Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper.

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

Martian valleys: morphology, distribution, age, and origin.

Branching valley networks throughout the heavily cratered terrain of Mars exhibit no compelling evidence for formation by rainfall-fed erosion. The networks are diffuse and inefficient, with irregular tributary junction angles and large, undissected intervalley areas. Rather, the deeply entrenched canyons, with blunt amphitheater terminations, cliff-bench wall topography, lack of evidence of interior erosion by flow, and clear structural control, suggest headward extension by basal sapping. The size-frequency distributions of impact craters in these valleys and in the heavily cratered terrain that surrounds them are statistically indistinguishable, suggesting that valley formation has not occurred on Mars for billions of years.

The surface of Mars: the view from the viking 2 lander.

Viking 2 lander began imaging the surface of Mars at Utopia Planitia on 3 September 1976. The surface is a boulder-strewn reddish desert cut by troughs that probably form a polygonal network. A plateau can be seen to the east of the spacecraft, which for the most probable lander location is approximately the direction of a tongue of ejecta from the crater Mie. Boulders at the lander 2 site are generally more vesicular than those near lander i. Fines at both lander sites appear to be very fine-grained and to be bound in a duricrust. The pinkish color of the sky, similar to that observed at the lander I site, indicates suspension of surface material. However, the atmospheric optical depth is less than that at the lander I site. After dissipation of a cloud of dust stirred during landing, no changes other than those stemming from sampling activities have been detected in the landscape. No signs of large organisms are apparent at either landing site.

Evaluation of antinociceptive activity of Casearia sylvestris and possible mechanism of action.

The antinociceptive properties of Casearia sylvestris Sw. (Flacourtiaceae) were investigated in various models of pain-related behavior in mice. The hydroalcoholic crude extract of the plant (30-300mg/kg, per os) clearly inhibited nocifensive responses induced by ovalbumin (hindpaw licking) or acetic acid (writhes) in graded fashion. At 300mg/kg, the extract reduced nocifensive behaviors (from 71.1+/-13.3 to 14.8+/-9.3s; from 31.3+/-4.5 to 3.3+/-1.2 writhes, respectively) to similar extents as indomethacin (5mg/kg; 5.7+/-1.1s and 3.3+/-1.2 writhes, respectively). Significant antinociceptive effects in the hot plate test were only detected following administration of the highest extract dose, but this analgesic action appeared to be specific as the extract failed to change motor and exploratory activities. The antinociceptive effect of Casearia sylvestris extract in the acetic acid test was prevented by prior treatment with the non-selective opioid receptor antagonist naloxone (1mg/kg; 5.8+/-4.2 and 31.5+/-3.1 writhes in vehicle-treated and naloxone-treated groups, respectively), indicating that the endogenous opioid system is involved in its analgesic mechanism of action. Thus, our investigation suggests a potential therapeutic benefit of Casearia sylvestris Sw. in treating conditions associated with inflammatory pain.

Supraventricular tachycardia in infants: use of the "diving reflex".

The effectiveness of the "diving reflex" in treating paroxysmal supraventricular tachycardia (PSVT) in 10 infants aged under 6 months is demonstrated. No rhythm disturbances were encountered during the maneuver, even in patients receiving digitalis. The recommended water temperature is 5 degrees C and the total time of facial immersion, between 6 and 7 seconds. The diving reflex might be considered the first therapeutic approach in infants under 6 months old with PSVT.

Acute effects of oxygen administration on transmural pulmonary artery pressure in obstructive sleep apnea.

