El cociente de flujo cuantitativo en pacientes con estenosis aórtica grave y lesiones coronarias intermedias / Quantitative flow ratio for evaluation of borderline coronary lesions in patients with severe aortic stenosis

Introducción y objetivo: El cociente de flujo cuantitativo (quantitative flow ratio [QFR]) es un método novedoso y no invasivo para evaluar la fisiología coronaria. Sin embargo, los datos sobre QFR en pacientes con estenosis aórtica (EA) y enfermedad coronaria son escasos. Por lo tanto, se evaluó el rendimiento diagnóstico del QFR contra la relación del cociente de presión coronaria en reposo distal/aórtica (Pd/Pa), la reserva fraccional de flujo (FFR) y el índice diastólico instantáneo sin ondas (iFR), así como índices angiográficos. Métodos: Se incluyó un total de 221 pacientes con EA con 416 vasos en los que se midieron los valores de FFR/iFR. Resultados: El porcentaje medio de estenosis del diámetro (%DS) fue 58,6±13,4% y las medias de Pd/Pa, FFR, iFR y QFR, 0,95±0,03, 0,85±0,07, 0,90±0,04 y 0,84±0,07 respectivamente. Se observó una FFR ≤ 0,80 en el 26,0% de los vasos evaluados, iFR ≤ 0,89 en el 33,2% y QFR ≤ 0,80 en el 31,7%. El QFR tuvo mejor correlación con la FFR (coeficiente de correlación intraclase [ICC]=0,96; intervalo de confianza del 95% [IC95%], 0,95-0,96) que con el iFR (ICC=0,79; IC95%, 0,75-0,82) y la Pd/Pa (ICC=0.52; IC95%, 0,44-0,58). Además, el QFR mostró una mejor precisión diagnóstica (el 98,6 frente al 94,2%; p <0,001) y la función discriminatoria (área bajo la curva, 0,996 frente a 0,988; p <0,001) al utilizar como referencia el iFR en lugar de la FFR. Conclusiones: En pacientes con EA, el QFR muestra una buena correlación con la FFR y el iFR. Sin embargo, esta podría ser aún mejor utilizando el iFR como referencia, presumiblemente debido a la naturaleza compleja de la fisiología coronaria en la evaluación de la enfermedad coronaria de pacientes con EA grave (AU)

Introduction and objectives: Quantitative flow ratio (QFR) is a novel noninvasive method for evaluating coronary physiology. However, data on the QFR in patients with aortic stenosis (AS) and coronary artery disease are scarce. Thus, we compared the diagnostic performance of the QFR with that of the resting distal to aortic coronary pressure (Pd/Pa) ratio, fractional flow reserve (FFR), and instantaneous wave-free ratio (iFR), as well as angiographic indices.Methods: A total of 221 AS patients with 416 vessels undergoing FFR/iFR measurements were enrolled in the study. Results: The mean percent diameter stenosis (%DS) was 58.6%±13.4% and the mean Pd/Pa ratio, FFR, iFR, and QFR were 0.95±0.03, 0.85±0.07, 0.90±0.04, and 0.84±0.07, respectively. A FFR ≤ 0.80 was noted in 26.0% of interrogated vessels, as well as an iFR ≤ 0.89 in 33.2% and QFR ≤ 0.80 in 31.7%. The QFR had better agreement with FFR (intraclass correlation coefficient [ICC], 0.96; 95% confidence interval [95%CI], 0.95-0.96) than with the iFR (ICC, 0.79; 95%CI, 0.75-0.82) and Pd/Pa ratio (ICC, 0.52; 95%CI, 0.44-0.58). In addition, the QFR showed better diagnostic accuracy (98.6% vs 94.2%; P <.001) and discriminant function (area under the curve=0.996 vs 0.988; P <.001) when the iFR was used as the reference instead of FFR. Conclusions: In patients with AS, the QFR has good agreement with both FFR and iFR. However, the agreement appears to be even better when the iFR is used as the reference, presumably due to the complex nature of the coronary physiology in the assessment of coronary artery disease in patients with severe AS U(AU)

Evaluation of profilin 1 as a biomarker in myocardial infarction.

