Prevalence of multiple sclerosis in the L'Aquila district, central Italy.

OBJECTIVE: To estimate the prevalence of multiple sclerosis in the L'Aquila district, central Italy. METHODS: All available case sources were screened. Definite and probable cases of multiple sclerosis, classified according to the Poser criteria, were considered as prevalent cases. RESULTS: On the prevalence day, 31 December 1996, 158 patients (105 women and 53 men; ratio 2:1) affected by definite (n=131) or probable (n=27) multiple sclerosis were alive and resident in the L'Aquila district. Mean (SD) age was 38.4 (11.9) years (38.9 (11.7) years for women and 38.5 (12.3) years for men, p=0.9). The overall crude prevalence was 53.0/100 000 (95% confidence interval (95% CI)=45.4-62.0); 68.4/100 000 (95% CI=56. 5-82.8) in women, and 36.7/100 000 (95% CI=28.1-48.0) in men. The prevalence was similar (55.9/100 000) when standardised to the 1996 European population. Mean (SD) age at onset of multiple sclerosis was 29.4 (9.6) years and mean (SD) duration of the disease was 9.4 (7.4) years, without any significant difference between sexes. Mean age at onset was significantly higher in patients with the primary progressive than in those with the relapsing-remitting course (p=0. 0002, Scheffé's test). CONCLUSIONS: The prevalence found in the L'Aquila district gives support to the consideration of Italy as an area in which multiple sclerosis has been shown to have high prevalence at least in the populations that were surveyed recently.

[The surgical treatment of chronic ischemic mitral insufficiency]. / Il trattamento chirurgico dell'insufficienza mitralica ischemica cronica.

BACKGROUND: Operative correction of chronic ischemic mitral regurgitation (CIMR) is associated with a high-risk approach. The objective of this retrospective study was to evaluate the short- and long-term results of surgical treatment of CIMR. METHODS: From 1989 to 1997, mitral valve replacement or repair was performed on 46 patients with CIMR. The average age range was 63.7 +/- 6.9; 8 patients were females; 30 patients (65.2%) were in New York Heart Association (NYHA) functional class III or IV; 4 patients (8.6%) were in chronic atrial fibrillation and preoperative myocardial infarction was lower in 23 patients (50%). Preoperative echo-Doppler analysis showed severe mitral insufficiency in 15 patients (32.6%). Preoperative mean pulmonary artery pressure (PAP) was 33.6 +/- 13.6 mmHg, mean ejection fraction (EF) 37.8 +/- 13.5%. Mitral valve replacement was performed in 12 patients (26%). Mitral valve repair was performed in 34 patients (73.9%). Myocardial revascularization was performed in 42 patients (91.3%) (mean graft/patient 2.2 +/- 0.8); aneurysmectomy was performed in 5 patients (10.8%), and in 2 patients (4.3%) tricuspid insufficiency was corrected by performing annuloplasty. RESULTS: The overall operative mortality was 8.6% (4 patients). The operative mortality for repair was 5.8% (2 patients) and for replacement was 16.6% (2 patients). One patient was reoperated three days after first operation due to annuloplasty dehiscence. Postoperative morbidity included low output syndrome in 7 patients (15.2%), bleeding in 2 patients (4.3%), and cerebral embolism in 2 patients (4.3%). The mean length of stay in intensive care was 6.5 +/- 10.5 days. Follow-up (mean 27.6 +/- 3.3 months) was 88% complete and revealed good functional and clinical results: 86.4% of the patients in I-II NYHA class. One patient was reoperated due to mitral insufficiency progression. Two late deaths occurred, one due to acute myocardial infarction and the other to lung cancer. CONCLUSION: While long-term follow-up is mandatory, our results suggest that: a) surgical treatment of CIMI is feasible with acceptable operative risks; b) mid-term functional and clinical results are favorable; c) the choice of treatment--valve replacement or repair--is still debatable.

Myocardial revascularization in patients with ischemic cardiomyopathy: functional observations.

