Multiple malignant tumors.

BACKGROUND: Due to the improvement in diagnosis and therapy for certain malignant tumors, we are now faced with patients who develop in time multiple malignancies. METHODS: We conducted a retrospective analysis of the patients diagnosed with at least two primary cancers that were admitted and treated in Cluj-Napoca Municipal Hospital. The study followed patients for a period of 7.5 years. RESULTS: We included in the present study 217 patients (4.33%) with two or more malignant primary tumors from 5003 cases diagnosed with a primary cancer. The most common sites for multiple malignant tumors were related to the breast, colorectum, urinary bladder, prostate and kidneys. CONCLUSIONS: We should always take into consideration the possibility of synchronous tumors and we have to keep in mind that a successful treatment of cancer might not prevent the onset of another primary mass.

GST gene variants in synchronous colorectal cancers and synchronous association of colorectal cancers with other cancers.

BACKGROUND: the present study evaluates genetic polymorphisms of three glutathione S-transferases (GSTM1, GSTT1and GSTP1) in patients with synchronous malignant colorectal tumors and the association of synchronous colorectal cancers with other cancers. MATERIAL AND METHODS: from 420 patients with a colorectal cancer admitted to our hospital between 2005-2012, we selected for genetic analysis 20 patients with multiple synchronous malignant colorectal tumors and 9 patients with asynchronous association of colorectal cancer with another cancer. We searched for GST genotypes, comparing the results with controls. RESULTS: the genetic analysis was possible only in 19 patients with colorectal synchronous cancers and 9 patients with asynchronous association of colorectal cancer with another cancer; we found a statistically significant difference for null GSTM1 genotype frequency between these patients and the control group; we found no differences regarding the frequency of null GSTT1 genotype and Ile105Val polymorphism of GSTP1 in patients with synchronous cancers compared with the control group. CONCLUSION: in our study we found the null GSTM1 genotype as a risk factor for multiple colorectal synchronous cancers and for an association of synchronous colorectal with other cancers

[TIVA-TCI (Total IntraVenous Anesthesia-Target Controlled Infusion) versus isoflurane anesthesia for laparoscopic cholecystectomy. Postoperative nausea and vomiting, and patient satisfaction]. / TIVA-tCI vs. anestezia inhalatorie pentru colecistectomia laparoscopica. Incidenta sindromului emetic postoperator si satisfactia pacientilor.

UNLABELLED: Numerous studies have shown that TIVA is followed by a significant reduction in the incidence of PONV in day-case surgery, including laparoscopic cholecystectomy, where the incidence of PONV can reach 70% according to some studies. TCI is the TIVA technique that maintain a constant plasma concentration due to pharmacokynetic models incorporated in TCI device that inject the anesthetic agent. Besides implementing TIVA-TCI in clinical practice in Romania, our study was designed to evaluate the impact of TIVA-TCI on postoperative outcome and our patient satisfaction after laparoscopic cholecystectomy. PATIENTS AND METHODS: After informed consent, 70 patients ASAI/II undergoing laparoscopic cholecystectomy were randomized in 2 equal study groups: group 1 (n = 35) included patients with TIVA-TCI with propofol (Cpi = 4 microg/ml) and remifentanil, and group 2 (n = 35) were patients undergoing Isoflurane anesthesia. In both groups propofol was administered during induction and remifentanil followed the same protocol: 0.5 microg/kg/min in the first minute during induction, followed by 0.25 microg/kg/min. This infusion was modified by 0.05 microg/kg/min steps according to analgesic needs. PONV (evaluated as both incidence and number of episodes), severity of pain and patient satisfaction score IOWA were compared between study groups. RESULTS: Both the incidence of PONV (p = 0.03) and the number of episodes/24 h/patients (p = 0.01) were significantly lower in TIVA-TCI group, while there was no significant difference in opioid requirements in study groups (p = 0.21). Patients IOWA satisfaction score at 24 hours postoperatively was significantly higher in TIVA-TCI groups (p = 0.0001). CONCLUSIONS: Compared with Isoflurane, TIVA-TCI was followed by significantly lower incidence of PONV and significantly greater patients satisfaction.

Long-term results of thrombolytic therapy with and without percutaneous transluminal coronary angioplasty.

