Symptomatic Improvement In Most Patients Research Articles

S2779 A Drug After My Own Heart: Mesalamine-Induced Perimyocarditis

Introduction: Mesalamine is a commonly used first line treatment to induce remission in mild to moderate Ulcerative Colitis (UC) that many patients tolerate well. However it does not come without risk and can rarely cause serious and life threatening cardiac and lung inflammation including myocarditis. Case Description/Methods: A 33 year old male with recently diagnosed ulcerative pancolitis presented with one day of pleuritic, positional chest pain and exertional dyspnea. Two months prior to presentation he had been diagnosed with moderate pancolonic ulcerative colitis and started on mesalamine 1.2 gm twice daily and mesalamine 1000mg suppository every evening, with significant improvement in his symptoms. On presentation, laboratory evaluation was remarkable for elevated troponin to 0.918 and elevated brain naturetic peptide to 2770. Electrocardiogram showed diffuse PR depression and ST elevations consistent with pericarditis. The patient was admitted for further evaluation. Mesalamine was stopped and he was started on Ibuprofen and colchicine with improvement in his pain. Common viral etiologies were ruled out with polymerase testing. A transthoracic echocardiogram revealed moderate global hypokinesis with a reduced ejection fraction (EF) of 25%. A cardiac MRI showed hyperenhancement throughout basal-to-mid inferior and inferolateral wall with ∼5% scar burden proving the diagnosis of perimyocarditis. At 1 month follow up his EF recovered to 52%. His UC symptoms have returned since stopping therapy though he remains hesitant to start other UC therapy given concerns regarding adverse effects. (Figure) Discussion: Mesalamine induced myocarditis is a rare but potentially lethal complication. It typically occurs within 1-2 weeks of starting the medication but has been reported as early as 48 hours and as late as 4 weeks. The specific pathogenesis of Mesalamine induced myocarditis is unknown. Withdrawal of mesalamine leads to symptomatic improvement in most patients as well as recovery of ejection fraction within weeks of discontinuing the medication, as seen with our patient. Future treatment with mesalamine and other 5-ASA derivatives should be avoided as they can trigger recurrent symptoms. Our case highlights a rare and life threatening complication of a commonly used medication. It also highlights the importance of discussing the potential risks of medications with patients. While rare, these authors recommend discussing the potential for myocarditis when counseling patients on treatment options for UC.Figure 1.: Cardiac MRI with myocardial inflammation.

LB925 Bullous pemphigoid associated with immune checkpoint inhibitor therapy: A systematic review of the literature

Bullous pemphigoid (BP) is a rare and debilitating autoimmune blistering disorder reported to occur secondary to immune checkpoint inhibitors (ICIs). Management is challenging, often necessitating ICI discontinuation and prolonged immunosuppressive treatment. There is limited original research comprehensively characterizing ICI-induced BP (ICI-BP), with most existing studies being small case-based studies. We thus sought to summarize the risk factors, presentation, diagnostic findings, treatments, and outcomes of ICI-BP. A systematic review of several databases was performed according to PRISMA guidelines. Studies reporting data on individual patients meeting pre-established inclusion criteria were selected and a predefined set of data was abstracted. 531 articles were initially screened, and 70 studies reporting data on 127 individual patients were ultimately included and quantitatively combined whenever possible. Patients ranged in age from 35-90. ICI-BP often occurred during the course of anti-PD-1 (84.7%), PD-L1 (3.9%), or CTLA-4 (2.4%) therapy but was also found to develop after treatment cessation. 48.2% of patients experienced prodromal symptoms (e.g. pruritus). Immunotherapy was discontinued after ICI-BP development in 55.1% of patients. Common treatments were systemic (84.2%) and topical (53.5%) corticosteroids. Biologic and targeted agents, used predominantly in steroid-refractory cases, led to marked symptomatic improvement in most patients (13/16, 81.3%). Although rituximab and IVIG are included in the National Comprehensive Cancer Network treatment algorithm for ICI-induced bullous dermatoses, we do not have clear safety data and anecdotally avoid them. As steroid-sparing agents mitigate the need for ongoing immunosuppression and other negative sequelae, further research is needed to allow for the earlier utilization of targeted and immunomodulatory therapies in affected patients.