OBJECTIVE: A prospective angiographic study was undertaken to investigate, with an objective analysis, the global and regional wall response to myocardial revascularization. METHODS: Thirty-one patients (30 men and 1 woman, mean age, 61 years) with a left ventricular ejection fraction of less than 0.30 were admitted to our institution between 1992 and 1995 for two- or three-vessel coronary artery disease requiring myocardial revascularization. All patients underwent isolated coronary artery bypass grafting and were studied 3 months later with angiography. Preoperative and postoperative wall motion were analyzed using special software that computed a segmental left ventricular ejection fraction, generating a segmental score. Computerized analysis allowed us to distinguish patients with diffuse hypokinesis and a symmetric contraction pattern from patients with akinesis involving at least two segments and an asymmetric contraction pattern. RESULTS: There were no operative deaths and no patient required intraaortic balloon counterpulsation. One patient had postoperative enzymatic evidence of myocardial infarction. Postoperative angiography showed a graft patency rate of 84%. Global analysis showed a small but significant rise in the left ventricular ejection fraction (0.25 +/- 0.51 to 0.31 +/- 0.70, p < 0.001) and a fall in the left ventricular end-diastolic pressure (23.7 +/- 10 to 16.5 +/- 9 mm Hg, p < 0.01). Mean scores always have been lower after the operation than before it, with the best results obtained for the apex and the worst for the anterobasal segment. The group with a symmetric contraction pattern showed a trend toward a better hemodynamic response than the group with an asymmetric contraction pattern. Regression analysis revealed two important predictors of segmental functional improvement: (1) the absence of an echocardiographic scar, and (2) the presence of a collateral circulation. CONCLUSIONS: Coronary artery bypass grafting produced a small but substantial improvement in patients with ischemic cardiomyopathy. The greater benefit occurred in patients with a symmetric contraction pattern. The absence of an echocardiographic scar and the presence of a collateral circulation predicted segmental functional improvement.

Repair of aortic cusp traumatic laceration caused by cardiac catheterization.

A case of iatrogenic aortic insufficiency due to laceration of the aortic right coronary leaflet at the time of diagnostic heart catheterization is presented. The situation was remedied by repairing the lacerated leaflet.

Severe diastolic dysfunction after endoventriculoplasty.

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Surgical timing in aortic regurgitation: left ventricular function analysis by contractility score.

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Functional results of left ventricular reconstruction.

From 1988 to 1991, 48 patients with left ventricular aneurysm underwent endoventriculoplasty with a circular patch to preserve the left ventricular geometry. Of these patients, 98% underwent concomitant myocardial revascularization, and in 77% the left anterior descending coronary artery was bypassed. The overall operative mortality rate was 4.1%. The 3-year survival rate was 91%, and 67% of patients had no further cardiac complications. Cardiac performance was assessed postoperatively by ventriculography in 28 patients. The global ejection fraction rose from 0.39 +/- 0.11 to 0.57 +/- 0.14 (p < 0.001); the left ventricular end-diastolic pressure fell from 20 +/- 7.5 mm Hg to 15 +/- 7.8 mm Hg (p < 0.05). Computerized analysis of regional contraction revealed a significant improvement in the anterolateral and apical segments and in the transitional zone. In 61% of the patients, a normal contraction pattern resumed, whereas in the remaining 39%, a residual deformity of the left ventricular chamber was present. The best results were obtained in patients with a preserved proximal septum at echocardiography.

Correction of anterior mitral prolapse. Results of chordal transposition.

From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9%, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% +/- 5.2% at 3 years. Freedom from all morbidity was 85.5% +/- 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eighty-seven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in all patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease.

[Echo-Doppler study of myxomatous mitral valve insufficiency and the results of reparative surgery]. / Studio eco-Doppler dell'insufficienza mitralica mixomatosa e dei risultati della chirugia riparativa.