The effects of combined intravenous and intracoronary streptokinase without (Group I, n = 103) or with (Group II, n = 103) immediate coronary angioplasty were evaluated during a long-term (3 year) follow-up of 206 patients with acute transmural myocardial infarction. There were no baseline differences between the groups with regard to gender, age, infarct location, serum creatine kinase levels, time between onset of symptoms and treatment and coronary artery patency rate. Angioplasty was performed with a success rate of 69% and a reocclusion rate of 2%. Elective angioplasty was performed in 22 (21%) of 103 patients in Group I and 9 (9%) of 103 patients in Group II, with a success rate of 86% and 100%, respectively, reflecting the higher incidence of angina pectoris and antianginal therapy in Group I. Coronary bypass surgery was performed in 21 (20%) of 103 patients in Group I and 20 (19%) of 103 patients in Group II; there was one operative death in each group. During follow-up, coronary reocclusion or reinfarction, or both, occurred in 25 (29%) of 87 patients in Group I and in 16 (18%) of 87 patients in Group II with reperfused vessels (p = NS). Heart failure occurred in 40% of the patients in both groups who had increased end-diastolic and end-systolic volumes. The survival rate after 3 years was 78% in Group I and 80% in Group II (p = NS). Thus, long-term follow-up of patients with acute transmural infarction treated with and without immediate angioplasty does not demonstrate any difference with regard to clinical outcome and mortality.

Intracoronary thrombolysis with an acylated streptokinase-plasminogen activator (BRL 26921) in patients with acute myocardial infarction.

The fibrinolytic efficacy and systemic effects on coagulation variables of intracoronary administration of an acylated streptokinase-plasminogen complex (BRL 26921) were assessed in 23 patients with an acute transmural myocardial infarction. The infarct vessel was totally occluded in 22 patients and subtotally stenosed in 1 patient. Reperfusion was achieved in a total of 17 patients (74%), in 2 patients with the use of a guide wire. Reperfusion time in those patients treated with BRL 26921 alone amounted to 42 +/- 37 minutes. Reocclusion occurred in two patients subsequently. Four patients died; in two of these, intracoronary thrombolysis was unsuccessful. Reptilase time increased from 13 +/- 3 to 49 +/- 31 seconds (p less than 0.001), fibrinogen levels decreased from 280 +/- 65 to 126 +/- 76 mg% (p less than 0.001). Factor V decreased from 96 +/- 11 to 53 +/- 26% (p less than 0.001), and factor VIII from 99 +/- 1 to 55 +/- 36% (p less than 0.001). Peripheral hyperplasminemia, defined as a reduction of fibrinogen (less than 100 mg%) with a reduction of factor V and VIII (less than 75%) simultaneously occurred in eight patients. Six (75%) of these 8 patients demonstrated reperfusion, whereas 9 (64%) of 14 patients without peripheral hyperplasminemia were also successfully reperfused. Bleeding complications occurred in two patients who demonstrated hyperplasminemia. Thus, effective intracoronary thrombolysis could be achieved with only minor effects on peripheral coagulation variables in the majority of patients.

Percutaneous transluminal coronary angioplasty after thrombolytic therapy: a prospective controlled randomized trial.

In 162 patients with acute transmural myocardial infarction, combined intravenous and intracoronary thrombolytic therapy with streptokinase was initiated. In vessels that remained occluded, mechanical recanalization was performed with a 3F recanalization catheter (group I, n = 79) or a 4F Grüntzig balloon catheter (group II, n = 83). After reperfusion, intracoronary streptokinase was administered superselectively. After termination of streptokinase infusion, angioplasty was performed only in patients in group II. There was no difference between the groups in relation to sex, age, infarct location, creatine kinase levels and time between onset of symptoms and start of treatment. Initial coronary angiography showed an open vessel in 27 (34%) of 79 patients in group I and 21 (25%) of 83 patients in group II. The final reperfusion rate was 90% (71 of 79) in group I and 86% (71 of 83) in group II. Angioplasty was attempted in 69 of the 71 patients in group II with a success rate of 65% and an occlusion rate of 3%. During the hospital stay, reocclusion occurred in 14 (20%) of 71 patients in group I. After thrombolytic therapy, coronary luminal narrowing in group I was 75 +/- 17% in patients without and 87 +/- 6% in patients with reocclusion (p less than 0.05). In group II, reocclusion was found in 10 (14%) of 71 patients. After angioplasty, the degree of coronary stenosis in group II was reduced from 82 +/- 12 to 51 +/- 30% (p less than 0.001). Reocclusion was found in 3 (7%) of the 45 patients with successful angioplasty and in 7 (32%) of the 22 patients with unsuccessful angioplasty (p less than 0.01). Improvement in regional left ventricular function was observed only in patients from group II with anterior myocardial infarction. In conclusion, by combined medical and mechanical recanalization, the rate of coronary reperfusion can be increased and infarct time shortened, providing the possibility of full revascularization by angioplasty, with improvement of regional wall motion and reduction of the rate of reocclusion.