In order to investigate the role of hypoxia on the cyclic oscillation of transmural pulmonary artery pressure (PAP) in obstructive sleep apnea, oxygen was administered during one half of the night to six patients affected by obstructive sleep apnea syndrome during a nocturnal polysomnographic study. In each patient, transmural PAP measurements were performed on 15 randomly selected apneas recorded while breathing room air, and on 15 during O2 administration. During O2 administration in all patients, apneas were associated with a higher oxyhemoglobin saturation (SaO2), a smaller SaO2 swing, and a higher transcutaneous PCO2. The mean highest level of transmural PAP in the apneic episodes, commonly reached at their end, was significantly lower than while breathing room air in only two patients; however, due to a decrease in the mean lowest PAP level (at the beginning of apneas), the extent of the PAP increase within apneas did not differ between air and O2 breathing; these patients showed the smallest increase in transcutaneous PCO2 in our sample. End-apneic transmural PAP during O2 administration was significantly higher in one subject (for systolic values) and was not significantly different in the remaining three subjects. The extent of the increase in transmural PAP within apneas was greater in one patient; it was smaller in another one, but only for the diastolic values; and it did not differ significantly with respect to the value observed while breathing room air in all of the other subjects. The results suggest that hypoxia in obstructive apneas, at least in some patients, may lead to a steady increase in PAP, detectable both at the beginning and at the end of the episodes; conversely, the increase in PAP within apneas does not seem to be influenced by the simultaneous decrease in SaO2.

Patent ductus arteriosus closure using the new Amplatzer Duct Occluder. Preliminary results and review of the literature.

BACKGROUND: Patent ductus arteriosus (PDA) is the second most common congenital heart disease. A large number of surgical and transcatheter techniques for the interruption or closure of PDA has been reported. The aim of this study was to assess the immediate and short-term results of transcatheter closure of PDA using the new, self-expandable, self-centering, and repositionable Amplatzer Duct Occluder device. METHODS: We attempted occlusion of PDA with the Amplatzer Duct Occluder in seven consecutive patients, one child and six adults, four females and three males, between September 1999 and January 30th 2000. All PDAs but one were approached from the femoral venous site; the Amplatzer Duct Occluder size was selected in order to be 2 mm larger than the duct's diameter at its narrowest site and the mean PDA diameter was 5.4+/-2.5 mm (range 3-9). All patients underwent physical examination, chest X-ray and echocardiography within 48 hours and on first and third month after PDA occlusion. RESULTS: Four patients had a megaphone type (type A), and three had an elongated, conical type (type E) PDA. Four patients had immediate, complete angiographic closure of the ductus 10 minutes after the procedure, one had a trace shunt and two had small shunts which all disappeared within 48 hours. The average fluoroscopy time and procedural time were 34.4+/-10.6 min (range 21-50) and 105+/-38.9 min (range 75-190) respectively. There were no complications at follow-up. CONCLUSIONS: Transcatheter closure of PDA using the new Amplatzer Duct Occluder is an easy and effective technique. Moreover it is safe even in the presence of wide PDAs.

[Pulmonary arteriovenous aneurysm coexisting with rheumatic mitral valvulopathy in Rendu-Osler-Weber syndrome. Image diagnosis using bidimensional and Doppler echocardiography]. / Aneurisma arterovenoso polmonare coesistente con valvulopatia mitralica reumatica in sindrome di Rendu-Osler-Weber. Diagnostica per immagini con ecocardiografia bidimensionale e Doppler.

The authors report a case of the rare association described in the title in which echocardiography played an important role in the recognition of the pulmonary arteriovenous aneurysm. By 2-D approach it was possible to visualize a wide anechogenic concamerated area containing an echodense mass and continuous with the left heart cavities. Pulsed Doppler interrogation at the level of the extra-cardiac cavity showed a flow signal which gave the first diagnostic evidence of a vascular lesion. Direct visualization of pulmonary arteriovenous aneurysms has never before been obtained with echocardiography. This was possible in the present case due to contiguity with heart chambers and the large dimension of the aneurysm. Doppler examination gave the first confirmation of the vascular nature of the lesion. Angiography is still a mandatory pre-operative procedure but 2-D and Doppler echocardiography may play an interesting role in the diagnostic non invasive procedure of pulmonary arteriovenous aneurysms.

[Modified technique for dilatation of pulmonary valve stenosis (nearly atresia) in a neonate]. / Tecnica modificata per la dilatazione della stenosi critica (quasi atresia) della valvola polmonare in un neonato.

A modified technique for pulmonary valvuloplasty is described in a 1-day-old newborn with near pulmonary atresia. A transumbilical venous approach and a complete set of devices for coronary angioplasty were utilized; the principal technical innovation was the use of a 7 French right coronary artery guiding catheter. This allowed a firm support to advance the first balloon catheter (a 3.5 coronary angioplasty catheter) through the pulmonary valve, maintaining the guidewire in a stable position in the descending aorta. The dilation was easily completed with progressively larger balloons. The total procedure time was 82' (fluroscopy time 20'), significantly shorter than the previous personal experience and the data from the literature.