The aim of conservative management of mitral regurgitation caused by floppy mitral valve is to restore a valvular function which closely resembles that of normal physiology. Fifty-eight patients affected by floppy mitral valve underwent surgical procedures for severe mitral regurgitation due to chordal elongation and/or rupture. Of these, 28 presented posterior mitral prolapse corrected by quadrangular excision of the prolapsed part and posterior anuloplasty achieved by apposition of a polytetrafluoroethylene conduit. The remaining 30 patients presented anterior or bilateral prolapse corrected by transposition of chordae from the posterior leaflet to the anterior cusp together together with anuloplasty. A complete echo-Doppler study was performed preoperatively, 10 days after the operation and every 6 months thereafter. Mean follow-up was 16.1 +/- 6.3 months. Preoperatively, 44 patients presented severe mitral regurgitation and 14 had moderate regurgitation (quantified by means of pulsed Doppler). All patients showed severe enlargement of the left cavities (LVDD 67.1 +/- 8.6 mm, left atrium 53.4 +/- 10.9 mm) with normal mitral area (6.08 +/- 2.14 sqcm, Doppler measurement). Following surgery we found a significant reduction in: 1) the degree of mitral regurgitation (29 patients had no regurgitation; 20 had mild protosystolic mitral regurgitation (29 patients had no regurgitation; 20 had mild protosystolic mitral regurgition, confirmed by color-M-mode; moderate or severe regurgitation was found in 6 cases); 2) the left ventricle and left atrium dimensions (LVDD 53.4 +/- 5.2 mm, p less than 0.01; left atrium 43.8 +/- 11.1 mm, p less than 0.01). Color flow imaging provided information about the recovery of a normal valvular function.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral insufficiency caused by floppy valve: results of conservative surgical treatment]. / Insufficienza mitralica da "floppy valve": risultati del trattamento chirurgico conservativo.

Between January 1986 and November 1987, 31 patients (pt.) underwent reconstructive surgery for mitral regurgitation secondary to floppy valve. Six pt. were in NYHA functional class IV, 22 in III class and 3 in II class. The mitral valve prolapse was posterior in 20 cases, anterior in 7 cases and bilateral in 4 cases. Chordal rupture was present in 18 pt. The mitral valve was repaired by quadrangular excision of the mural leaflet and posterior annuloplasty performed by insertion of polytetrafluoroethylene graft. The anterior prolapse was managed by transposition of chordae from the mural leaflet to the prolapsed part of the anterior leaflet (11 cases). One patient died perioperatively from myocardial infarction. Subsequent follow-up (length: 12.1 +/- 4.9 months) revealed good functional and clinical results: all pt. were alive, in NYHA class I or II (3 pt.). Echocardiographic studies revealed a decrease in diastolic (3.68 +/- 0.6 vs. 3.17 +/- 0.3 cm/m2) and systolic (2.4 +/- 0.5 vs. 2.15 +/- 0.4 cm/m2) diameter. The shortening fraction did not decline significantly. The mitral area fell from 6.0 +/- 2.0 cm2 to 3.1 +/- 1.1 cm2. A moderate residual regurgitation was present in two pt. and a severe regurgitation was found in only one pt. Our experience suggests that valve repair may be considered the most suitable type of operation for mitral regurgitation secondary to floppy valve.

Effect of D-glucitol-hexanicotinate on platelet aggregability in patients with coronary heart disease.

D-glucitol-hexanicotinate (sorbinicate) was administered at a daily dose of 1.6 mg to 16 male patients who had survived myocardial infarction. Platelet aggregation induced by collagen (5 micrograms/ml), by ADP (2, 1.2, 0.8, and 0.4 X 10(-6)M), and by epinephrine (1 and 0.5 X 10(-6)M) was significantly decreased after 3 months of therapy. In a group of 13 comparable patients, who did not receive sorbinicate, platelet aggregation induced by ADP (1.2, 0.8, and 0.4 X 10(-6)M) and by epinephrine (1 X 10(-5)M and 1 X 10(-6)M) was significantly increased 3 months after entry into the study. Sorbinicate has effective lipid-lowering activity; the combination of hypolipidemic and anti-aggregating properties may prove important in primary and secondary prevention of atherosclerotic disease.