OBJECTIVE: Profilin 1 (Pfn1) is likely to be involved in atherogenesis and myocardial infarction (MI). Clinical data on this subject are very limited. The aim of this study was to search for associations between serum Pfn1 and a number of parameters in MI patients: symptom onset to PCI time (OPT), myocardial necrosis markers, thrombolysis in myocardial infarction (TIMI) flow, antiplatelet drugs, heparin administration and typical atherosclerosis risk factors. PATIENTS AND METHODS: We included patients with type 1 MI (according to the Third Universal Definition of Myocardial Infarction) who were able to precisely determine the time of symptom onset. Exclusion criteria involved conditions potentially altering platelet function. We screened 114 patients and included 65. We assessed serum Pfn1 in three time points: on admission (Pfn1_0), 24 hours post PCI (Pfn1_24) and 48 hours post PCI (Pfn1_48) and correlated it with OPT, cardiac necrosis markers (troponin T, CK, CKMB), TIMI flow in the infarct-related artery, pre-hospital P2Y12-antagonist and heparin administration and known atherosclerosis risk factors. RESULTS: Patients with a shorter OPT had higher Pfn1_0 (838.5 vs. 687.1 pg/ml, p=0.007). Patients with impaired coronary flow post PCI had lower Pfn1_24 (748.2 vs. 925.2 pg/ml, p=0.017) and Pfn1_48 (744.5 vs. 879.8, p=0.031. Pfn1_24 and Pfn1_48 were lower in patients who received a P2Y12 antagonist prior to hospital admission. Diabetic patients presented with lower Pfn1_0 concentrations. CONCLUSIONS: This is the first study assessing Pfn1 in type 1 MI patients in relation to the chosen parameters. Pfn1 may be a biochemical tool to objectify information on OPT in MI patients. We found an association between Pfn1 and post-PCI TIMI flow, antiplatelet drug administration and diabetes mellitus.

[Optical coherence tomography of coronary arteries--a novel intravascular imaging modality]. / Optische Kohärenztomographie der Koronararterien.

Optical coherence tomography (OCT) is the latest intravascular imaging modality for the investigation of coronary arteries. It can be used in patients with stable coronary artery disease as well as in patients with acute coronary syndrome. Its almost microscope-like resolution of 10-20 µm (10-times greater than intravascular ultrasound) gives us the most detailed insight into the coronary artery wall in vivo so far.Optical coherence tomography can be used for accurate qualitative and quantitative assessment of stenoses in stable coronary artery disease and accurate guidance of percutaneous coronary interventions as well as accurate postprocedural control. In patients with acute coronary syndrome it can be used for the detection of culprit of the culprit lesion (vulnerable plaque) which allows the operator to cover not only angiographically tightest stenosis (angiographic culprit lesion, caused in most cases by thrombus only) but most importantly the vulnerable plaque, which led to the acute event, as well. Furthermore, optical coherence tomography allows accurate assessment of thrombotic burden, stent apposition/malapposition, edge dissections and tissue prolaps or thrombus protrusions throught stent struts, etc.

Late complications after antireflux procedures using intraoperative continuous computer-video manometry monitoring.