Assessment of refractoriness of the human Purkinje system.

In 35 unselected patients premature right ventricular stimulation during a constant right ventricular drive rhythm was performed at the rates of 80, 100, and 120 per min. Several surface ECG leads and intracardiac electrograms were simultaneously recorded. To assess the beginning of decreased conductivity of the His-Purkinje system for retrograde conduction the premature test pulse interval was measured when the retrograde intraventricular conduction to the bundle of His prolonged for the first time. This interval was defined as the beginning of relative refractoriness of the Purkinje system. Additionally, the effective refractory period of the right ventricular muscle was determined. A rate dependancy between the beginning of relative refractoriness of the Purkinje system and the effective refractory period of the right ventricular muscle, as it is known from animal experiments, could be established with significantly different (P less than 0.001) mean values at the three different heart rates. The method described may be the only means by which to obtain approximate information about normal and abnormal conductivity of the human Purkinje system. It is inferred that critical prolongation of refractoriness of the Purkinje system relative to the refractoriness of the myocardium may be relevant to the occurrence of ventricular arrhythmias.

Pharmacogenetics aspects of oral anticoagulants therapy.

RATIONALE: Vitamin K antagonists (VKA), such as warfarin and acenocoumarol, are widely used for the prevention and treatment of thromboembolic diseases and they are some of the most commonly prescribed types of medications. They are characterized by narrow therapeutic indices and inter-individual or intra-individual variability in response to the treatment. OBJECTIVE: to establish the influence of several genetic factors on VKA efficacy and adverse reactions. METHODS AND RESULTS: The metabolism of VKA differs depending on their chemical structure: indandiones derivatives (fluindione) or coumarin derivatives (acenocoumarol, phenprocoumon or warfarin). They are mostly metabolized in hepatocytes via a monooxygenase, cytochrome P450 2C9 (CYP2C9), resulting in inactive products. The gene encoding CYP2C9 is polymorphic, its genetic variants being associated with differences in the enzymatic activity of CYP2C9. The most important in terms of their frequency in the general population are CYP2C9*2 and CYP2C9*3. Both alleles are associated with a marked decrease in CYP2C9 enzyme activity. VK epoxide reductase (VKOR) is an enzyme with an important role in VK metabolism. Various polymorphisms in the VKORC1 gene have been described. VKORC1*2 haplotype seems to be the most important in relation to the variability in response to VKA. DISCUSSIONS: Various studies have shown a relationship between the genotype and the mean warfarin maintenance dosing: in patients carrying 2C9*1/*2 alleles, the dose is reduced by 18-40% in patients carrying 2C9*2/*2 alleles, by 21-49% in patients carrying 2C9*1/*3 alleles. The A allele of the c.-1639G>A polymorphism in the VKORC1 gene is associated with the need for a lower dose of acenocoumarol in patients on anticoagulant therapy. ABBREVIATIONS: SNP = Single Nucleotide Polymorphism, VKA = vitamin K antagonists, C1 - VKORC1 = vitamin K epoxide reductase complex subunit, INR = International Normalized Ratio.

Alinidine in angina.

Alinidine--N-allyl-clonidine--reduces heart rate without blocking beta adrenoreceptors. It may be used in patients with angina without inducing the adverse effects of beta-adrenergic blockers. We therefore evaluated alinidine efficacy in patients with angiographically proven coronary artery disease and stable angina during a 10-wk placebo-controlled randomized double-blind trial. Alinidine (40 mg three times a day) reduced the number of anginal attacks and the average number of nitroglycerine capsules consumed. The double product was slightly lowered during rest but more pronounced during exercise. This effect was mainly due to decreased heart rate. The ischemic S-T segment depression was diminished. Exercise tolerance was clearly improved in six, slightly improved in two, and unchanged in four subjects.

Diagnosis of increased pulmonary blood flow by suprasternal M-mode echocardiography in atrial septal defect.

