Does routine fenestration improve early and late postoperative outcomes in patients undergoing Fontan palliation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In [patients undergoing Fontan palliation] does [fenestration] affect [early and late postoperative outcomes]?' Altogether 509 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Current data suggest that the use of fenestration has advantages in the immediate postoperative course, with fewer complications such as pleural effusions, shorter hospitalization and decreased early Fontan failure, but comparable long-term outcomes to a non-fenestrated approach. Fenestration should be used in high-risk patients or based on the haemodynamic parameters measured before weaning from cardiopulmonary bypass. Routine use may potentially lead to additional late fenestration closure procedures in some patients, without improving long-term outcomes.

Recurrent atrial myxoma.

We have chosen this case of sporadic atrial myxoma for our presentation because it had a particular evolution, with recurrence at 8 years after surgical excision (echocardiography was performed every year) and a particular diagnostic means - at echocardiographic follow-up, the patient being asymptomatic. This presentation, together with a review of literature included in the article, emphasizes the importance of a careful postoperative follow-up of the patients and the existence of some particular aspects of the evolution and symptomatology of recurrent atrial myxoma.

The therapy by ischemic stress induces a durable EEG synchronization in alpha frequency band.

The effect of forearm or calf ischemia on computerized EEG was studied in five patients with peripheral nervous system affections and five patients with cerebral infarction. Spatial analysis of power spectra in various frequency bands was performed in two 8-sec epochs, the former before ischemia and the latter after 5-min from the cessation of circulatory arrest which lasted 15 min. Transient peripheral ischemia resulted in consistent augmentation of alpha activity involving both the anterior and the posterior hemispheric areas, bilaterally. On the other hand, the slower frequency bands (theta, delta) underwent minor, nonsignificant alterations after ischemic stress. The rise of alpha amplitude induced by ischemic stress was ascribed to the activation of nonspecific thalamic system. The activation of this system might also be involved in the favourable effects exerted by ischemic stress on motor recovery of paretic limbs.

A new trend in the therapy of orthostatic arterial hypotension: prevention by propranolol or metoclopramide of the excessive adrenaline release of brainstem infarct patients with postural hypotension.

The catecholamine (CA) response to upright posture was studied in 30 brainstem infarct patients with orthostatic arterial hypotension; the investigation was made before and after 10 days propranolol therapy (in 15 cases) and before and after 10 days metoclopramide therapy (in other 15 cases). Before treatment almost all patients responded to posture by a rise in adrenaline (A) excretion and by a depression in noradrenaline (NA) excretion. Propranolol therapy prevented the excessive A release produced by standing and normalized their NA response to posture. Metoclopramide administration also prevented the post-orthostatic A discharge but had no significant influence on NA response to posture. Both drugs exerted a favourable influence on postural hypotension of investigated patients. As post-orthostatic A discharge observed in patients with postural hypotension is involved in the pathogeny of this syndrome and both metoclopramide and propranolol are able to correct this disorder one may maintain that the clinical favourable results obtained with these drugs are ascribable at least partly to their blocking effect on A release.

Catecholamine response to exercise in migraine.

Catecholamine (CA) response to exercise was studied in patients with common (16 cases) or classic (7 cases) migraine as well as in subjects with lumbar disc disease (20 control cases). In migrainous patients exercise induced constantly a rise in epinephrine (E) urinary excretion and a depression in norepinephrine (NE) excretion; the post-exercise E excretion represented the double or the treble of basal E excretion. In controls the pattern of CA response to exercise was opposite to that noted in migraineurs: the exercise induced in almost all controls an augmentation in NE excretion and a depression in E excretion. The pattern of CA response to exercise of migrainous patients is similar to that noted in them after light exposure. As such patients responded by an E discharge to both exercise and light exposure, two conditions preceding quite often the onset of migraine attack, the data suggest the participation of this biochemical abnormality in the pathogeny of migraine. The interpretation is also supported by our previous data demonstrating that the antimigraine drugs are able to prevent the E discharge induced in migrainous patients by light exposure.