BACKGROUND: Gastroesophageal Reflux Disease (GERD) is a common non-malignant gastrointestinal disease. The introduction of minimally invasive surgical techniques and the high costs of pharmacotherapy increased the number of patients subjected to surgical antireflux treatment. Furthermore, the use of advanced technique of manometry--including intraoperative video-assisted continuous pressure monitoring--made possible complicated but objective analysis of the pressure profile in the newly created area of gastroesophageal junction. MATERIAL AND METHOD: The current study was conducted in 159 patients. A group consisted of 93 men and 66 women, mean age of 38 years (range 18-72), subjected to antireflux surgery with continuous intraoperative video-assisted manometry of pressure in the newly created gastroesophageal junction (fundoplication wrap). Surgical procedure was individually tailored in each case depending on the motility parameters and GERD etiology. Eighty seven patients (55%) underwent 360 degrees Nissen fundoplication, 17 "floppy" Nissen procedure (11%), 22 Dor hemifundoplication (14%), and 33 Toupet hemifundoplication (21%). RESULTS: Out of the 159 patients subjected to antireflux procedures only 8 (5.0%) developed dysphagia, and 12 (7.5%) recurrent reflux disease. Recurrent reflux symptoms were most frequently caused by the dislocation of the fundoplication wrap. Dysphagia occurred in patients with too tight fundoplication wrap or because of its dislocation with subsequent rotation and angulation that impaired food passage. In some patients objective causes of dysphagia have not been found. In these patients no abnormalities were detected by the postoperative visualising examinations, and mean pressure in the fundoplication wrap did not exceed critical values. In these cases, dysphagia was caused probably by impaired gastric motility. CONCLUSIONS: 1. GERD with multifactor etiology requires individually tailored surgery based on the results of motility studies. 2. Final result depends on appropriate calculations of the intraoperative pressure in the newly created fundoplication wrap. 3. Appropriate fixing of the fundoplication wrap to the diaphragm is very important in order to decrease the rate of GERD recurrences due to wrap dislocation.

Comparison of dual-chamber pacing with nonsurgical septal reduction effect in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: The aim of the study was to compare the influence of dual-chamber pacing vs. nonsurgical septal reduction on hemodynamic and morphological parameters in patients with obstructive form of hypertrophic cardiomyopathy. METHODS: Nineteen patients with dual-chamber pacing (group I) and 9 patients who underwent nonsurgical septal reduction (group II) were studied at baseline and after a 6-month follow-up. The changes of left ventricular outflow tract gradient and posterior wall thickness (as an index of left ventricular hypertrophy regression) were compared. RESULTS: The baseline left ventricular outflow tract gradient was comparable between group I and group II (77+/-25 vs. 82+/-25 mm Hg, p>0.05). At 6-month follow-up, the left ventricular outflow tract gradient was reduced to a similar level in both groups (28+/-19 vs. 25+/-12 mm Hg, p>0.05). At baseline, posterior wall hypertrophy was comparable between groups (12.9+/-1.7 vs. 13.6+/-2.2 mm, p>0.05). During follow-up, the posterior wall thickness was unchanged in the pacing group (12.9+/-1.7 vs. 12.6+/-1.6 mm, p>0.05), whereas nonsurgical septal reduction induced regression of left ventricular hypertrophy in myocardial region remote from the infarcted septal segment (13.6+/-2.2 vs. 10.5+/-2.3 mm, p<0.003). CONCLUSION: Despite comparable reduction of instantaneous left ventricular outflow tract gradient, the nonsurgical septal reduction decreased posterior wall thickness, whereas pacing did not reduce left ventricular hypertrophy. Thus, regression of left ventricular hypertrophy that appeared solely after nonsurgical septal reduction may reflect the more permanent reduction of left ventricular pressure overload. Thus, not only hemodynamic but also morphological benefit from nonsurgical septal reduction seems to indicate the superiority of this method over dual-chamber pacing.

History of Polish gastrointestinal surgery.

Surgery is the oldest discipline of medicine. The first Poland's University Chair of Surgery was established in the 18(th) century. Surgery that had been until then the domain of barbers became a clinical discipline. In the 19(th) century Polish surgeons were actively involved in the development of gastrointestinal surgery. Most famous among them, J. Mikulicz Radecki and L. Rydygier. They invented novel surgical techniques used for the treatment of many diseases. Their achievements contributed to creating Polish school of surgery, that was further developed throughout the 20(th) century. The progress in gastrointestinal surgery has been continued in the 21(st) century in spite of existing economic barriers.

[Restenosis after coronary balloon angioplasty. Prevention and treatment]. / Restenoza po balonowej angioplastyce. Zapobieganie i leczenie.