Boswellia resin extract and propolis derived polyphenols in patients with type III chronic prostatitis/chronic pelvic pain syndrome: An Italian prospective multicenter study

ObjectiveTo assess the efficacy and safety of a treatment regimen based on rectal administration of Boswellia resin extract and propolis derived polyphenols in patients with type IIIa and type IIIb chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS). MethodsPatients with type IIIa and type IIIb CP/CPPS received one rectal suppository a day for 15 days per month for 3 consecutive months. Participants were evaluated with National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), the International Prostate Symptom Scores (IPSS), International Index of Erectile Function (IIEF), four-glass test, uroflowmetry, and prostate-specific antigen assessments at baseline and at Week 4, and Week 12. Primary endpoints were improvement in pain domain of NIH-CPSI and improvement of NIH-CPSI total score. Secondary outcomes included improvement of micturition and quality of life (QoL) domains of NIH-CPSI questionnaire. ResultsA total of 61 males were enrolled. No adverse events were reported. Significant improvements from baseline to Day 30 were reported for NIH-CPSI total score (mean difference: −9.2; p<0.01), NIH-CPSI pain domain (mean difference: −5.5; p<0.01), NIH-CPSI micturition domain, NIH-CPSI QoL domain, and IPSS total score (mean difference: −5.6; p<0.01). No significant changes from baseline in terms of IIEF score or maximum flow rate were observed. At final follow-up (Day 90), further significant improvements in terms of NIH-CPSI total score (mean difference: −12.2; p<0.01), NIH-CPSI pain domain (mean difference: −6.6; p<0.01), NIH-CPSI micturition domain, NIH-CPSI QoL domain, and IPSS total score were reported. ConclusionRectal administration of Boswellia resin extract and propolis derived polyphenols is well tolerated and delivers a significant symptomatic improvement in most patients with type IIIa and type IIIb CP/CPPS.

Symposium 4: Neuromuscular junction and related disorders SY4.1. Myasthenia gravis and related disorders

Autoimmune myasthenia gravis (MG) results from autoantibodies that bind to the neuromuscular junction (NMJ). Incidence and prevalence vary worldwide; the estimated US prevalence is 20/100,000, or ∼60,000 patients. Women develop MG more often before age 40, men after 50. Drooping eyelids or double vision is the first symptom in 60%; weakness remains limited to periocular muscles in 10–15% – ocular myasthenia. The voice may be nasal or hoarse, especially after prolonged talking, and swallowed liquids may escape through the nose. Weakness typically worsens throughout the day. Spontaneous improvement may occur early on but is rarely permanent. The diagnosis depends on recognizing distinctive patterns of weakness and confirmation by serologic and electrodiagnostic tests. 80–85% of patients have circulating anti-AChR antibodies; repetitive nerve stimulation (RNS) demonstrates abnormal neuromuscular transmission (NMT) in up to 90% of generalized MG and 60% of ocular myasthenia. Increased jitter is found in almost all patients if appropriate muscles are examined. Approximately 10% of patients have antibodies to muscle specific tyrosine kinase (MuSK). Clinical findings resemble non-MuSK MG in some patients; many have predominant weakness in cranio-bulbar muscles with marked atrophy. Others have predominant neck, shoulder and respiratory weakness. With selected treatment most non-MuSK and MuSK-MG patients have only minimal long-term morbidity. Congenital myasthenic syndromes result from genetic defects of muscle endplate molecules involved in NMT; most have autosomal recessive inheritance. The diagnosis is suggested by clinical features and response to cholinesterase inhibitors, or electrodiagnostic findings. Identification of specific genetic or physiologic defects requires genetic studies or specialized morphological and electrophysiological studies. Lambert-Eaton myasthenia results from antibodies to voltage-gated calcium channels (VGCC) on presynaptic nerve terminals, which produces the classic triad of weakness, reduced muscle stretch reflexes and autonomic dysfunction. Approximately 50% have an underlying malignancy, usually small cell lung cancer. The diagnosis is confirmed by a decrementing pattern during low frequency RNS and low muscle responses that increase at least 60% after muscle activation. Antibodies to the VGCC are found in most cases. Treatment is initially directed against any underlying malignancy. Amifampridine produces symptomatic improvement in most patients; immunomodulatory therapy may provide modest benefit in some.

