritis, in 2 cases. In case 2, goniosynechialysis was performed before the trabeculotomy to identify the trabecular meshwork. The sclera and conjunctiva were not incised in either case. The patients' postoperative intraocular pressure (IOP) levels (which were achieved without medication) were lower than their preoperative IOP levels (which were recorded during the administration of the maximum tolerable medication dosage); that is, they had dropped from 24 to 12 mm Hg in case 1 and from 33 to 11 mm Hg in case 2 by 12 postoperative months. No recurrent scleritis or postoperative worsening of the patient's scleromalacia was seen in either case. Trabeculotomy ab interno is a very valuable treatment for secondary glaucoma combined with scleromalacia.

Percutaneous transportal outflow‐vessel‐occluded sclerotherapy for gastric varices unmanageable by balloon‐occluded retrograde transvenous obliteration

In this report we introduce percutaneous transportal outflow-vessel-occluded sclerotherapy (PTOS) for gastric varices unmanageable by balloon-occluded retrograde transvenous obliteration (BRTO) in two cases and evaluate its safety and efficacy. The PTOS is a technique which could obstruct gastric varices subsequent to the occlusion of the outflow route, being based on the rationale of BRTO. In the PTOS procedure, coil embolization of the outflow vessel is first conducted through a microcatheter advanced beyond the gastric varices via the percutaneous transhepatic approach; sclerosing agent (5% ethanolamine oleate) is then injected into the gastric varices after confirmation of static blood flow in the varices. Two patients underwent initial BRTO that eventually failed because of the presence of numerous fine and abruptly angled outflow vessels (case 1), and the presence of a tortuous and elongated outflow vessel accompanied by numerous small collateral outflows that could not be occluded (case 2). Cases 1 and 2 received PTOS using 5% ethanolamine oleate (15 mL and 10 mL, respectively). Portal venous pressure following PTOS showed an increase from 29 to 34 mmHg in case 1 and remained at 24 mmHg in case 2. No major complication was encountered in either patient. One-year follow-up gastroendoscopy showed no recurrence of gastric varices in either patient. Although PTOS is slightly more invasive than BRTO, PTOS can be used as an alternative catheter treatment procedure for gastric varices that are unmanageable by BRTO.

Relationship of central corneal thickness to postural IOP changes in patients with and without glaucoma in southern India

To evaluate the relationship of central corneal thickness to the changes in intraocular pressure (IOP) in the sitting and supine position. Observational case-control study. The study group included Primary open-angle and chronic angle closure glaucoma patients. The control group consisted of patients without glaucoma seen for their routine eye examination. Central corneal thickness was measured by ultrasound pachymetry. Patients were then randomized to IOP measurement by Tonopen either sitting or supine after maintaining that position for 5 min. The position was then reversed and IOP measurements taken again after 5 min. Main outcome measure was change in IOP. One hundred and eighty-two eyes (90 in cases and 92 in controls) were examined. The mean CCT was 538.11 ± 37.17 μm in the study group and 545.34 ± 36.01 μm in the control group (P = 0.185). The mean IOP in the sitting position was 19.54 ± 5.39 mmHg in cases and 14.82 ± 4.01 in controls (P < 0.001). The mean IOP in the supine position was 20.51 ± 5.48 mmHg in cases and 16.02 ± 3.24 in controls (P < 0.001). Mean IOP change from sitting to supine was statistically significant in both groups (P < 0.001 for both). Postural change was greater in cases than controls (P = 0.020). There was no correlation between postural IOP change and CCT in cases (r = 0.143, P = 0.180) and controls (r = 0.096, P = 0.362). Postural IOP change is greater in glaucoma patients than non-glaucomatous patients. There was no correlation between postural IOP change and CCT.

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Sturge-Weber syndrome: decrease in intraocular pressure after transpupillary thermotherapy for diffuse choroidal haemangioma

To report intraocular pressure (IOP) reduction after selective and partial destruction of diffuse choroidal haemangioma (DCH) by transpupillary thermotherapy (TTT) using an 810 nm infrared diode laser in two patients with Sturge-Weber syndrome (SWS) having late-onset juvenile glaucoma (LOJG). An interventional small case series. Laser spots (diameter, 1 mm) were applied to the tumour surface located outside the posterior pole. Energy level (600-1700 mW) and exposure time (1-4 seconds) were increased stepwise until the tumour exhibited a greyish discoloration. The treatment was split into 2-4 sessions. Before TTT, both patients had uncontrolled LOJG with an IOP of 23 mmHg (Case 1) and 45 mmHg (Case 2) in spite of topical medications. In both cases, TTT led to normalization of IOP to 15 mmHg and 24 mmHg, respectively, and stopped the progression of LOJG during a follow-up period of 6 years (Case 1) and 1 year (Case 2). Visual loss or other complications were not observed. Our study highlights the close link that exists between LOJG and DCH in SWS. A single treatment modality such as TTT may both reduce IOP in LOJG and help to prevent exudative retinal detachment in DCH. We believe that TTT is a good therapeutic option for SWS patients who have both DCH and LOJG.