The right pulmonary artery (PA) was quantitatively assessed by suprasternal M-mode echocardiography in 25 patients in whom an atrial septal defect (ASD) was suspected clinically. In 10 patients an ASD was excluded (Group 1) and in 15 it was confirmed (Group 2). The smallest diameter of the right PA at end-diastole in Group 1 was 8.8 +/- 1.5 mm/m2 body surface area and in Group 2 14.8 +/- 3.6 mm/m2 (p less than 0.001). The greatest diameter of the right PA during systole was also much smaller in Group 1 (11.3 +/- 1.2 mm/m2) than in Group 2 (17.7 +/- 3.5 mm/m2) (p less than 0.001). The absolute and percent systolic expansion of the right PA did not differ in the 2 groups (2.7 +/- 0.5 mm [29.1 +/- 10.8%] in Group 1 and 2.9 +/- 0.8 mm [20.8 +/- 9.8%] in Group 2). No correlation was found between measured and derived echocardiographic variables of the right PA and the magnitude of the left-to-right shunt. Patients in Group 2, who had an additional pressure elevation in the PA, showed, on average, a larger right PA and a smaller percent systolic expansion. The study demonstrates characteristic alterations in the wall motion pattern of the right PA in patients with ASD, indicating increased pulmonary blood flow.

Electrophysiologic effects of lorcainide on the accessory pathway in the Wolff-Parkinson-White syndrome.

The electrophysiologic effects of lorcainide, a class I antiarrhythmic agent with local anesthetic properties, were studied in 20 patients with the Wolff-Parkinson-White syndrome. After intravenous administration of lorcainide (2 mg/kg), the sinus cycle length decreased in all patients from 705 +/- 117 to 636 +/- 94 ms (p less than 0.001). The atrioventricular conduction time lengthened from 84 +/- 22 to 94 +/- 22 ms (p less than 0.01) and the QRS duration increased from 92 +/- 19 to 120 +/- 29 ms (p less than 0.001). The effective refractory period of the atrium increased from 230 +/- 27 to 243 +/- 35 ms (p less than 0.05), whereas the ventricular refractoriness was unaffected. Retrograde conduction over the accessory pathway was blocked in 5 of 18 patients after lorcainide; in the remaining 13 patients a prolongation from 107 +/- 32 to 162 +/- 57 ms (p less than 0.001) was found. Anterograde conduction over the accessory pathway was blocked in 6 patients, and in all other patients it increased considerably. Circus movement tachycardia could be induced in 14 patients before and in 10 patients after the drug. The shortest R-R interval during tachycardia lengthened from 326 +/- 40 to 364 +/- 67 ms (p less than 0.05). The tachycardia zone was unaffected by lorcainide. In 15 patients atrial fibrillation was induced. After lorcainide anterograde conduction during atrial fibrillation was blocked (n = 5). The shortest R-R interval over the accessory pathway during induced atrial fibrillation increased from 228 +/- 35 to 304 +/- 103 ms (p less than 0.05). Intravenous administration of lorcainide produced a pronounced negative dromotropic effect on the conduction properties of the accessory pathway. Lorcainide appears to be a promising new antiarrhythmic agent in patients with the Wolff-Parkinson-White syndrome.

Sudden cardiac death while wearing a Holter monitor.

The Holter tapes of 61 patients (46 men, mean age +/- standard deviation 65 +/- 11 years) with sudden cardiac death while being monitored were analyzed. Thirty-eight patients were known to have coronary artery disease, 5 had cardiomyopathy, and 7 had aortic valve disease. Etiology remained unknown in 11 patients. Mean New York Heart Association functional class was 2.5 +/- 0.7. Thirty patients had received antiarrhythmic drugs and 32 had received digitalis. Sudden death occurred at rest in 73%. In the hours before death, repetitive ventricular arrhythmias were found in 50 patients (82%), with atrial fibrillation in 34%. Patients with bradyarrhythmic death (18%) had less complex ventricular activity compared to patients with tachyarrhythmic death (p less than 0.01). Lethal arrhythmias--monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, torsades de pointes, primary ventricular fibrillation, and 1:1 conducting atrial tachycardia--were found in 26 (43%), 15 (25%), 5 (8%), 3 (5%), and 1 patient, respectively. The coupling interval of the final ventricular tachycardia correlated inversely with the initial frequency of ventricular tachycardia (p less than 0.05). For patients with tachyarrhythmic death, an increase of heart rate within the last 3 hours was noted (83 vs 89 beats/min, p less than 0.05). Ventricular premature complexes and the proportion of patients with greater than 2 couplets and greater than 2 triplets increased significantly only within the last hour before death.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term antiarrhythmic therapy with flecainide.