The paper describes the mechanisms as well as clinical and angiographic risk factors for the development of restenosis after balloon coronary angioplasty. Based on literature findings and personal experience the ways of preventing restenosis were reviewed taking into account the optimisation of immediate angioplasty results based upon intracoronary ultrasound and physiological measurements of the coronary flow reserve. The paper also reviews the available techniques in the management of restenosis after balloon coronary angioplasty.

[Current diagnosis of gastroduodenal reflux and biliary gastritis]. / Wspólczesna diagnostyka refluksu dwunastniczo-zoladkowego i zólciowego zapalenia zoladka.

Though primary and secondary duodenogastric reflux (DGR) have been accepted in the medical literature as separate clinical units, reliable and standardised methods of detection have not been known since long. Therefore, the role of DGR in the pathogenesis of upper GI tract diseases makes a problem. So far applied measurement techniques allow only indirect diagnosis of DGR, which is often unphysiological and not objective. These methods do not allow also quantitative evaluation. Unsatisfying results obtained with the use of these methods and further search for the effective system of 24-hour monitoring of bilirubin concentration, which is indirect marker of alkaline reflux Bilitec 2000 is the most physiologic technique of ambulatory recording of the retrograde duodenogastric reflux. It makes possible objective diagnosing of alkaline gastritis as a result of excessive exposure of gastric mucose to destructive effect of bile and pancreatic juice.

[Direct stent implantation under control of intracoronary ultrasonography. Immediate and late results]. / Bezposrednia implantacja stentów pod kontrola ultrasonografii sródwiencowej. Wyniki bezposrednie i odlegle.

UNLABELLED: Stents of a new generation have been developed, permitting immediate implantation without predilatation of the lesion site. Intracoronary ultrasound (ICUS) has been found useful in precise evaluation of stent expansion and in improvement of long-term therapeutic outcomes. The purpose of the study was to evaluate the safety and efficacy of direct stent implantation using intracoronary ultrasound. The study comprised 30 patients (8 women and 22 men) aged below 70 years with stable and unstable angina pectoris. ICUS was performed at baseline before making a decision about direct stent implantation and during the procedure to evaluate stent expansion. Direct stenting was performed in 26 patients achieving an angiographically and clinically optimal result (100% efficacy). In four patients direct stenting was abandoned because of massive calcifications in the affected artery detected by ICUS at baseline. During the 9-month follow-up recurrence of anginal pain requiring repeated intervention was observed in 3 patients (11.5%). CONCLUSIONS: The use of ICUS prior to direct stenting considerably improves the efficacy of the procedure and long-term therapeutic outcomes. Before wide popularisation of direct stenting under ICUS guidance it is necessary to carry out multicentre randomised clinical studies to verify the expected improvement of long-term results as compared with conventional stent implantation with pre-dilatation.

[Pathogenesis and significance of gastroduodenal reflux]. / Patogeneza i znaczenie refluksu dwunastniczo-zoladkowego.

For over a century duodenogastric reflux (DGR) has been considered the main cause of the primary or secondary alkaline gastritis. In the first case it occurred in patients who had not been operated earlier, in the latter one in those after surgery of stomach, duodenum, gallbladder and bile ducts. Since first time many reports of clinical and experimental studies have demonstrated destructive effect of pancreatic enzymes, bile acids and their by-products on stomach mucose producing in consequence non-specific histologic lesions. It has been also observed that duodenogastric reflux plays the basic role in the patho-genesis of gastritis and other GI tract diseases (gastric ulcer, reflux oesophagitis, progressing metaplasia or oesophageal and gastric cancer). As far as diagnosing of alkaline gastritis requires histologic confirmation, duodenogastric reflux brings many more problems. However, the progress in medicine and technology allow direct measurement of quality and quantity of this reflux.

Ischemic and reperfusive release of the endogenous purines and its influence on the myocardial viability during beta-adrenergic blockade.