Treatment of Gastroenteropancreatic Neuroendocrine Tumors with 177Lu-DOTA-TATE: Experience of the Portuguese Institute of Oncology in Porto

The purpose of this article is to report the experience of the Portuguese Institute of Oncology - Porto in the treatment of gastroenteropancreatic neuroendocrine tumors with 177Lu-DOTA-TATE, regarding the safety and efficacy of this treatment modality. A retrospective analysis of clinical reports of patients with gastroenteropancreatic neuroendocrine tumors undergoing treatment with 177Lu-DOTA-TATE between April 2011 and November 2013 was performed. Thirty six cases were reviewed and 30 completed all 3 cycles of 177Lu-DOTA-TATE (83.3%). In these patients it was registered: acute side effects in 8.9% of cycles; grade 3 CTCAE liver toxicity in 13.3% of patients (all with previous abnormal liver function); absence of significant renal or hematologic toxicity; symptomatic improvement in 71.4% of patients; median overall time to progression of 25.6 months; median overall survival from diagnosis of 121.7 months. Patients with higher expression of somatostatin receptors had longer progression-free survival and overall survival times (p < 0.05). Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE is an effective, safe and well-tolerated treatment, as evidenced in our study by the following findings: symptomatic improvement in most patients and increased time to disease progression and survival (especially in those with higher sstr expression), with acute and significant subacute/chronic side effects reported only in a minority of cases. Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE is a promising treatment for patients with gastroenteropancreatic neuroendocrine tumors, with demonstrated benefits in terms of safety and efficacy.

Péptidos inmunogénicos del gluten en deposiciones. Nuevo método para evaluar la adherencia a la dieta en pacientes celíacos

Celiac disease (CD) is an autoimmune pathology caused by the ingestion of gluten in genetically&#x0D; susceptible people, currently considered multisystemic. The treatment of CD is a lifelong strict&#x0D; Gluten-Free Diet (GFD), which allows a symptomatic improvement in most patients and achieve&#x0D; intestinal mucosa healing confirmed with histological study. The adherence to the GFD is&#x0D; variable, arguing as possible factors related to failure the economic, cultural, social aspects&#x0D; and the consumption of gluten inadvertently. The management of celiac patients contemplates&#x0D; instructing in the proper follow-up of GFD and evaluating their adherence. So far, the only way&#x0D; to assess adherence to GFD is through surveys, self-reports of eating habits and serology,&#x0D; being the main disadvantage the subjectivity factor. Recently the immunogenic gluten peptides&#x0D; have acquired relevance for the objective evaluation of the adherence to the GFD and the&#x0D; measurement appears as an efficient and sensitive option to determine the gluten intake,&#x0D; providing relevant information for the clinical management.

A new paradigm in treatment of brain metastases

Dada la escasez de directrices abordando este tema y con motivo de la futura creación de la Unidad de Cuidados Paliativos (CP) en nuestro centro de neurorrehabilitación, los miembros del equipo médico de la Clínica San Vicente hemos decidido proponer una serie de sugerencias sobre el empleo de fármacos antiepilépticos (FAEs) en el manejo de las crisis epilépticas (CEs) en CP.Búsqueda de artículos en PubMed, últimos libros y recomendaciones de las guías de práctica clínica y sociedades científicas publicadas más relevantes, referentes al manejo de las CEs en CP.La confección de este tipo de guías, además de identificar pacientes candidatos a recibir CP, es fundamental para garantizar un buen control sintomático de las CEs y evitar el sufrimiento innecesario de estos enfermos y sus familiares. Dadas las características de estos pacientes, se recomienda usar FAEs con presentación vía parenteral (preferiblemente intravenosa) y un perfil bajo de interacciones. Diazepam y/o midazolam serían los más idóneos para la fase aguda, y levetiracetam, ácido valproico y/o lacosamida para casos refractarios y/o como tratamiento crónico.Estas recomendaciones deben considerarse una guía de abordaje integral, debiendo adaptarse a la idiosincrasia de cada caso clínico en particular. Sin embargo, se necesitan ensayos clínicos controlados, aleatorizados, bien diseñados, que incluyan muestras amplias de pacientes subsidiarios de CP, para redactar un documento de consenso que permita recomendar con un mayor nivel de evidencia y de forma generalizada, la utilización adecuada, racional y efectiva de FAEs en este ámbito médico-asistencial de elevada complejidad.Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies.Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment.These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.

