Severe MS Research Articles

Outcome of cases of Mitral Stenosis after Percutenuous Transvenous Mitral Commissurotomy (PTMC)

This prospective study was carried out in the National Institute of Cardiovascular Diseases and Hospital (NIC VD), Dhaka, Bangladesh during the period January 2002 to December 2002. The result of percutenuous ballon mitral valvotomy were evaluated in 153 cases of mitral stenosis patients (mean age 36±15 years) with symptomatic rheumatic mitral stenosis with single Inoue ballon technique PTMC results significant increase mitral valve area. 79.18 to 1.86 ±.37. Transmitral mean pressure gradient 19.6 ± 8.9 to 3.7±38, Decrease mean left atrial size 41.33±9.3 to 30.56±8.16 and Pulmonary artery systolic pressure 56±24 to 39 ±17, Peak pressure gradient (PPG) 19.6±8.9 to 8.7 ±3.8, But lower incidence of mitral regurgitation, only two cases developed MR grade Ill which were treated medically, one patient develop moderate haemopericardium which was treated conservatively. One patient was failed due to severe tight MS of valve area 0.5. No surgical intervention was needed.

September 24 Highlights

Ghalie et al. reviewed records of 1,378 patients who received mitoxantrone in MS clinical trials. At median cumulative dose 62.5 mg/m2 and follow-up 29 months, 2 of 1,378 patients (<0.20%) experienced congestive heart failure (CHF). Whether the incidence of CHF in MS patients will prove to be higher with greater cumulative mitoxantrone doses is not yet established. see page 909 Brassat et al. report acute leukemia in a mitoxantrone-treated patient with severe MS—the first case among 802 French mitoxantrone-treated MS patients. see page 954 Commentary by John W. Rose, MD Mitoxantrone is an important new therapy recently approved by the FDA for treatment of severe relapsing and secondary progressive multiple sclerosis. In this issue of Neurology, two articles discuss potential side effects of the drug. The article by Ghalie et al. examines the cardiotoxicity of the drug in multiple sclerosis patients demonstrating a low incidence of clinical congestive heart failure across several studies. The result of a 0.2% incidence for …

PCV18 The Impact of Acute Renal Failure on Cost in Elderly Patients with Congestive Heart Failure

The impact of acute renal failure (ARF) on cost was evaluated in elderly patients with congestive heart failure (CHF). METHODS: We reviewed medical records of 2,176 Connecticut Medicare beneficiaries, aged 65 and older who were hospitalized with CHF, excluding CHF due to severe AS, MS, or primary non-cardiac illness, between January 1994 and December 1995 at 20 hospitals. ARF was defined as an increase in serum creatinine level of 25% from admission, to at least 2 mg/dL during hospitalization. We excluded patients who did not have at least two creatinine measurements (N = 251). To avoid including patients with ARF as a result of procedures or complications, we excluded all patients with major complications or procedures during hospitalization (n = 531). Linear regression models were used to examine the relationship between ARF and length of hospital stay and hospital cost. RESULTS: A total of 1,681 patients were included in the study sample. Of those, 164 (10%) developed ARF during hospitalization. After adjusting for confounding effects of sex, age, history of CHF, history of hypertension, diabetes, rales, hematocrit, creatinine, systolic blood pressure, and left ventricular ejection fraction, ARF was associated with a significant increase in the length of stay (LOS) by 3.31 days (p < 0.0001) and a significant increase in hospital cost by $2,714 (p < 0.0001). CONCLUSION: ARF in hospitalized older patients with CHF is associated with a longer LOS and higher cost. Strategies to prevent the development of ARF in high-risk hospitalized patients may provide the opportunity for marked reductions in cost.

Reduced glucose metabolism in the frontal cortex and basal ganglia of multiple sclerosis patients with fatigue: a 18F-fluorodeoxyglucose positron emission tomography study.

To investigate the pathophysiology of fatigue in MS, we assessed cerebral glucose metabolism (CMR-Glu) in 47 MS patients using PET and 18F-fluorodeoxyglucose. Applying the Fatigue Severity Scale (FSS), we first compared MS patients with severe fatigue (MS-FAT, n = 19, FSS > 4.9) and MS patients without fatigue (MS-NOF, n = 16, FSS < 3.7) on a pixel-by-pixel basis using Statistical Parametric Mapping (SPM95). Second, we compared FSS values of all 47 patients covering the whole range of this scale with CMRGlu using an analysis of covariance (SPM95). In addition, we determined global CMRGlu by region-of-interest analysis. Sixteen healthy subjects served as control subjects (CON). Global CMRGlu was significantly lower in both MS groups compared with CON (CON 43.3 +/- 6.9 mumol/100 mL/min, MS-FAT 34.7 +/- 4.4, MS-NOF 35.4 +/- 4.5) but was not related to fatigue severity. Comparing the two MS groups, SPM95 analysis revealed predominant CMRGlu reductions bilaterally in a prefrontal area involving the lateral and medial prefrontal cortex and adjacent white matter, in the premotor cortex, putamen, and in the right supplementary motor area of MS-FAT. In addition, there were CMRGlu reductions in the white matter extending from the rostral putamen toward the lateral head of the caudate nucleus. FSS values were inversely related to CMRGlu in the right prefrontal cortex. CMRGlu in the cerebellar vermis and anterior cingulate was relatively higher in MS-FAT than in MS-NOF patients. CMRGlu of both regions showed positive correlations with FSS values. Our data suggest that fatigue in MS is associated with frontal cortex and basal ganglia dysfunction that could result from demyelination of the frontal white matter.