Time course of right ventricular stroke volume and output in obstructive sleep apneas.

Because the behavior of right ventricular stroke volume (RVSV) in the obstructive sleep apnea syndrome (OSAS) is undefined, we studied the time course of RVSV by right heart catheterization during sleep in five OSAS patients. In 55 obstructive apneas, heart rate (HR) and RVSV were calculated beat-by-beat. RVSV was estimated by integrating the area under the pulmonary arterial (PA) blood velocity signal obtained by a velocity sensor-/micromanometer-tipped catheter. Compared with preapnea, mean RVSV did not change significantly during apnea, but decreased by 15% during postapnea. Analysis of RVSV in the respiratory cycle showed that postapneic RVSV was mostly reduced at maximal inspiration, suggesting a role of increased lung volume in decreasing RVSV. As for HR, it decreased significantly during apnea in four out of five patients. In all patients, HR returned to preapneic values during postapnea. Therefore, right ventricular output decreased slightly in most patients during late apnea because of decreased HR, whereas it decreased in all patients during postapnea because of decreased RVSV. These results, together with the known finding that PA pressure increases towards the end of apneas and remains elevated in the immediate postapnea, suggest that the most relevant changes in the pulmonary circulation occur at the resumption of ventilation, not during the apneic phase.

[Manual obliteration of femoral artery pseudoaneurysm. Report of a case and brief review of the literature]. / Obliterazione manuale di uno pseudoaneurisma dell'arteria femorale. Presentazione di un caso con breve rassegna della letteratura.

The authors report a case of non-surgical repair of a femoral artery pseudoaneurysm due to percutaneous catheterization. The procedure was performed by direct manual compression under intermittent color-flow duplex ultrasound control. Some conditions reported in the Literature as unfavorable for a prompt resolution were present (long time interval between invasive procedure and treatment, anticoagulant medication); nevertheless the manoeuvre was successful after only 20'. In comparison with previous experiences (reporting direct compression with the ultrasound transducer or with a mechanical vascular clamp device) the authors underline some observations: a) direct manual compression seems to guarantee a better stability in the optimal position allowing flow interruption in the lesion; b) ultrasound guide is necessary to prove the efficacy of compression, but a continuous monitoring doesn't seem necessary; c) in order to stop the procedure perhaps it is sufficient to interrupt completely the flow in the pseudoaneurysm cavity; a small flow, limited to the neck of the lesion, can be resolved if a pressure bandage is applied and the patient is maintained at bed rest for 12 hours. Manual, ultrasound guided obliteration may be considered a safe and efficacious method for non-surgical treatment of femoral artery pseudoaneurysms.

Childhood cancer in Uruguay: 1992-1994. Incidence and mortality.

BACKGROUND: The referral of all children with cancer in Uruguay to a single center affords the opportunity to generate population-based incidence and mortality rates in this developing country in Latin America. PROCEDURE: All incident cases of cancer in children, 0-14 years of age, were ascertained from a combination of three sources for the period January 1992-December 1994. Diagnoses were grouped according to the International Classification of Childhood Cancer. Information on the size and age distribution of the total population was obtained from national census records. Follow-up was undertaken until December 1999 to afford a minimum interval of 5 years and the determination of mortality rates. RESULTS: The average annual incidence was 133.6 cases of cancer per million children per year and the disease distribution was similar to that in industrialized countries, with the exception of a higher rate and younger age distribution for the Hodgkin disease. The overall age-standardized mortality rate from cancer in childhood, at 6.5 per 100,000, was approximately twice that in the United States and Canada. CONCLUSIONS: Basic indicators of development suggest that Uruguay is more akin to the countries of North America and Western Europe than to those in the developing world. An opportunity has been identified to improve the outcome for children with cancer in this country.

[Mitral valve replacement in young children: a long-term follow-up]. / Sostituzione valvolare mitralica nella prima infanzia: follow-up a lungo termine.