Arthroscopic release of resistant stiff elbow

IntroductionElbow stiffness represents a difficult therapeutic challenge. The complaints are classically characterized by pain and loss of motion. Treatment options include nonoperative and operative techniques, all attempting to provide pain relief and restoration of function. If nonsurgical treatment fails, operative intervention is indicated. Treatment of the stiff elbow by means of arthroscopic capsular release is a relatively new and effective procedure; however, the surgery is technically demanding. The aim of this study was to evaluate the clinical outcomes of arthroscopic release of resistant stiff elbow.Patients and methodsTwenty patients with elbow stiffness were treated by means of arthroscopic capsular release through anterolateral and anteromedial elbow portals, using arthroscopic ablation device and shaver. Posterior and posterolateral portals were used to remove loose bodies, debris, or scar tissue in the olecranon fossa. The patients were prospectively followed up clinically for a mean of 24 months (range = 16-30 months). The clinical assessment was performed with the Mayo Elbow Performance score.ResultsEighteen patients were satisfied with the outcome. There was a significant improvement in the range of motion and reduction of pain. The mean Mayo Elbow Performance score was significantly improved from a mean of 45.3 preoperatively to 95.3 postoperatively.ConclusionThe early results of arthroscopic release of resistant stiff elbow are encouraging and provide symptomatic improvement in most patients. It shortens the time to achieve a good function.

Benefit of ventriculoperitoneal cerebrospinal fluid shunting and intrathecal chemotherapy in neoplastic meningitis: a retrospective, case-controlled study

Neoplastic meningitis (NM) is a debilitating and increasingly frequent neurological complication of cancer characterized by infiltration of tumor cells into the leptomeninges and the subarachnoid space. Although NM is rarely curable, combined intrathecal chemotherapy and focal radiation can improve disease-related symptoms and survival. Hydrocephalus occurs in a significant proportion of patients, is associated with poor prognosis and reduced quality of life, and usually precludes the use of intrathecal therapy. Since January of 2005, the authors have used a combined treatment approach for patients with both NM and hydrocephalus that employs a subcutaneously placed reservoir connected in series to an on/off valve and a ventriculoperitoneal shunt for both diversion of CSF and injection of intrathecal chemotherapy. They conducted a retrospective, case-controlled study from 2 independent institutions to review their experience. Twenty-four patients with NM and hydrocephalus underwent placement of a CSF reservoir-on/off valve-ventriculoperitoneal shunt (RO-VPS) construct. There was no perioperative mortality, and there were only 2 minor complications. One shunt failure and no shunt-associated infections were observed over a median of 28 weeks of follow-up. Symptomatic improvement and improved performance status were seen in 20 patients (83.3%) and were sustained over 6 months. Eighteen patients received intraventricular chemotherapy without unexpected toxicity, and cytological responses were found in 11 patients (61.1%). Median progression-free and overall survival was 14 and 31 weeks, respectively. Compared with a contemporaneous comparison group of 24 demographically matched patients with NM who underwent CSF reservoir placement only, those who received RO-VPS constructs (p = 0.02) and had primary diagnosis of breast cancer (p = 0.04) had significant advantage in overall survival. A combined RO-VPS system is safe and practical to install, results in symptomatic improvement in most patients, and allows uncomplicated and effective administration of intrathecal chemotherapy in patients with NM. Cerebrospinal fluid diversion surgery should be considered in NM patients in conjunction with intrathecal and systemic treatments.

Functional Outcome of Arthroscopic Extensor Carpi Radialis Brevis Tendon Release in Chronic Lateral Epicondylitis

To evaluate outcomes of arthroscopic tennis elbow release in a population of patients with chronic, recalcitrant symptoms, a large number of workers' compensation claims, and high occupational demands using standardized outcome measures, including a detailed objective assessment of workplace demands. We treated 36 patients with chronic lateral epicondylitis with an arthroscopic release. A standardized protocol was used to measure strength, motion, and outcomes (American Shoulder and Elbow Surgeons Elbow [ASES-e] score, Short Form-12, Patient-Rated Tennis Elbow evaluation [PRTEE], and Work Limitations Questionnaire-26). The mean duration of symptoms before surgery was 30 months. A total of 25 of 36 patients were employed in heavy or repetitive occupations and 23 of 36 were involved in a workers' compensation claim. The final overall results were favorable, with 30 of 36 subjects reporting improvement with surgery. The final mean Mayo Elbow Performance Index score was 78.6 +/- 16.5 (22 = good to excellent, 9 = fair, and 5 = poor). The average total PRTEE was 26.2 +/- 24.3 out of 100. The average ASES-e pain score was 16.1 +/- 15.0 and the average ASES-e function score was 27.9 +/- 8.8. Patients in heavy or repetitive occupations and those with workers' compensation claims had significantly worse outcome scores (Mayo Elbow Performance Index, ASES, and PRTEE). Based on Work Limitations Questionnaire-26 scores, patients with workers' compensation claims had significantly greater difficulties with physical (36.8 vs 3.2, p < .001), output (40.8 vs 3.1, p = .002), mental (36.0 vs 9.0, p = .05), and social (27.7 vs 6.3, p = .05) workplace demands. Arthroscopic tennis elbow release provides symptomatic improvement in most patients with lateral epicondylitis. Patient selection and reported occupational demands have an important role in determining outcomes. More work is required to identify factors predicting outcome in this difficult subgroup.