Letter To The Editor: Autopeep Due To Cardiac Pulsations

37 year old Malay lady undergoing operation for uterine fibroid: Total abdominal hysterectomy with salphingooopherectomy as an elective procedure. She has history of chronic rheumatic heart disease with atrial fibrillation with moderate tricuspid regurgitation, mitral stenosis and aortic regurgitation. Mitral valvotomy was performed in 1990 for severe MS /MR. Presently not in heart failure. Current medications are :

Treatment of relapsing experimental autoimmune encephalomyelitis with largely MHC-matched allogeneic bone marrow transplantation.

BUF rats suffering from severe relapsing experimental autoimmune encephalomyelitis (R-EAE), a model for multiple sclerosis, were treated with intensive cytoreductive therapy and grafting of allogeneic bone marrow (BM). BN.1B rats were used as EAE-resistant, largely MHC-matched donors, resembling human BMT from HLA-identical siblings. The treatment induces complete remission and low recurrence rates of R-EAE. Evidence is provided that the efficacy of the treatment depends on a high degree of lymphoablation: a minority of rats had host-type residual activated T lymphocytes in the CNS after treatment. Furthermore, complete replacement of host-type BM by donor-type hemopoietic cells is essential, as higher relapse rates were observed in animals with incomplete reconstitution by donor cells than in completely reconstituted rats. Overall, our results indicate that patients with severe MS might benefit from treatment with HLA-matched allogeneic BM.

Left ventricular systolic dysfunction diastolic filling characteristics and exercise cardiac reserve in mitral stenosis

In summary, our data indicate that a significant number of patients with severe MS have LV systolic dysfunction. This results, at least in part, from diastolic flow reduction caused by the tight mitral valve and possibly by the poorly compliant LV posterior wall, which reduces LV end-diastolic volume. Although ejection fraction increases with exercise, LV filling is further compromised by the shorter diastolic periods at higher heart rates, resulting in a severe reduction in LV end-diastolic and stroke volumes, and an attenuated increase or actual decrease in cardiac output.

717-6 Indications, Complications and Mid-term Outcome of Percutaneous Balloon Mitral Valvotomy During Pregnancy

We performed double balloon mitral valvotomy (BMV) in 36 consecutive pregnant women (mean age 26 years). Pregnancy mean age was 26 weeks (range 14–38 weeks). Thirty patients (pts) had pliable valves, 4 pts semi pliable valves and 2 pts calcific valves at fluoroscopy. Four pts had moderately severe MS (MVA 1.4 to 1.7 cm 2 ). Moderate (2 +) mitral regurgitation (MR) was present in 2 pts. Thirty pts were in NYHA functional class III or IV and 6 pts were in class II. The patient's pelvic-abdominal area was shield. Double balloon technique was used in 35 pts and Inoue device in one pt. The total mean time of BMV was 76 ± 19 min and that of fluoroscopy was 18 ± 8 min. Left atrium pressure decreased from 28 ± 9 to 14 ± 5 mmHg, cardiac index increased from 3.2 ± 0.9 to 4.6 ± 1 l/mn/m 2 and MVA increased from 0.9 ± 0.2 to 2.5 ± 0.4 cm2 There were no mortality nor residual MS. Impressive symptomatic improvement was obtained in all pts but 1 who developed severe (4 +) MR and underwent mitral valve replacement 5 days later. Thirty three pts delivered at full-term, 31 pts delivered vaginally and 2 pts by cesarean section due to obstetrical problems; 30 babies were normal and 3 were hypotrophic. At mean 24 ± 11 months post partum follow-up, the 33 infants had shown normal growth and development. Pregnancy evolves normally in the 3 remaining pts. During pregnancy BMV is the treatment of choice of severe pliable MS. Indications may be broadened to pts with rigid and calcific valves and to pts who had moderately severe MS or associated moderate MR and refractory disability.