The aim of this study was to estimate ischemic and reperfusive release of myocardial adenosine degradation products (MADP) during beta-adrenergic blockade and its relation to infarct size (IS) and viable myocardium size (VM). In a group of 24 shepherd-mongrel dogs, randomly assigned to a metoprolol (M-) and placebo-group (P-group), occlusion of the left anterior descending coronary artery (LAD) followed by reperfusion with recombinant tissue plasminogen activator was performed. Regional myocardial blood flow (MBF) was measured by the radiolabelled microsphere technique. Blood samples from aorta and great cardiac vein were collected to evaluate the concentrations of MADP. The triphenyltetrazolium chloride perfusion and fixation technique was used for infarct size measurement. MBF in the area at risk decreased in both groups during ischemia, but it was significantly higher (p = 0.013) in M-group. Recanalization of LAD was associated with an increase in flow in postischemic vascular bed. MBF was significantly higher (p = 0.024) in P-group during late reperfusion. In M-group IS was smaller (p = 0.007) and VM was bigger (p = 0.007). The correlation between arterial adenosine concentration during early reperfusion and IS (p = 0.044, r = -0.588) or VM (p = 0.036, r = 0.607) in M-group was noted. Values of net MADP balances significantly increased during early reperfusion. The correlation between reperfusive net MADP balance and IS (p = 0.00005, r = 0.906) or VM (p = 0.016, r = -0.675) in M-group was observed. The amount of MADP released during reperfusion correlates with the IS and is inversely proportional to the area of VM. The endogenously released adenosine may have additional cardioprotective effect during beta-adrenergic blockade.

[Intracoronary ultrasound assessment of balloon angioplasty with "stent-like' angiographic result]. / Ultrasonograficzna ocena skutecznosci balonowej angioplastyki wiencowej z wynikiem angiograficznym "porównywalnym do stentowania".

The aim of the study was to evaluate by intracoronary ultrasound (ICUS) the efficacy of optimal coronary balloon angioplasty (POBA) guided by quantitative coronary angiography (QCA). The study population included 40 patients who underwent conventional coronary balloon angioplasty, in whom a stent-like result was achieved (percent diameter stenosis (%DS) < 35% in QCA). In all patients diagnostic ICUS assessment was performed after the procedure. The site of stenosis and the proximal and distal reference segments were analysed with respect to residual plaque burden (RPB), true vessel dimension (the media-to-media diameter) and type of vascular remodelling. Despite an optimal angiographic result residual plaque burden was 70 +/- 6% at the site of stenosis, whereas in the reference segments it was around 45% indicating the severity of atherosclerosis in angiographically normal vascular segments. No significant differences were seen between averaged reference vessel diameter in QCA (Ref.D) and averaged luminal reference diameter in ICUS. In contrast, true vessel diameter in ICUS was significantly larger than Ref.D in QCA (p < 0.001). Positive vascular remodelling at the site of stenosis was observed in most patients. Optimal angiographic result of QCA-guided POBA does not indicate optimal dilatation of the lesion. In most patients ICUS reveals marked residual plaque burden, which is an independent predictor of restenosis after percutaneous coronary interventions.

The importance of ventricular septal morphology in the effectiveness of dual chamber pacing in hypertrophic obstructive cardiomyopathy.

It has been reported that older patients with hypertrophic obstructive cardiomyopathy (HOCM) benefited the most from dual chamber (DDD) pacing. Since in older patients the distribution of septal hypertrophy and left ventricular (LV) cavity shape differs from that in younger patients, we decided to study the efficacy of DDD pacing on the reduction of LV outflow tract (LVOT) gradient in different patterns of septal hypertrophy. We compared HOCM patients with nonreversed septal curvature, thus preserving the elliptical LV cavity contour (common in the elderly), (group I) versus patients with reversed septal curvature, deforming the LV cavity to a crescent shape (common in the young), (group II). Eighteen HOCM patients were studied (11 patients in group I and 7 patients in group II). After implantation of a DDD pacemaker, the LVOT gradient was measured using Doppler echocardiography at various programmed AV delay intervals to determine the maximal percentage decrease of LVOT gradient from baseline. The measurement was repeated after at least a 6-month follow-up (chronic DDD pacing). The baseline LVOT gradient was comparable between groups (79 +/- 28 vs 81 +/- 25 mmHg, P = 0.92). The LVOT gradient reduction at acute DDD pacing was significantly greater in group I than group II (61 +/- 18% vs 23 +/- 10%, P = 0.0001). This difference in favor of the patients from group I was maintained at midterm follow-up (69 +/- 17% vs 40 +/- 17% P = 0.0076). In conclusion, patients with normal septal curvature and preserved elliptical LV cavity shape had a greater reduction of LVOT gradient after DDD pacing than patients with reversed septal curvature deforming LV cavity. The proposed criterion assessing the septal curvature may be useful to predict the efficacy of DDD pacing in the reduction of LVOT gradient.

