The randomized, controlled ATLANTIS trial of aquatic therapy for chronic venous insufficiency.

OBJECTIVE: There are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion. METHODS: A total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months. RESULTS: The primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P < .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS -4.08 ± 2.08 vs -1.15 ± 1.26, Villalta score -4.00 ± 2.68 vs -1.01 ± 1.34, thigh circumference -3.40 ± 1.78 cm vs -1.40 ± 2.55 cm, leg circumference -1.27 ± 1.34 cm vs -0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P < .001 for all comparisons; ± denotes mean ± standard deviation). CONCLUSIONS: The addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years.

Effect of anticoagulation on endothermal ablation of the great saphenous vein.

BACKGROUND: A growing number of patients who are on systemic anticoagulation with warfarin require endovenous thermal ablation for reflux disease in the great saphenous vein (GSV). Little is known about the effects of anticoagulation on periprocedural bleeding and long-term closure rates of the treated veins. This study evaluated the effects of uninterrupted anticoagulation in patients undergoing endovenous thermal ablation. METHODS: In this prospective observational study, 88 limbs of patients on warfarin (anticoagulation group [AG]) who underwent endovenous thermal ablation for GSV reflux disease were compared with 92 limbs in patients receiving no anticoagulation or antiplatelet agents (control group [CG]). Forty percent of AG patients were also receiving antiplatelet therapy. Periprocedural bleeding and closure rate at 1 year were evaluated. RESULTS: No major bleeding occurred in either group. Minor bleeding was noted in 8 of 88 procedures in the AG vs 4 of 92 in the CG (P = 0.24); all in patients receiving radiofrequency ablation. Four of the eight minor bleeds in the AG were noted in patients receiving "triple therapy" with warfarin, aspirin, and clopidogrel or ticlopidine. Triple therapy in the AG was associated with a higher risk of minor bleeding compared with the CG (relative risk, 13.0; 95% confidence interval, 4.10-41.19, P < .001). All treated venous segments remained closed at the 1-year follow-up in both groups. CONCLUSIONS: In this relatively small, nonrandomized study comparing endovenous thermal ablation in patients with and without warfarin, no differences were found in periprocedural risk of major bleeding or closure rate of the treated venous segments. Minor bleeding was increased in patients receiving triple therapy with warfarin, aspirin, and a thienopyridine who underwent radiofrequency ablation.

Is transesophageal echocardiography necessary before D.C. cardioversion in patients with a normal transthoracic echocardiogram?

PURPOSE: Transesophageal echocardiography has emerged as an accepted approach before D.C. cardioversion for atrial fibrillation. The frequency of atrial thrombi detected on transesophageal echocardiography has varied from 7% to 23%. Many patients undergoing transesophageal echocardiography have had a previous transthoracic echocardiogram. Though transthoracic echocardiography has a low yield for the detection of intracardiac thrombi, it is highly accurate in diagnosing a structurally abnormal heart. The purpose of this study was to assess the frequency of thrombi detected by transesophageal echocardiography in patients with an entirely normal transthoracic echocardiogram and hence the advocacy of a selective approach in performing transesophageal echocardiography in patients undergoing D.C. cardioversion for atrial fibrillation. METHODS: 112 consecutive patients with atrial fibrillation who had undergone transesophageal echocardiography before D.C. cardioversion were evaluated. They all had a transthoracic echocardiogram within the 2 months preceding their transesophageal echocardiogram. Based on their transthoracic echocardiographic study, they were divided into two groups: Group 1 consisted of patients with a normal transthoracic echocardiogram and Group 2, those with an abnormal study. RESULTS: Thrombi or spontaneous echo contrast were found in 14 of 112 patients (16%). All however were detected in Group 2 patients. There was no patient with a normal transthoracic echocardiogram who had thrombus on his/her transesophageal echocardiogram. CONCLUSIONS: Our results suggest that a selective approach may be exercised in the use of transesophageal echocardiography prior to D.C. cardioversion for atrial fibrillation. Patients with an entirely "normal" transthoracic echocardiogram may proceed directly to cardioversion without a precardioversion transesophageal echocardiogram.

Percutaneous balloon aortic valvuloplasty: a new look at an old procedure: a case report.

There has been little change in the technical approach to balloon aortic valvuloplasty (BAV) over the last two decades. Large-caliber sheaths and extra-stiff wires have been used routinely to accommodate the large balloons used for this purpose. Consequently the morbidity (and possibly mortality) rates have been high. With the recent advances in the interventional hardware, a new look at the current approach to BAV is justified. In this report we describe an 89-year-old woman with critical aortic stenosis who underwent rapid and successful BAV by the use of a single 8-French arterial sheath, a regular (and not stiff) wire, and one peripheral balloon. We conclude that BAV can be done easily and safely with the technique and equipment described in this case report.

Intense migraines secondary to percutaneous closure of atrial septal defects.

In this study we evaluated the development of migraine after percutaneous closure of atrial septal defect. An abrupt and excruciating form of migraine developed shortly after shunt closure in 5 of 13 consecutive patients undergoing this procedure. A dramatic relief of pain was achieved almost instantaneously after administration of 300 mg of clopidogrel.