Transient peripheral ischemia may restore quickly the motility in patients with compression neuropathy.

Transient ischemia of the extremities was applied in compression or traumatic neuropathies affecting radial nerve (17 cases), ulnar nerve (3 cases), upper brachial plexus (4 cases) or peroneal nerve (10 cases). The limb opposite to that displaying paresis was submitted repeatedly to a 15-minute-period of ischemia every other day for two weeks. The procedure induced in most patients (27 out of 34 cases) a motor improvement of variable degree. In some patients (13 cases) the motor recovery occurred two days or more after starting the procedures, while in others (14 cases) during the very day in which the initial session of ischemia was made or even during the first hour of procedure application. The most beneficial effects of peripheral ischemia were noted in compression neuropathy of peroneal nerve palsy, 9 out of 10 patients with such a disorder being improved by the procedure. We suppose that the method of therapy proposed by us restores promptly the motility of patients with compression neuropathy by inducing a long-lasting activation of some central neural mechanisms.

The influence of amitriptyline and flunarizine on catecholamine response to light in patients with migraine.

The effect of amitriptyline on catecholamine (CA) response to light of 20 migrainous patients was studied. The drug was given orally, 36 mg daily (12 mg x 3), for ten days. Before therapy, the migraineurs responded to light by an increase in epinephrine (E) excretion and not by the rise in norepinephrine (NE) excretion, noticed in controls. The NE excretion of migrainous subjects underwent very often a depression after photostimulation. Amitriptyline therapy prevented the post-photic rise in E excretion of migraineurs, without influencing significantly the variation in NE excretion produced in them by light. In other 8 migrainous subjects the effect of flunarizine, a selective calcium channel blocker, on CA response to light was tested. The dosage was of 5 mg daily, for ten days. Flunarizine had similar effects to those displayed by amitriptyline; the drug prevented the rise in E excretion produced by light without normalizing the NE response to light of migrainous subjects. The results suggest that the efficiency of these two drugs in migraine prophylaxis is connected with the ability of these substances to block the E discharge produced in migraineurs by light or by other stimuli. The interpretation is all the more likely as propranolol, another drug applied in migraine prophylaxis also blocks the post-photic E discharge of migraineurs.

Deficiency of sympathetic nervous system function in myasthenia.

The norepinephrine (NE) and epinephrine (E) responses to forearm ischemia were studied in 24 myasthenic patients and 22 subjects with lumbar disc disease (control group). In some of these myasthenic (11 cases) and control (11 cases) subjects the NE and E responses to orthostasis were also investigated. In controls both stimuli induced a rise in NE urinary excretion without significantly changing the E excretion. On the other hand, in myasthenic patients forearm ischemia and orthostasis were followed by an augmentation in E excretion, the NE excretion remaining unchanged or even undergoing a depression. In other myasthenic patients (10 cases) and subjects with lumbar disc disease (10 cases) NE and E responses to exercise were tested. The results were similar to those presented above: controls reacted to exercise by a rise in NE excretion, while myasthenic patients, by an augmentation in E excretion; the NE excretion underwent no change or even decreased after exercise in myasthenia. The obliteration of NE response to all three testing stimuli found in myasthenic patients may be considered as a sign of their sympathetic deficiency. In such patients the normal E discharge produced by forearm ischemia, orthostasis or exercise may be interpreted as a compensatory reaction, being probably the consequence of sympathetic deficiency. The noradrenergic deficit of myasthenic patients is ascribable to their cholinergic hyperactivity.

Correction by centrophenoxine of abnormal catecholamine response to postural stimulus in patients with orthostatic hypotension due to brainstem ischemia.