The antiarrhythmic efficacy and safety of oral flecainide were assessed during a controlled 2-week and a subsequent 48-week long-term trial. Fifteen patients with frequent (more than 30 per hour) and complex ventricular arrhythmias (Lown grade IVA or IVB) who had been resistant or intolerant to 2 or more antiarrhythmic agents, were included in the study. Antiarrhythmic efficacy was controlled by 24-hour Holter monitoring at 2, 12, 24 and 48 weeks. The administration of 100 to 200 mg flecainide twice daily resulted in more than 90% suppression of VPCs and of complex ventricular arrhythmias in 14 of 15 patients. The minimum effective therapeutic dose could be titrated in 9 of 14 patients to 100 mg twice daily, in 3 of 14 patients to 150 mg twice daily and in 2 of 14 patients to 200 mg twice daily. During this therapy and a mean plasma concentration of 886 +/- 103 ng/ml, PQ and QRS duration, as well as QTc time and JTc interval were not significantly changed. Side effects (gastrointestinal complaints, nausea, obstipation, dizziness, visual disturbances, headache and impaired potency) were seen in 5 of 14 patients after 12 weeks, in 3 of 4 patients after 24 weeks and in only 2 of 14 patients after 48 weeks. Side effects were described as mild and tolerable and did not limit flecainide therapy except in 1 patient, who had discontinued therapy with flecainide after 3 days because of intense gastrointestinal symptoms. In conclusion, flecainide is highly effective and well tolerated in the long-term treatment of serious ventricular arrhythmias.

Atrioventricular dissociation detected by suprasternal M-mode echocardiography: a clue to the diagnosis of ventricular tachycardia.

Twenty-two patients were studied by suprasternal M-mode echocardiography during ventricular tachycardia (VT). Adequate echocardiograms were obtained from 19 patients. Thirteen patients showed atrioventricular (AV) dissociation and 6 patients a ventriculoatrial contraction pattern according to the left atrial (LA) contraction obtained from the suprasternal notch. In 1 of these 6 patients, a 2:1 block retrograde was found by echocardiography. In another patient, an intermittent block occurred in the retrograde direction. In 4 patients, a constant relation between the QRS complex and LA contraction soon after the beginning of the QRS complex was seen, demonstrating a 1:1 ventriculoatrial conduction. According to the LA contraction obtained from the suprasternal echocardiogram, 13 patients showed AV dissociation and 6 patients a retrograde conduction to the LA. From the analysis of the 12-lead standard electrocardiogram obtained simultaneously during VT, AV dissociation could be recognized in only 3 patients. Thus, AV dissociation during VT is more easily diagnosed with suprasternal M-mode echocardiography than with the standard electrocardiogram.

Recombinant single-chain urokinase-type plasminogen activator during acute myocardial infarction.

Recombinant single-chain urokinase-type plasminogen activator was intravenously administered in 2 different doses in 24 patients with acute myocardial infarction and angiographically proved occlusion of the infarct-related artery. Patients with first infarction without contraindications of thrombolysis were treated within the first 4 hours after the onset of symptoms. Group A (12 patients) received 20 mg of rscu-PA as a bolus followed by 60 mg infused over 1 hour and group B received 10 mg as a bolus and 30 mg as infusion. The 2 groups showed no significant difference in age, sex, height, weight, time between onset of symptoms and start of therapy, peak values and course of infarct-related enzymes. Time to reperfusion was 43 minutes in group A versus 67 minutes in group B (p less than 0.005). The rate of reperfusion 90 minutes after start of treatment was 91% in group A and 50% in group B (p less than 0.001). Plasma levels of fibrinogen, plasminogen and alpha-2-antiplasmin did not differ significantly in both groups. Systemic lytic state (fibrinogen less than 100 mg/dl) occurred in 33% of group A and in 9% of group B. Intravenous infusion of 80 mg (but not 40 mg) of rscu-PA led to reperfusion of the occluded coronary artery in nearly all patients. Approximately one-third of the patients treated with this dose demonstrated systemic lysis.

Determinants of prognosis in idiopathic dilated cardiomyopathy as determined by programmed electrical stimulation.