起立性めまいと血圧低下の関係‐起立試験による検討‐

Some patients have different vertiginous symptoms such as faintness, rotatory sensation or swaying sensation when rising to the standing position. These symptoms, hereafter referred to as orthostatic vertigo (OV), are believed to occur due to hypoperfusion of the brain with the orthostatic decrease in blood pressure (BP). However, it is unclear whether the orthostatic decrease in blood pressure is directly involved in the onset of OV. Therefore, we studied the influence of the orthostatic change in BP on OV. All 780 subjects in the present study had orthostatic changes in their BP examined, including 239 cases with OV and 541 cases without OV. Orthostatic hypotension (OH) was defined as a systolic BP decrease of more than 20 mmHg when standing. In subjects with a BP of 140 mmHg and over before standing, the orthostatic decrease in BP was more than 20 mmHg in cases with OV, significantly different from those without OV. In the case of a BP over 160 mmHg, subjects with OV showed a severe OH greater than 30 mmHg. In contrast, when the BP was under 140 mmHg, OH was not detected even in those subjects with OV. Under 110 mmHg BP, there was no difference of orthostatic decrease in blood pressure between in cases with OV and those without OV. These results suggest that it is necessary to consider the BP before standing when assessing the incidence of OV due to OH.

Large Diurnal Variation of Intraocular Pressure Despite Maximal Medical Treatment in Juvenile Open Angle Glaucoma

To report the clinical significance of large fluctuations in intraocular pressure (IOP) and the effect of trabeculectomy on diurnal IOP variations in 2 cases of maximally medically treated juvenile open angle glaucoma (JOAG). A 24-hour IOP monitoring was performed before and after trabeculectomy on both eyes of 2 JOAG patients-one with transiently blurred vision early in the morning, the other with progression of visual field defect despite apparently well-controlled IOP. The patients' optic discs were scanned with Heidelberg retina tomograph (HRT) during peak and trough IOPs before trabeculectomy. Preoperatively, diurnal IOP varied widely up to 20/19 (OD/OS) mm Hg in case 1 and up to 16/22 (OD/OS) mm Hg in case 2, even though both patients were using 4 different types of antiglaucoma eye drops. Peak IOP was associated with temporary blurring of vision and mild corneal edema in 1 patient (case 1). Heidelberg retina tomograph revealed a deepening of the optic cup and a resultant narrowing of the neuroretinal rim at peak IOP in this patient; this was not detected in the second patient who had tilted optic discs. After trabeculectomy, diurnal IOP fluctuations were reduced to 4-6/2-4 (OD/OS) mm Hg in case 1 and to 6-7/3-7 (OD/OS) mm Hg in case 2, with a decrease in peak IOPs as well. Wide diurnal variation should be suspected in JOAG patients, even when receiving maximal medical treatment; this is especially important in cases with temporary blurred vision and/or progression of visual field defect despite apparently well-controlled IOP. Trabeculectomy was more effective in reducing diurnal IOP variation than medical treatment.

Argon Laser Trabeculoplasty in Triamcinolone Acetonide Induced Ocular Hypertension Refractory to Maximal Medical Treatment

To report two cases of intraocular hypertension after intravitreal injection of triamcinolone acetonide (iTAA) that were refractory to maximal medical therapy and were successfully treated with argon laser trabeculoplasty (ALT). Two patients with history of primary open angle glaucoma were treated with intravitreal injection of triamcinolone acetonide for chronic macular edema secondary to branch retinal vein occlusion. Both patients (Case 1 after 2 months and Case 2 after 5 days) developed intraocular hypertension that did not respond to maximal medical therapy. Despite medical therapy, intraocular pressure (IOP) was 45 mmHg in Case 1 and between 34 and 37 mmHg in Case 2. ALT was performed in the inferior 180 degrees angle using the following parameters: 50 microm size, 700 mW, 0.50 sec, 100 spots. In both patients IOP returned to normal level a few days after ALT. ALT seems to be effective at reducing IOP in patients with intraocular hypertension secondary to iTAA that does not respond to maximal medical treatment.

Screen detected high blood pressure under 40: a general practice population followed up for 21 years.