Long-Term Effect of Acetyl-L-Carnitine for Antiretroviral Toxic Neuropathy

Background: Nucleoside analogue reverse transcriptase inhibitors (NRTIs) used for the treatment of HIV can a cause distal symmetrical peripheral polyneuropathy by disruption of mitochondrial metabolism. Treatment with acetyl-L-carnitine (ALCAR) has shown short-term symptomatic and histological improvement. Long-term effects have not been investigated. Purpose: To assess the subjective and objective degree of antiretroviral toxic neuropathy (ATN) during treatment with ALCAR. Method: A cohort of 21 patients with ATN who commenced treatment with ALCAR between March 1999 and October 2001 was reviewed after a mean of 4.3 years using standardized questionnaires and neurological examination. Results: Of the 21 patients, 2 had died and 3 were lost to follow-up. 16 patients were assessed. 10 were still on potentially neurotoxic drugs. 13 were still taking ALCAR. 9 were pain free. The most common symptom was numbness (mild, moderate, and severe in 12, 3, and 0 patients, respectively), followed by paraesthesia (8, 2, 2), pain (4, 3, 0), and burning (5, 2, 0). There was mildly reduced sensation in the toes of 8 patients. 13 patients reported that ALCAR had improved their symptoms very much or moderately, 2 reported no change, and 1 reported a moderate worsening. Conclusion: ALCAR led to long-term symptomatic improvement in most patients without the need to discontinue neurotoxic drugs. Although in this study there was no control group, this agent appears to be an effective pathogenesis-based treatment for ATN.

Long-lasting improvement after septal myectomy for hypertrophic obstructive cardiomyopathy

Background. The most effective treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy is still disputed. Treatment options include medical therapy, pacemaker insertion, percutaneous transluminal septal myocardial ablation, mitral valve replacement, and surgical resection of obstructing muscle. The long-term results of the various treatment options are not well defined. We aimed to demonstrate that septal myectomy is efficacious in reducing or abolishing left ventricular outflow tract gradient and leads to long-lasting symptomatic improvement in most patients. Methods. Twenty-two consecutive patients had septal myectomy between 1981 and the present. Their records were reviewed to document the details of their preoperative status, hospital course, their subsequent clinical outcome, and current status. Results. Mean age at operation was 31.3 years. Preoperatively all patients were disabled by typical symptoms despite aggressive medical treatment. Mean resting gradient was 78 mm Hg. Nine patients required simultaneous associated cardiac procedures. There were no perioperative deaths and minimal morbidity. Two patients died at 6 and 9 years postoperatively of congestive heart failure and arrhythmias. Long-term survivors have been followed up for a mean of 6.6 years. Currently all have minimal or no symptoms. The mean resting gradient was 12 mm Hg. No patient has required reoperation for residual obstruction. Conclusions. Septal myectomy reduces or abolishes left ventricular outflow tract gradient in hypertrophic obstructive cardiomyopathy. Myectomy provides long-lasting symptomatic improvement in most patients. The clinical status of patients late postoperatively can be affected by arrhythmias and myocardial dysfunction.