First the Body, Then the Mind

Sexual abuse of children has in recent years bee n he ra lded as an a rea of concern to psych ia tric profession als. An increasin g number of pat ien ts who present for psych iatric treatm ent a re revea lin g a hist ory of sexual abuse d uri ng child hood or adolescence . Psychiat ry has just begun invest igating the short and long term psych ological se que lae of th ese traumata, a nd a pproaches to t reatmen t are re latively you ng . For many patients th e conse q ue nces are severe. One of th e most severe case s I have enco u nte re d is th at ofa fellow psychiatric resid ent who committ ed sui cide during the last yea r of he r resid ency. She had ba ttl ed a major d ep ression and severe sym pto ms of PTSD for a year a fte r uncovering a m emory of se xual abuse during psych oa nal ytic treatment. She was tortured by th e experie nce of havin g her en t ire iden tity built arou nd a defen sive posture d esign ed to keep he r child hood tra uma hidden . I did not understand, then or now, wh y suicid e was th e only opt io n for my colle ague , but a ft er reading Levine 's book a nd others on th e subj ect , I do a pprec ia te th at sexual abuse tak es healthy narcissism a nd a n emerging libido a nd makes the m u nsafe, fri ghtening a nd forever d eprived territories. Most importantly, it co mprom ises or e rad ica tes th e se pa ra te identity of another person since it s victims a re possessed by a nother. It is one form of wh at She ngold I so poign antly ca lls soul murd er. Howard Levine 's Adult A nalysis and Childhood Sexual Abuse is in par t a response to the need for more synthesized th eo retica l a nd clinica l m aterial whi ch will a id psych othe rap ist s in th e recognition a nd treatment of th e psych op a thological se que lae of child hood sexual abuse . Adult A nalysis and Childhood Sexual A buse is co m posed of e leve n chapt ers. Three a re a n in t rod uct ion and overview ; six cha pte rs a re devoted to cl inica l co nsid e rations a nd t he psych oa nalyti c process; a nd two chap te rs cover issu es of technique. Mo st of the a u tho rs use d escript ive , inde pth case mate r ial as the basis for d iscussion. While the ca se m at eria l tends to be lengthy co m pare d to th e theoretical cons idera tions , t he cl inica l informat ion does help the reader a pprecia te th e range of sym p tomat ology a nd the degrees of psych op athology in this group as we ll as t he com plex a nd cha llenging issues that a rise in their treatment. Severa l of the chapte rs warrant spe cific m ention. Both chapters written by Stee le, and Burland and Raskin a re in format ive ove rv iews of the subj ect. St eele

Frequency of angiographically significant coronary arterial narrowing in mitral stenosis

Ninety-six consecutive patients older than 40 years with severe mitral stenosis were retrospectively analyzed to determine the relation of angina pectoris (AP) and coexistent coronary artery disease (CAD). Of the 96 patients, 27 (28%) had angiographically significant CAD, 10 (37%) with AP and 17 (63%) without AP. Of the 96 patients, 21 had AP, 10 (48%) with angiographically significant CAD and 11 (52%) without (CAD). Of 75 patients without AP, 17 (23%) had angiographically significant CAD AP had a specificity of 84% and a sensitivity of 37% in its ability to detect significant CAD. The pulmonary artery systolic, diastolic and mean pressures and the pulmonary vascular resistance did not differ between patients with and those without AP (p > 0.05). It is concluded that coexistent CAD is commonly found in patients older than age 40 with severe MS, and is usually clinically silent.

Combined mitral stenosis and coronary artery disease: A clinical syndrome characterized by paroxysmal pulmonary edema with rapid resolution

Four women, aged 57 to 75 years, were hospitalized for the abrupt onset of pulmonary edema, which resolved within 24 hours after small doses of intravenous diuretic drugs. In 2 patients, these clinical episodes were recurrent. Cardiac catheterization was performed in 3 patients (Table I) and moderate to severe MS and significant CAD were documented in each. Left ventricular (LV) ejection fractions ranged from 53 to 62%; left ventricular end-diastolic pressures were normal. One patient died before cardiac catheterization could be performed, but severe MS was diagnosed by 2-dimensional echocardiography and CAD was documented by enzymatic and electrocardiographic evidence of acute anterolateral myocardial infarction after repeated episodes of recurrent pulmonary edema. In our 2 oldest patients, aged 75 and 77 years, classic ischemic discomfort did not occur, and MS was not detected by clinical examination.

Multiple sclerosis and pregnancy

Gestation is a period of decreased risk for a relapse of MS, whereas the 3 months postpartum is a period of high risk. Taken together, the pregnancy year may also be a period of higher risk for relapse than non-pregnancy periods. However, the lifetime risk rate does not appear to change because of pregnancy, and on the basis of current retrospective studies, long-term disability is not higher in pregnant women or even women experiencing relapses during the pregnancy year. MS has little or no effect on the course of pregnancy or delivery, although patients with severe MS may have difficulty fully caring for their newborns. The decision to become pregnant should be made by the patient and her husband after they are appropriately informed about the risks involved.