The Authors report follow-up data (mean 60, range 13-101 months) from 4 patients under two years of age (mean 11.5 months) operated on for prosthetic mitral valve implantation. Two patients were male and two female. Pre-operative diagnosis was partial atrioventricular septal defect with parachute mitral valve in one case and isolated mitral valve anomaly in the others (1 parachute, 2 hammock valves). One bioprosthesis (Liotta n. 23) and three mechanical prostheses (Björk-Shiley) were implanted. Complications occurred in two patients: one case of endocarditis on the bioprosthesis, leading to substitution with a Björk-Shiley valve; one case of acute thrombosis 8 months after implantation in the only pt receiving aspirin as prophylactic therapy. This complication was resolved by intravenous thrombolytic agents. All the patients are alive, in I NYHA functional class and receiving oral anti-coagulants. Instrumental follow-up with eco-Doppler demonstrated normal functioning prostheses in all the patients. A sub-aortic gradient was found in the patient with partial atrioventricular septal defect. Prosthesis-patient mismatch was identified in a patient operated on when she was 6 months old who was followed-up for 5 years.

[Interventricular defect with discrete aortic stenosis below the defect]. / Difetto interventricolare con stenosi sottoaortica discreta sotto il difetto.

"Discrete" (fixed) subaortic stenosis associated with ventricular septal defect (VSD) is a rare but important anomaly. Two types of left ventricular outflow tract obstruction should be distinguished on the basis of its relation with the VSD, depending on whether the stenosis is above or below the defect. The four cases presented here are all in the latter category. Usually the patients belonging in the former category are associated with severe anomalies of the aortic arch. The diagnosis was made by clinical examination and by means of non invasive techniques, ecg, chest x-rays and ecocardiograms in all but one patient (the case "3"), in whom a subpulmonary stenosis (SPS) was associated. The final diagnosis was established by catheterization, which demonstrated the pressure gradient on the withdrawal curve from the apical part of the left ventricle to the aorta, and by contrastography. Three of four patients underwent total correction and are in good condition from 6 to 18 months after surgery, one of these cases had also SPS. In the remaining case, we thought the operation was not indicated on the basis of small size of VSD, of mild pressure gradient, and mild aortic valvular insufficiency (case "4"). The surgical approach to resect the "fixed" obstruction and to closure the VSD was carried out through a right atriotomy in two patients, and through a right ventriculotomy in the patient with SPS. The trans-aortic approach has to be discarded because it affords limited exposure of both defects and could increase the risk of damage of conducting tissue. A careful evaluation of aortic and left ventricular pressure, in association with angled angiography is highly recommended in the study of VSD.

[Persistence of fetal circulation. Clinical and angiographic evaluation of two cases. Review of the literature (author's transl)]. / Persistenza della circolazione fetale. Descrizione clinica ed angiocardiografica di due casi. Revisione della letteratura.

Persistent fetal circulation ("PFC") is a condition characterized by perduring after birth of fetal hemodynamic pattern: persistence of high pulmonary vascular resistance then occurs. "PFC" is a high mortality syndrome recently recognized as a cause of severe cyanosis and tachypnea in full-term newborns. Perinatal hypoxia, hyperviscosity, acidosis etc, may be also responsible of a persistence of high pulmonary vascular resistance. The increased right heart pressures cause a right to left shunt across the ductus arteriosus and foramen ovale not yet completely closed at birth. In this paper the clinical and angiographic evaluation of two full-term newborns, males, 5 days and 5 months old, are described, who presented with tachypnea, cyanosis and heart failure. Moreover we want to make a critical review of medical literature about this subject. The electrocardiogram of both patients showed right ventricular hypertrophy and myocardial ischemia. The chest roentgenograms showed cardiac enlargement and increased pulmonary vascular markings. Lung and central nervous system disorders were excluded by clinical and instrumental exams. Both patients underwent cardiac catheterization and angiocardiography in order to exclude a congenital heart disease. There was just evidence of pulmonary vascular resistance and right to left shunt at ductal and atrial level. O2 100% administration in one patient determined a decrease in pulmonary resistance and the shunting abolition. Clinical and hemodynamic patterns of this syndrome are very different. There are "simple forms" with normal myocardial function and "complex" higher mortality forms with evidence of cardiac involvement. It is often difficult to distinguish such forms from the other causes of central cyanosis and/or cardiac failure in the newborn as transposition of the great arteries, total anomalous pulmonary venous connection: the individualization of the syndrome then may be impossible without cardiac catheterization. A correct diagnosis for a precocious and reasonable treatment are extremely important for the survival of such critical newborns.