Case Control Study of Chronic Fatigue in Pediatric Patients

To determine the demographic characteristics, medical features, psychological profile, and natural history of children with chronic fatigue. Case control study. Pediatric Infectious Diseases Clinic of Kosair Children's Hospital, 1990 to 1992. Forty-four patients referred for persistent fatigue were evaluated. Twenty patients participated in a psychological study; 20 healthy controls of similar age and gender were recruited from community pediatric practices and 20 matched depressed controls were recruited from university psychiatry services (subjects were treated as groups in the analyses). Demographic data were obtained for all referred patients. Those with fatigue for at least 2 months and no alternative diagnosis received a detailed history, physical, and battery of laboratory tests (complete blood count, sedimentation rate, chemistry panel, chest X-ray thyroid stimulating hormone, thyroxine, anti-nuclear antibodies, urinalysis, immunoglobulins, and Epstein-Barr virus (EBV), toxoplasma, and cytomegalovirus serologies). Psychological study participants completed the following: background structured interview; Kaufman Brief Intelligence Test; Children's Depression Inventory; Child Behavior Checklist; Youth Self Report; Diagnostic Interview for Children and Adolescents-Revised; mail-in follow-up survey. The median age of fatigue patients was 14.3 years; 60% were female, 96% white, and 87% from the mid/upper socioeconomic status (SES). Fatigue patients were demographically similar to 21 patients referred for infectious mononucleosis (IM) but were older than other clinic patients (P < .0001). White race (P = .0568) and mid/upper SES (P = .0403) were over-represented among fatigue patients compared to patients referred for other diagnoses. Of 36 patients meeting criteria for further study, 5 had an IM-like illness including evidence of recent EBV infection. For the remaining 31 patients, clinical and laboratory evaluations were unrevealing. Psychological study subjects reported marked declines in quality-of-life and scored high on measures of internalizing, withdrawal, and social isolation. Nine met diagnostic criteria for depression, although depressive symptoms were not as prominent as those reported by depressed controls. Fatigue subjects scored higher on somatization than both control groups. The follow-up survey indicated symptomatic improvement in most patients. Chronic fatigue was a common reason for referral, with over-representation of white children from mid/upper SES. After exclusion of EBV-associated IM, screening laboratory tests were not helpful in establishing specific organic diagnoses. Whereas the natural history was favorable, chronic fatigue resulted in major quality-of-life changes and was associated with significant levels of psychosocial distress. Psychological evaluation is warranted in these patients, as some may have treatable psychological conditions. Given the absence of proved medical therapies, psychosocial interventions to improve quality-of-life should be studied.

Comparison of results of percutaneous balloon valvuloplasty in patients with mild and moderate mitral stenosis to those with severe mitral stenosis

Most reported studies of percutaneous balloon valvuloplasty in adults with acquired mitral stenosis have used patients with severely stenosed valves. The risks and benefits of valvuloplasty were examined in a multicenter registry of patients to determine whether balloon valvuloplasty can effectively dilate less severely obstructed valves, and to clarify the rote of this procedure in symptomatic patients with mild and moderate mitral stenosis. The study groups were derived from the North American Inoue Balloon Valvuloplasty Registry. Full hemodynamic data were available in 264 patients; 45 (17%) with mild or moderate mitral stenosis (mitral valve area ≥1.3 cm 2) were compared with the remaining 219 with severe mitral stenosis (valve area <1.3 cm 2). Percutaneous balloon valvuloplasty was performed using the anterograde transseptal technique with an Inoue balloon. The mean age of patients with mild and moderate mitral stenosis was 53 ± 13 years, and all were symptomatic with a mean New York Heart Association functional class of 2.9 ± 0.7. Balloon valvuloplasty resulted in an increase in calculated mitral valve area from 1.4 ± 0.1 to 2.3 ± 0.7 cm 2 (p < 0.05), and a final valve area ≥1.9 cm 2 was achieved in 37 patients (82%). There were no procedural deaths, but complications included right atrial perforation, transient ischemic attack and emergency surgery for severe mitral regurgitation. One-year follow-up evaluation revealed symptomatic improvement in most patients (mean New York Heart Association class 1.4 ± 0.6; p < 0.0001). However, 2 patients needed repeat valvuloplasty for restenosis, and 5 had mitral valve replacements. Patients with less severe stenosis had lower pulmonary artery pressures and transmitral gradients, higher cardiac outputs and lower total echocardiographic scores than did those with severe mitral stenosis. A larger final valve area was achieved in patients with mild and moderate stenosis (2.3 ± 0.7 vs 1.7 ± 0.5 cm 2; p < 0.05).