[Propolis: its properties and administration to patients treated for some surgical diseases]. / Propolis--wlasciwosci i zastosowanie u pacjentów leczonych z powodu niektórych schorzen chirurgicznych.

The authors tested a bee-hive product propolis as a drug to treat patients operated for goitre, patients with wounds and ulcerations difficult to heal and patients with non-specific rectal inflammation. They also tested the effectiveness of propolis as supplementary means in eradicating treatment of Helicobacter pylori. It was found that the drug was tolerated very well, practically had no side-effects and was highly effective. Preparations of propolis can be successfully used in surgery.

Balloon positioning difficulties during nonsurgical septal reduction therapy in a patient with hypertrophic obstructive cardiomyopathy.

Dual chamber (DDD) pacing and catheter-based nonsurgical septal reduction therapy (NSRT) with ethanol are evaluated for treatment of patients with hypertrophic cardiomyopathy. This report describes a patient with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction who had failed to respond to DDD pacing but showed benefit from subsequent NSRT. Procedural difficulties during NSRT due to massive septal hypertrophy are presented.

[Intraoperative manometry in laparoscopic antireflux procedures --indications, methods and clinical results]. / Sródoperacyjna manometria w laparoskopowych zabiegach antyreflusowych--wskazania, metodyka i wstepne wyniki kliniczne.

UNLABELLED: The aim of the study is evaluating the efficiency of intraoperative manometry during laparoscopic Nissen fundoplication and its ability to prevent postoperative complications. METHOD: Sixteen patients with Gastroesophageal Reflux Disease were included in the study. Clinical examinations, x-ray, endoscopy, pH-metry, and manometric studies were performed before, and 3-6 m.o. after surgery. Fourteen patients were undergoing Nissen fundoplication, and two "floppy Nissen" fundoplications due to the specific preoperative manometric indications. RESULTS: Postoperatively the mean proportion of time at pH < 4.0 on pH-metry decreased from 188 min. (range 96-263) to 8.5 min. (range 2-25). Mean number of reflux episodes significantly lowered after fundoplication from 18.9 (range 2-36) to 0.5 (range 0-3). Gastroesophageal junction mean pressure measured postoperatively reached 24.7 mmHg, and was significantly higher than preoperatively (8.9 mmHg). Mean length of LES increased from 1.2 cm (range 0.8-2.5) to 3.6 cm (range 2.4-4.6) postoperatively. CONCLUSIONS: Laparoscopic Nissen fundoplication assisted by the simultaneous continuous intraoperative manometry is feasible and effective procedure. Continuous LES pressure monitoring during laparoscopic fundoplication with simultaneous computer-video assisted display can be advised as an objective method of intraoperative evaluation of antireflux mechanism.

[Hormonal islet cell tumors. Proposition of a diagnostic-therapeutic model]. / Guzy hormonalnie czynne trzustki. Propozycja modelu diagnostyczno-terapeutycznego.

Islet cell tumors make a serious therapeutic problem due to their specific clinical presentation and the necessity of applying a variety of multidisciplinary diagnostic and therapeutic methods. The authors present their own algorithm for diagnosing and treatment of islet-cell tumors worked out basing on many-year experience.

Multicenter evaluation of dual-therapy (omeprazol and amoxycillin) for Helicobacter pylori-associated duodenal and gastric ulcer (two years of the observation).