The incidence and prognostic significance of electrically induced ventricular arrhythmias were prospectively assessed in 42 patients with idiopathic dilated cardiomyopathy. All patients underwent 24-hour, long-term electrocardiographic (Holter) monitoring and 30 were analyzed by a signal-averaging vectorcardiographic procedure at entry into the study. Their response to programmed electrical stimulation during basic right ventricular pacing was investigated using 1 and 2 ventricular extrastimuli. A monomorphic tachycardia was not induced in any patient. In 36 patients (86%) polymorphic ventricular arrhythmias were initiated. Three or more induced consecutive ventricular premature complexes occurred in 9 patients (21%), nonsustained polymorphic ventricular tachycardia in 2 (4.8%) and ventricular fibrillation in 1 patient (2.4%). There was no association between electrically induced polymorphic ventricular arrhythmias and the degree of impairment of left ventricular function. Furthermore, the incidence of induced ventricular arrhythmias was not related to the Lown grade or to the total number of ventricular premature complexes during Holter monitoring. A late potential was detected by the averaged vectorcardiogram in only 1 of the 30 patients. During follow-up (mean 16 +/- 7 months) 7 patients died, 5 from chronic congestive heart failure and 2 from sudden cardiac death. No patient had an electrically induced arrhythmia of 3 or more ventricular premature complexes.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of ventricular arrhythmias in idiopathic dilated cardiomyopathy.

The incidence and prognostic significance of ventricular arrhythmias identified by 24-hour ambulatory electrocardiography (Holter) was prospectively assessed in 74 patients with idiopathic dilated cardiomyopathy (IDC). The criteria for diagnosis of IDC were based on clinical and cardiac catheterization findings. Holter monitoring was performed at the time of entry into the study. Patients were followed for 2 to 21 months (mean 11 +/- 3). Frequent ventricular premature complexes (VPCs) (greater than 1,000/24 hours) were seen in 35%, and complex VPCs (Lown grade III and IV) in 87% of the patients. Forty-nine percent of the patients had nonsustained ventricular tachycardia (VT) consisting of 3 to 32 beats with rates from 110 to 230 beats/min, and 20% had ventricular pairs. No correlation was found between clinical symptoms or the degree of left ventricular (LV) impairment and the number of ventricular pairs or episodes of VT. During follow-up, 19 patients died, 7 from congestive heart failure (CHF) and 12 suddenly. Patients who died suddenly had significantly more episodes of VT, ventricular pairs or total VPCs (p less than 0.01 each) compared with survivors and those who died from CHF. No significant differences were found between patients who died from CHF or suddenly with respect to LV end-diastolic pressure, LV end-diastolic volume index, LV ejection fraction (EF) and cardiac index. A linear stepwise discriminant function analysis using hemodynamic (LVEF and cardiac index) and arrhythmic (number of VT episodes and ventricular pairs) variables resulted in a meaningful separation between survivors and patients who died from CHF or suddenly.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of intravenous flecainide on atrial vulnerability in man.

Sixteen patients were investigated by means of programmed atrial stimulation at 2 different driving rates: 100/min and 120/min. All patients had an increased atrial vulnerability at both driving rates. After the administration of intravenous flecainide (1 mg/kg bodyweight as a bolus, followed by the same amount infused over a period of 20 minutes), the increased vulnerability was abolished in 11 and 9 patients, respectively. In the remaining patients the rate of induced atrial tachyarrhythmia decreased. These findings correlate with a significant prolongation of the effective refractory period of the right atrium and a corresponding significant shortening of its relative refractory period. It is concluded that flecainide may be effective in the treatment of atrial arrhythmias in humans.

The suprasternal approach to recording aortic valve prostheses: a comparison with the precordial and subxiphoid approaches.

We evaluated 56 consecutive patients echocardiographically 9 days to 104 months after aortic valve replacement by the precordial, subxiphoid and suprasternal approach. In 11 patients, the mitral valve had also been replaced. For comparison, a subjective grading system (score 1 up to 3) was applied to the records obtained from each approach. Disc valves (n = 41) were equally scored from the precordial and suprasternal approach (score 2.6). Ball prostheses (n = 6) were best imaged from the suprasternal approach (score 3.0), whereas bioprostheses (n = 9) were best visualized from the precordial (1.8). Simultaneous imaging of both valves was possible in 6 out of 11 patients with a double prosthesis using the suprasternal approach but not from precordial and subxiphoid approaches. Six patients presented prosthetic valve dysfunction. Five patients had paravalvular insufficiency; 4 of these patients had a Björk-Shiley valve and one patient a Lillehei-Kaster valve. The echograms of 4 out of 5 patients with a paravalvular leak were normal from each approach. In another patient an obstructed Björk-Shiley prosthesis was found. The pre- and postoperative echograms demonstrated that the suprasternal approach was best to visualize the obstructed valve. The study shows that the suprasternal technique is superior for evaluation of most patients with aortic valve prostheses.