Aortic Valvuloplasty

Balloon aortic valvuloplasty is a palliative treatment for adult patients with aortic stenosis who are not candidates for AVR. BAV can be performed using a single balloon (one balloon, one shaft), multiple balloons (multiple balloons, multiple shafts), or complex balloon configurations (bifoil or trefoil balloons on a single shaft) by the retrograde (femoral or brachial) or antegrade (transseptal) approach. The mechanisms of successful BAV are fracture of calcified nodules, separation of fused commissures, and simple stretching of valve leaflets, leading to increased leaflet mobility and larger orifice dimensions. Clinically, these changes lead to a 50% to 70% decrease in transaortic valve gradient and a 50% to 70% increase in aortic valve area, resulting in immediate improvement in symptoms in most patients. Despite the fact that these beneficial hemodynamic results are achieved with a low incidence of life-threatening complications, the major limitation of BAV is the high incidence of restenosis. About 80% of patients have recurrent symptoms within 2 years of BAV, leading to death of the patient or requiring late AVR or repeat BAV. As a result of the high incidence of restenosis after BAV, elderly patients with aortic stenosis should not be denied the opportunity for AVR solely on the basis of age. BAV may have a role, however, in the following situations: (1) to treat patients in whom AVR is contraindicated for clinical or technical reasons; (2) to treat patients who require urgent noncardiac operations; (3) to clarify the extent of surgery required in patients with aortic stenosis, severe mitral regurgitation, and poor LV function; and (4) to predict the likelihood of successful outcome after AVR in patients with aortic stenosis, low gradients, low cardiac output, and poor LV function.

Southwestern Internal Medicine Conference: The Multifacetted Role of Angiotensin Converting Enzyme Inhibitors in Congestive Heart Failure

The angiotensin converting enzyme (ACE) inhibitors constitute a major breakthrough in the medical management of congestive heart failure. The incidence of side effects with these agents is surprisingly low when they are used in the appropriate dosage. They produce sustained beneficial hemodynamic and symptomatic improvement in most patients with congestive heart failure and may produce greater symptomatic benefit than digoxin when given as second-line therapy to patients with heart failure on diuretics. Their neurohumoral effects generally are advantageous, resulting in normalization of sodium and potassium balance and a reduction in ventricular arrhythmias. The ACE inhibitors may improve survival in patients with congestive heart failure, and recent data suggest that they may prevent or delay the development of left ventricular dilatation and overt heart failure in patients with asymptomatic left ventricular dysfunction.

Surgical resection in idiopathic hypertrophic subaortic stenosis with a combined approach through aorta and left ventricle: A long-term follow-up study in 49 patients

The operative technique and the immediate and long-term results are described in 49 patients who have undergone myectomy for IHSS. There was a 4 percent early and 12 percent late mortality rate and surviving patients have been followed for up to 13 years. The operation has resulted in a striking symptomatic improvement in most patients in association with relief of outflow obstruction and mitral regurgitation. Chronic atrial fibrillation was poorly tolerated but has not occurred as a late complication in any of the patients operated upon.

The treatment of muscular subaortic stenosis

Of 100 patients with muscular subaortic stenosis, 26 have been followed prospectively with no treatment, 55 have had a trial of propranolol therapy, and 39 were operated upon prior to July, 1973. Transaortic ventriculomyotomy can abolish the outflow gradient, the abnormal systolic anterior movement of the anterior mitral leaflet, and the mitral regurgitation, and it can reduce the left ventricular end-diastolic pressure. Thus the operation produces symptomatic improvement in most patients. This report analyzes the hospital deaths, complications, late deaths, and clinical failures in our series. We have reached the following conclusions: Ventriculomyotomy through the aorta, with or without resection of muscle, is a simple and effective method of treating most patients with muscular subaortic stenosis who have resting obstruction. However, in some of these patients, the gradient is eliminated by angiotensin, but the degree of mitral insufficiency is either increased or else not lessened by the drug. Such patients should have a ventriculomyotomy and mitral valve replacement, provided that the mitral insufficiency is significant. In patients with far-advanced disease, surgical therapy may be of limited value.

Reappraisal of digitalis. Part II. Hemodynamic effects of the cardiac glycosides

The administration of the cardiac glycosides will result in a reduction in filling pressures, increase in cardiac output, diuresis, and symptomatic improvement in most patients in congestive heart failure, irrespective of cardiac rhythm. Although they exert direct effects on the peripheral arterial and venous beds and on kidney function, the improvement in heart failure that the cardiac glycosides produce is due primarily to an increase in contractility of ventricular muscle. The degree of increase in contractility is related to dosage in the therapeutic range.