Clinical results of carotid denervation by adventitial stripping in carotid sinus syndrome.

AIMS: Older patients with spells of syncope may suffer from a carotid sinus syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed carotid denervation by adventitial stripping for CSS treatment. METHODS: Carotid sinus massage (CSM) during cardiovascular monitoring confirmed CSS in patients with a history of repeated syncope and dizziness. The internal carotid artery was surgically denervated by adventitial stripping over a minimum distance of 3 cm via a standard open approach. Patient characteristics, perioperative complications and 30-day success rate were analyzed. RESULTS: A total of 39 carotid denervation procedures was performed in 27 individuals (23 males, mean age 70+/-3 years) between 1980 and 2007 in a single institution. Eleven patients had a bilateral hypersensitive carotid sinus. Procedure related complications included wound hematoma (n=4), neuropraxia of the marginal mandibular branch of the facial nerve (n=2) and dysrhythmia responding to conservative treatment (n=3). Significant alterations in systolic and diastolic blood pressure and heart rate were not observed. One patient developed a cerebral ischaemic vascular accident on the 24th postoperative day. One patient with residual disease had a successful redenervation within 1 month after the initial operation. Two patients with persistent symptoms received a pacemaker but also to no avail. At 30-day follow up 25 of 27 patients (93%) were free of syncope, and 24 free of a pacemaker (89%). CONCLUSION: Carotid denervation by adventitial stripping of the proximal carotid internal artery is effective and safe and may offer a valid alternative for pacemaker treatment in patients with carotid sinus syndrome.

Effective surgical treatment of the carotid sinus sindrome.

Elderly patients frequently suffer from dizziness and syncope; however, an underlying disease may not always be identified. Three patients aged 69, 71 and 56, respectively, experienced spells of dizziness and syncope. Massage of the carotid sinus demonstrated the presence of a carotid sinus syndrome (CSS), an abnormal baroreflex response of the carotid sinus that leads to asystole and extreme hypotension. Conventional treatment is generally by insertion of a pacemaker. These patients, however, were referred to the vascular surgery department of our hospital for removal of adventitial layers of proximal portions of the internal carotid artery. Recovery was uneventful; all three are now free of symptoms. CSS should be considered in the differential diagnosis of dizziness and syncope. Surgical denervation of the carotid artery is a valid treatment option, especially in the vasodepressive or mixed type of CSS.

Excessive vomiting abolished by carotid denervation.

The carotid sinus syndrome (CSS) is characterized by repetitive syncope due to prolonged heart rate slowing or a profound drop in systolic blood pressure. CSS is due to an inappropriate response of a hypersensitive carotid sinus following pressure on or stretching of the neck. We report on a patient with excessive gagging and vomiting elicited by pressure on the right side of the neck as an aberrant presentation of the carotid sinus syndrome. Her incapacitating symptoms were abolished by a surgical carotid denervation.

[Acute myocardial infarct following sulprostone administration]. / Acuut myocardinfarct na toediening van sulproston.

Because of intrauterine foetal death at 35 weeks, parturition in a woman aged 35 years was induced by intravenous sulprostone. A few hours after its start she sustained a myocardial infarction for which she was treated. Coronary angiography 4 weeks later showed normal coronary arteries and good left ventricular function. Mild cardiovascular reactions such as bradycardia and mild hypotension are frequently observed adverse effects. In some instances, sulprostone can induce myocardial ischaemia. However, the possibility of a myocardial infarction is not mentioned in the product information of sulprostone. As there was an obvious temporal relationship and other causative factors were sufficiently excluded, the causal relation between the administration of sulprostone and the occurrence of myocardial infarction can be regarded as almost certain. Several experimental studies provide support for the hypothesis that coronary spasms play a major role in the pathophysiology of a myocardial infarction during the administration of sulprostone.

Effects of epanolol and metoprolol on the heart measured by 24-hour holter monitoring.

Continuous 24-hour ECG monitoring was performed as an additional objective in 87 patients from 5 centres in the VISA 1 study. The aim of the study was to compare the continuous 24-hour ECG recordings before the study and during treatment with epanolol ('Visacor') or metoprolol. Parameters of particular interest were heart rate and premature ventricular contractions (PVCs). Using the Oxford 4000 system with a 5-lead recorder, 24-hour monitoring was carried out on entry to the study (no antianginal therapy was allowed, with the exception of short acting nitrates), and at the end of both treatment periods. Measurements included the total number of heart beats and PVCs and the incidence of bradycardia. 87 patients, of mean age 59 (range 32 to 80) years, were included in the study. 62 patients had evaluable tapes available on both active treatment periods. The mean heart rate during 24 hours was significantly lower with metoprolol compared with epanolol treatment (64 vs 72 beats/min, respectively, p less than 0.001). The total number of PVCs in 24 hours was similar in both treatment groups and not significantly different from the value recorded at entry. The median total duration of bradycardia (heart rate less than 60 beats/min) in 24 hours was significantly (p less than 0.001) less for epanolol (60 minutes) than metoprolol (428 minutes). Plots of the mean hourly heart rates show that during daytime, epanolol was associated with a mean heart rate in between the rate observed without treatment and with metoprolol treatment. At night-time, almost identical values were found in the groups treated with epanolol compared with the non-treatment period, whereas the metoprolol treatment induced significant lower heart rate levels. Thus, it was shown that there was greater heart rate reduction with metoprolol than with epanolol (p less than 0.001), and that there was no heart rate reduction at night with epanolol. No arrhythmogenic effect was seen for either drug.

Cross-over comparison of the fixed combination of hydrochlorothiazide and triamterene and the free combination of furosemide and triamterene in the maintenance treatment of congestive heart failure.

The fixed combination of hydrochlorothiazide 25 mg and triamterene 50 mg and the free combination of furosemide 40 mg and triamterene 50 mg were compared as maintenance treatment in patients who were in a stable condition after an episode of congestive heart failure. All the patients were on digitalis. The trial was of the cross-over design. The treatment order was randomized at each centre. Each treatment lasted for 8 weeks. Of the 37 patients entering the study 30 were suitable for analysis. Both treatments were equally effective in maintaining bodyweight at the same level and in influencing symptoms. The free combination decreased the blood pressure slightly more than the fixed combination, especially the systolic pressure. One-third of the patients were hypertensive at the outset (diastolic pressure greater than 95 mm Hg) and in them the effects of the two treatments were not significantly different. The majority of the patients (80%) preferred treatment with the fixed combination because it caused slower and less frequent micturition.