Effect of general anesthesia on the severity of mitral regurgitation by transesophageal echocardiography.

The effect of general anesthesia on the severity of mitral regurgitation (MR) was examined in 43 patients with moderate or severe MR who underwent preoperative and intraoperative transesophageal echocardiography. Systolic blood pressure, mean arterial pressure, and left ventricular end-diastolic and end-systolic dimensions were significantly lower during the intraoperative study, reflecting altered loading conditions. The mean color Doppler jet area and mean vena contracta decreased and the mean pulmonary venous flow pattern changed from reversed to blunted, reflecting a significant reduction in the severity of MR. Overall, 22 of the 43 patients (51%) improved at least 1 MR severity grade when assessed under general anesthesia. Thus, intraoperative transesophageal echocardiography may significantly underestimate the severity of MR. A thorough preoperative assessment is preferable when deciding whether to perform mitral valve surgery.

Multiplane transesophageal echocardiographic identification of the involved scallop in patients with flail mitral valve leaflet: intraoperative correlation.

Although the role of multiplane transesophageal echocardiography in the diagnosis of flail mitral valve leaflet is well described, the accuracy of this modality in localizing the involved posterior leaflet scallop (medial, middle, or lateral) has never been validated. For 54 patients undergoing intraoperative transesophageal echocardiography for severe mitral regurgitation due to flail mitral valve leaflet, we assessed the accuracy of a systematic approach to localization of the flail mitral valve leaflet. Surgical confirmation was performed for all patients. At blinded review, a sensitivity of 78%, specificity of 92%, and overall diagnostic accuracy of 88% were achieved for correct localization of the flail posterior leaflet scallop. The middle scallop was most commonly affected in this series. The medial scallop was affected least often, and diagnosis of lesions in that area was least accurate. This diagnostic approach appears to be accurate and feasible and may assist in planning specific surgical therapy for this disorder.

Long-term clinical follow-up after directional coronary atherectomy.

Although several studies have been done to assess the safety, efficacy, and angiographic restenosis rates of directional coronary atherectomy (DCA), there have been no studies to document the need for repeat revascularization of the target vessel based purely on recurrence of symptoms. To answer this question, clinical and angiographic data were obtained for 187 consecutive patients undergoing this procedure on a native coronary artery utilizing a lesion specific approach in a referral hospital. Most of the patients had anginal symptoms that were not well controlled with medical therapy. The decision to perform DCA was based on the lesion characteristics (i.e., eccentric, ulcerated, or irregular discrete lesions in a large epicardial vessel). The procedure was successful in 96% of patients. In-hospital major complications were seen in 6 patients (3%) including acute myocardial infarction in 3 (1.5%) and emergency coronary artery bypass surgery in the other 3 (1.5%). There were no deaths. Among 141 consecutive successful patients on whom the procedure was performed between January 1992 and June 1994, 128 (91%) were contacted. At 6 months, revascularization was required in 20 patients for recurrent anginal symptoms, and there were no deaths or myocardial infarctions. The clinical restenosis rate, therefore, was 15.6%. At long-term follow-up (25 +/- 9 months), revascularization was performed in 3 more patients. One patient had a myocardial infarction and 3 patients died of noncardiac causes. Among those without clinical restenosis, 83% patients were asymptomatic and the rest had infrequent chest pains effectively managed with medications. The patients in the study group were using an average of 1.2 cardiac medications. Quality of life improved in 74% of the patients. Thus, in this study utilizing a lesion specific approach, the success rate for DCA was comparable to the published trials and in-hospital complications were few. The long-term clinical outcome was favorable with a low rate of clinical restenosis requiring repeat revascularization.

Nephrotic syndrome and acute renal failure associated with hepatitis A virus infection.

Acute renal failure has been documented in association with hepatitis A virus (HAV) infection. This report describes a temporal relationship between HAV infection and immune complex mesangial proliferative glomerulonephritis associated with nephrotic syndrome. Animal experimental data have already shown that this is indeed a histological lesion associated with HAV infection. This case report is the first English documentation associating HAV infection with immune complex mesangial proliferative glomerulonephritis.

Three cases of familial hairy cell leukemia.

In a 10-year interval, a total of 12 cases of familial hairy cell leukemia have been published. They were noted in first degree relatives, mostly in men. In some instances, when the HLA type was performed, a specific HLA type was found in the studied family, but a different haplotype was seen in other families. It appeared that familial cases of hairy cell leukemia were not associated with a "specific HLA antigen" and other factor(s) such as environmental, or some kind of occupational exposure, were suggested to play a role in the familial occurrence of hairy cell leukemia. We add three more familial hairy cell leukemia cases which are different from other published cases, showing a female predominance. The HLA typing revealed interesting findings. The HLA type shared by case 1 and 3 was A2, A30/31(19), B27, Bw4, Bw6. From these, HLA A2, Bw4, and Bw6 were previously reported (Ward FT, Baker J, Krishnan J, Dow N, Kjobech CH: Cancer 65:319-321, 1990). Case 2, shared with the other two the antigen Bw6. Its specific HLA type was A3 and B7, the type previously reported in a family (Begley CG, Tait B, Crapper RM, Briggs RG, Brodie GN, Mackay IR: Leuk Res 11:1027-1028, 1987). Based on these observations, we may conclude that a "specific HLA type," A2, Bw4, Bw6 and A3, B7 might have a role in the genetic predisposition for hairy cell leukemia.