Treatment with the proton pump inhibitor (omeprazole) and single antibiotic (amoxycillin), two synergistic compounds, can cure Helicobacter pylori (H. pylori) infection, but this therapy is not as effective as had been expected. However, some studies show promising results. The aim of our study was to evaluate the effect of two weeks dual-therapy with omeprazole (O) and amoxycillin (A) on gastric (GU) and duodenal ulcer (DU) patients: ulcer healing, eradication of the H. pylori and recurrence rate of the ulcer. We studied 216 patients (aged 18-70) endoscopically proven GU (58 patients) and DU (158 patients). Rapid urease test from the two antrum biopses and two antral and two corporeal biopses using Giemsa stain method for confirmation of the H. pylori infection were used. The patients were treated with omeprazole 20 mg BID and amoxycillin 1.0 g BID for 2 weeks and investigated every 4 months during 2 years. Clearance effect of Hp infection was achieved in 65.1% GU and 66.4% DU patients. Eradication ("check point" after 4 months) in 43% DU and 56.6% GU patients was confirmed. Reinfection rate was found in 16% during 2 years. We conclude--dual-therapy (O and A) is not sufficiently effective to be recommended as an anti-H. pylori treatment. H. pylori eradication prevents recurrence of peptic ulcer and is an important issue in attempts to achieve permanent ulcer healing.

Determinants of depressed left ventricular ejection fraction in pure mitral stenosis with preserved sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: Although depressed left ventricular ejection fraction is present in a considerable proportion of subjects with pure mitral stenosis (MS), its mechanisms are not clearly identified. The purpose of this study was to identify determinants of depressed ejection fraction in young patients with isolated mitral stenosis in sinus rhythm. METHODS: We retrospectively analyzed 320 records of patients with MS (mitral valve area < or = 2.0 cm2) who underwent invasive diagnostic procedure in our center. Of these 39 subjects aged 20-40 years with isolated MS in sinus rhythm were selected for the final analysis. RESULTS: An ejection fraction not exceeding 50% was found in 12 patients (group A). When comparing group A to the remainder (group B), group A patients had lower left ventricular end-diastolic volume indices (60.5 +/- 21.6 ml/m2 vs. 76.1 +/- 16.1 ml/m2, p = 0.02) and stroke volume indices (28.0 +/- 10.4 vs. 47.9 +/- 12.0, p < 0.001). No significant differences between the groups in patients' age, end-systolic volume index, mitral valve area, mean transmitral gradient, left-sided cardiac pressures, pulmonary wedge pressure, systemic vascular resistance, and cardiac output were found. Indices of left ventricular isovolumic contraction and relaxation as well as end-systolic indices of left ventricular function were also comparable. Group A had significantly higher pulmonary vascular resistance, pulmonary artery pressures, and higher heart rate. An approximate index of left ventricular compliance was significantly lower in group A with similar left ventricular minimal and end-diastolic pressures. CONCLUSIONS: Depressed ejection fraction in pure mitral stenosis with preserved sinus rhythm seems attributable to left ventricular underfilling that appears to be precipitated by other factors in addition to a narrowed mitral orifice, e.g. decreased passive left ventricular compliance and/or altered interventricular interactions.

[Diabetic foot syndrome in clinical practice. I. A model of a Diabetic Foot Consulting Unit]. / Zesp57ol stopy cukrzycowej w praktyce klinicznej. I. Model Gabinetu Stopy Cukrzycowej.

Complex pathogenesis of the foot syndrome involving a number of body system and tissues provided us with grounds for making multispecialistic assessment of its severity. Also a decision about the type and intensity of procedure should be multispecialistic. An interdisciplinary team consists of a diabetologist, diabetic educator, podiatrist, kinesitherapist, orthopedist, general and vascular surgeon and a consultant from manufacturing corrective shoes. The make-up of the team implies that the procedure includes education, metabolic normalization of diabetes mellitus, orthopedic correction, possible surgical intervention and rehabilitation. Results discussed in part II of the study indicate the effectiveness of such approach.