The effects of centrophenoxine on catecholamine (CA) response to orthostasis and on postural blood pressure fall of 25 patients with orthostatic hypotension due to brainstem ischemia were studied. Before therapy, the patients responded to posture by a depression in norepinephrine (NE) excretion and a rise in epinephrine (E) excretion. After a 10-day treatment with centrophenoxine, 800 mg daily, the patients responded to posture like normals, i.e. by a rise in NE excretion and a reduction in E excretion. Although the orthostatic blood pressure fall was less marked after treatment, the favourable clinical effect of the drug could not be correlated significantly with the restoration of CA response to posture after treatment.

Norepinephrine and epinephrine responses to postural stimulus in orthostatic hypotension due to brainstem ischemic lesions.

Norepinephrine (NE) and epinephrine (E) responses to upright posture were investigated in 25 patients with orthostatic hypotension due to brainstem ischemic lesions and in 25 control subjects. In controls the postural stimulus induced constantly a rise in NE urinary excretion and a reduction in E excretion, while in patients with orthostatic hypotension it caused a depression in NE urinary excretion and a rise in E urinary excretion; the last alteration was noticed in all but one patient. The E discharge induced by posture in patients with orthostatic hypotension may be involved in the reduction of vascular peripheral resistance and then in postural fall of blood pressure displayed by such patients.

Propranolol corrects the abnormal catecholamine response to light during migraine.

The catecholamine (CA) response to light before and after propranolol therapy was studied in 25 migrainous subjects. Before therapy an abnormal CA response to light consisting of a rise in epinephrine excretion and a depression in norepinephrine (NE) excretion was noticed in migrainous patients. After propranolol administration (60 mg daily for 10 days) the post-photic augmentation in epinephrine excretion and the post-photic depression in NE excretion no longer occurred. As epinephrine discharge may be pathogenetic for migraine attack, the favorable effect of propranolol in migraine therapy could be due to its ability to prevent the epinephrine release induced by light or other stimuli.

Alterations in brain-stem auditory responses induced by head down tilting in hypertensives with supine brain-stem disorders.

The influence of head down (HD) tilting on brain-stem auditory evoked responses (BAER) was studied in hypertensives with supine brain-stem disorders (occipital headache, vertigo, nausea, diplopia, blurred vision occurring after night recumbency), in hypertensives without such phenomena and in normotensives. In the latter two categories of subjects HD tilting had no effect on BAER. On the contrary, in hypertensives with supine brain-stem disorders the manoeuvre induced a constant prolongation of I-V and III-V intervals and a depression in the amplitude of wave V; the alterations of BAER produced by HD tilting reveal probably a dysfunction of the superior brain-stem area and might be due to the impaired cerebral venous draining subsequent to the manoeuvre. The study of BAER after HD tilting seems to be a proper means to attest the supine brain-stem disorders displayed by some hypertensives.

Catecholamine response to light in migraine.

The effect of the shift from a low to a high luminosity of the environment on the urinary excretion of norepinephrine (NE) and epinephrine (E) was studied in migraineurs (26 cases) and controls (25 cases). In the latter the shift from a low to high light exposure increased NE excretion; in contrast, in migraineurs exposure to high luminosity resulted in a depression of NE excretion and an augmentation of E excretion. The possible participation of E discharge produced by photostimulation or by other stimuli in the pathogenesis of migraine attack is discussed.

Influence of continuous photostimulation on catecholamine urinary excretion in patients with cerebral hemorrhage.

Hypertensives with (25 cases) or without (27 cases) cerebral hemorrhage (CH) and normotensives (25 cases) were exposed from 7 to 8.30 a.m. to a low light input and from 8.30 to 10 to a high light input (HLI), and urinary epinephrine (E) and norepinephrine (NE) were measured at the end of these periods. In normotensives HLI had no effect on E and NE excretion; in hypertensives with and without CH it increased E excretion and depressed NE excretion. Light activation of E release may be responsible for the daytime occurrence of CH in hypertensives.