To assess hypertension detected under 40 in a general practice population. Prospective case-control study. Former coal mining community in south Wales. Systematic case finding for hypertension and associated risk factors applied to a mean total population of 1945 from age 20 on a five year cycle through 21 years. Mean population aged 20-39, 227 men and 213 women. Case criteria: age < 40 and mean systolic pressure > or = 160 mm Hg or diastolic pressure > or = 100 mm Hg. Age and sex matched controls randomly sampled from the same population. Mean initial pressures and pressures at follow up in 1989 or preceding death, and all cardiovascular events. 25 men and 16 women met criteria. Estimated five yearly inceptions were 26/1000 for men and 18/1000 for women. Male group mean initial blood pressure was 164/110 mm Hg for cases, falling to 148/89 mm Hg at follow up. Five male cases died at mean age 47.8, compared with two controls at 49.5. Female group mean initial pressure was 172/107 mm Hg for cases, falling to 145/86 mm Hg at follow up. One female case died aged 50, no controls. 10 male cases had non-fatal cardiovascular events at mean age 40.2, compared with two controls at mean age 50.5. Four female cases had non-fatal events at mean age 47.2, compared with one control aged 58. Male differences were statistically significant. Hypertension under 40 is dangerous, commoner in men than women, rarely secondary to classic causes, and may be controlled in general practice on a whole community basis.

SURGICAL TREATMENT OF DOUBLE CHAMBERED RIGHT VENTRICLE IN ADULTS

Double chambered right ventricle (DCRV) is common in children, and rarely occurs in adults. Three operated cases of DCRV in a 46-, 46-, and 62-year-old patients are described. The peak systolic pressure gradient in the right ventricle was 110 mmHg in case 1, 80 mmHg in case 2, and 150 mmHg in case 3. A right ventriculotomy in a low pressure chamber was performed in cases 1 and 3, and a longituidinal right ventriculotomy from a low to high pressure chamber was used in case 2 associating with VSD. After surgery, the pressure gradient in the right ventricle disappeared but end-diastolic high pressure was recognized in all patients. It was suggested that deterioration of right ventricular diastolic compliance remains after surgery in adult patients with DCRV.

Reopening Filtration Fistulas with Transconjunctival Argon Laser Photocoagulation

Three patients (a 15-year-old girl, a 45-year-old woman, and a 61-year-old woman) with previously successful full-thickness filtering procedures developed pigmented tissue in the fistula sites and uncontrolled intraocular pressures despite maximum tolerable medical therapy. The filtering procedures in the first and second patients spontaneously failed two and four years after surgery. The filtration bleb of the third patient, after successfully controlling intraocular pressure for six years, failed two months after cataract extraction. Argon laser therapy was applied through the conjunctiva to treat visible subconjunctival pigmented tissue within the sites of the previous surgical filtration blebs. In all three cases, there was an immediate and significant decrease in intraocular pressure associated with reestablishment of the filtration bleb (from 44 to 16 mm Hg in Case 1, from 40 to 15 mm Hg in Case 2, and from 25 to 12 mm Hg in Case 3). Long-term follow-up showed well controlled intraocular pressures without glaucoma medications (Case 1, 5 mm Hg after 18 months; Case 2, 17 mm Hg after one year; and Case 3, 9 mm Hg after five months).

Lipoprotein (a) level in pre-eclampsia patients

This study was carried in BSMMU from July 2001 to June 2003. During the study period, 60 pregnant women were studied. Thirty patients were preeclamptic and thirty were normal healthy pregnant women served as control. Serum lipoprotein(a) was found significantly higher in preeclamptic women 56.63 +/- 22.6 mg/dl and found within limit in normal healthy pregnant women, 12.89 +/- 4.59 mg/dl. Result is statistically highly significant (P < 0.001). Mean systolic blood pressure was 163.33 +/- 29.63 mmHg and 117.00 +/- 11.19 mmHg in case and control and Diastolic Blood Pressure was 108.53 +/- 14.54 mmHg and 76.00 +/- 6.87 mmHg respectively in case and control group. Result was highly significant as P < 0.001. The mean (+/- SD) serum lipoprotein(a) concentration in normal pregnancies and preeclampsia were found to be 12.91 +/- 4.94 and 56.65 +/- 22.62. Moderate proteinuria was found in 77.5% and severe proteinuria in 22.2% cases of preeclampsia respectively. Regardless of mechanism and pathophysiology of preeclampsia, we found high serum level of lipoprotein (a) in preeclampsia patients. These high levels of lipoprotein (a) significantly correlated with blood pressure and proteinuria.