[Clinical and angiocardiographic observations on the so-called absence of a branch of the pulmonary artery]. / Osservazioni cliniche ed angiocardiografiche sulla cosiddetta "assenza" di un ramo dell'arteria polmonare.

We present 5 cases with angiographically absent pulmonary artery: 4 with absence of right pulmonary artery and 1 with absence of the left. We excluded cases of atresia of pulmonary artery, ventricular septal defect and major aorto-pulmonary collaterals. We excluded also cases of anomalous origin of a pulmonary artery from the aorta. Surgical inspection in 3 patients demonstrated total absence of pulmonary main branch (1 case), with intraoperative death, and presence of the hilar portion of the pulmonary artery (2 cases), with successful palliative procedure. It is supportive of efforts to identify as early in life as is feasible the absent vessel, for surgical purposes. In fact the early surgical procedure will ensure development of the vessel and normal lung growth, and will decrease the risk of the following intracardiac repair, when needful.

[Atresia of the tricuspid valve and total anomalous supracardiac pulmonary venous return. Description of a case associated with severe extracardiac malformations]. / Atresia della tricuspide e ritorno venoso polmonare anomalo totale sopracardiaco. Descrizione di un caso associato a gravi malformazioni extracardiache.

The Authors report a case of tricuspid atresia and total anomalous pulmonary venous return of the supracardiac type, with mild pulmonary valve stenosis and extracardiac malformations as anal atresia, microphthalmia and irideo and chorioretinic coloboma. The Authors stress the importance of the electrocardiogram and standard chest X-Ray to "suspect" this rare association.

Early captopril treatment reduces plasma endothelin concentrations in the acute and subacute phases of myocardial infarction: a pilot study.

It has been reported that endothelin-1 (ET-1) increases in acute myocardial infarction (AMI). Experimental studies showed that captopril administration reduces ET-1 secretion. In addition, it was reported that the increased ET-1 levels are a negative prognostic index. The study sought to verify whether captopril can reduce plasma ET levels in the acute and subacute phases of reperfused anterior AMI. Forty-five patients, hospitalized for suspected anterior AMI within 4 h from the onset of symptoms, suitable for thrombolysis (first episode), Killip class I-2, were randomized (double blind) into two groups: group A (23; seven women/16 men) received captopril (as first dose) 2-4 h after starting thrombolysis (the dose was then increased up to 25 mg every 8 h). Group B (22; five women/17 men) received placebo after thrombolysis. All the patients met the reperfusion criteria. The two groups were similar with regard to age, sex, CK peak, ejection fraction, end-systolic volume and risk factors. Plasma ET levels were measured at entry, and 2, 12, 24, 48, and 72 h after starting thrombolysis. Mean concentrations of ET +/- SD: Group A basal, 1.50 +/- 0.67; at 2h, 2.31 +/- 1.24; 12 h, 1.84 +/- 1.45; 24 h, 1.30 +/- 0.72; 48 h, o.95 +/- 0.50; 72 h, 0.60 +/- 0.15 fmol/ml; p < 0.001. Group B basal, 1.58 +/- 0.83; at 2 h, 2.38 +/- 1.35; 12 h, 2.33 +/- 1.71; 24 h, 1.80 +/- 1.41; 48h, 1.46 +/- 0.88; 72 h, 0.93 +/- 0.44 fmol/ml; p < 0.001. Difference between the two groups was significant at the beginning of the test (between 2 and 12 h, p[=]0.002). After that, the values of the plasma endothelin decreased in parallel, p < 0.001. Our data suggest that captopril affects plasma ET levels in the acute and subacute phases of AMI. Moreover, these results provide additional evidence for a beneficial effect of early captopril treatment.