[Transposition of the gracilis muscle in reconstruction of the anal sphincter]. / Transpozicija m. gracilis-a u rekonstrukciji sfinktera anusa.

UNLABELLED: Fecal incontinence is a serious psychological and social problem for the patient, frequently leading to social isolation, loss of working potential and depression. Different static and dynamic methods for the reconstruction of anal sphincter are used in the surgical treatment of the incontinence. At the Clinic for Plastic Surgery and Burns, at the Military Medical Academy, we have been using the method of transposition of the gracilis muscle, previously described by Pickerill-Broadbent (1952) since 1970. The aim of this paper was to describe our results in the treatment of fecal incontinence with the gracilis muscle. We have operated on 14 patients: 5 with congenital absence of the anus, 2 with myelomeningocele, 2 with the teratoma in the sacral region, 2 with the injury after the surgical procedure in the anal region and 3 with war injuries in the perineal area. After the detailed clinical and neurological examinations and pre-surgical preparations, we have performed the operation using the already mentioned technique (Pickerill). The following postoperative complications were identified: one hematoma and two minor dehiscences of the perianal wounds that healed per secundam. The electrostimulations of the transposed gracilis muscle were performed postoperatively. All the operated patients have been followed up for three years after the operation. In 9 patients the result was estimated as the excellent, in 3 as affordable and in 2 as the poor (occasionally, they could not contain the liquid fecal incontinence)? CONCLUSION: Due to its anatomical characteristics, the gracilis muscle is the most suitable for the reconstruction of the anal sphincter. If the correct indication is made, and if the surgery is well prepared and technically performed, with the maximal protection of neurovascular pedicle, an excellent postoperative result can be expected in over 60% cases.

[The effect of cell phones on pacemaker function]. / Uticaj mobilnih telefona na funkciju pejsmejkera.

UNLABELLED: The aim of the study was to examine if there existed a risk from interference of cellular phones on patients with implanted permanent pacemakers. The study comprised 144 patients (134 VVI/VVIR and 10 DDD/DDDR) with permanent pacemakers of different manufactures. METHODS: During the routine pacemaker check, cellular phone aerial (Nokia 1610; GSM Standard) was placed against the skin of patients above the spot of pacemaker implantation, while the phone calls were repeated and ECG was continuously monitored. The effect of cellular phone on pacemaker was established upon: a) preexisting parameters of electric pacemaker stimulation; b) minimal ventricular rate of 90 beats/min, while electric stimulation parameters were set to their most sensitive values (MSV). RESULTS: Only in 9 (6.25%) patients was observed intermittent pacemaker inhibition, when pacemaker settings were on preexisting values of electric stimulation, while in 17 patients (11.8%) inhibition was noticed, when pacemaker settings were changed to their MSV. Besides, programmed values of electric stimulation in our patients remained unchanged. CONCLUSION: Although the electromagnetic interference interactions of cellular phones on pacemaker function were observed in relatively small number of our patients, we were of the opinion that pacemaker-dependent patients should avoid the use of cellular phones.

Lipid peroxidation intensity and lipid status parameters in the estimation of the severity of ischemic heart disease.

Atherosclerotic changes on the coronary arteries are the basis of the ischemic heart disease. It is assumed that the initial changes in this process occur as a consequence of the lipid peroxidation in the vessel wall. We estimated this process through the level of malondialdehyde (MDA) in the serum of 86 patients in whom selective coronary angiography was done for the suspected ischemic heart disease. According to the number of the stenotic coronary arteries (stenosis greater than 50%), we divided the patients into four groups: the control group with normal coronary angiography finding, simple, double or triple vessel coronary disease. In all the patients we also estimated the other parameters of the lipid status (cholesterol, triglycerides, LDL, HDL, Apo-AI, Apo B) and atherogenic indices Apo-AI/Apo B, LDL/HDL and HDL/total cholesterol. No significant changes were observed in the lipid parameters between the control and experimental group. However, mean MDA level in the whole experimental group was 3.89 mumol/L, 3.93 mumol/L in triple vessel coronary disease, 3.83 mumol/L in double vessel and 3.92 mumol/L in single vessel disease group. The difference between all the experimental and the control group was highly significant (p < 0.001). We concluded that the level of MDA--lipid peroxidation index had the better correlation with the disease status than the other parameters of lipid status and the sensitive atherogenic indices.

Late apical filling by color Doppler M-mode during dipyridamole stress echocardiography: a useful contribution to wall motion analysis.

It has been shown that regional myocardial ischemia during angioplasty is associated with retarded apical filling. To test the importance of retarded apical filling by color Doppler M-mode to detect ischemia during dipyridamole stress echocardiography, we evaluated 29 patients (12 women, aged 57 to 87 years). High-dose dipyridamole (0.84 mg/kg for 10 minutes) was used. The color M-mode record was used to calculate the duration of abnormal apical flow as measured from the onset of the QRS complex to the disappearance of color signals directed toward the apex. Echocardiographic images were compared at rest and during stress to identify the presence of new or worsening wall motion abnormalities (WMAs). Fourteen patients (group A) were designated as having coronary artery disease on the basis on WMAs during the stress test and abnormal coronary anatomy. Fifteen patients (group B) without WMAs in the presence of normal coronary anatomy were designated as having no coronary artery disease. All but two patients in group A had an abnormal apical filling response to dipyridamole stress (sensitivity 86%). In these patients the marked retardation of apical filling was detected during ischemia (55 +/- 18 msec versus 120 +/- 34 msec) (p <0.01). In group B there were no dynamics in apical filling (specificity 100%). Color M-mode Doppler imaging showed retarded apical filling during dipyridamole-induced myocardial ischemia. This abnormal filling pattern may be a useful adjunct to WMAs during dipyridamole stress echocardiography.

Bidirectional shunt flow across a ventricular septal defect: pulsed Doppler echocardiographic analysis.

Pulsed Doppler echocardiographic and hemodynamic examinations were performed in 31 patients (mean age 17.8 years) with isolated ventricular septal defect (VSD). Three groups were studied: group I (n = 6) patients had severe pulmonary vascular obstructive disease (PVOD); group II (n = 12) patients had pulmonary hypertension (PH) without severe PVOD; group III (n = 13) patients had no PH. Bidirectional shunting was detected in 9 VSD patients (6 in group I and 3 in group II). Patients with low to moderately elevated right ventricular pressures demonstrated left-to-right shunting across the defect throughout the cardiac cycle. When systolic pressure in the right ventricle reached approximately 60% of the left ventricular pressure, right-to-left shunting occurred across the defect during early and mid diastole. However, in patients with Eisenmenger syndrome (group I) the right-to-left shunting occurred during late systole with continuation during the early and mid diastolic period. The earlier occurrence of right-to-left shunting (index < 0.5 second) signifies the presence of severe PVOD.

Pulmonary venous flow pattern studied by transoesophageal pulsed Doppler echocardiography in mitral stenosis in sinus rhythm: effect of atrial systole.

In 13 patients with isolated mitral stenosis in sinus rhythm the pulmonary venous flow was evaluated by transoesophageal pulsed Doppler echocardiography. The patients were divided into two groups according to their mitral valve area (MVA); Group I (MVA < 1.5 cm2, n = 7 patients); and Group II (MVA > 1.5 cm2, n = 6). The patients in group I with haemodynamically significant mitral stenosis had lower velocities of systolic (S), diastolic (D) and atrial retrograde (A) waves of pulmonary venous flow (PVF) compared to milder stenosis (P < 0.05). The peak velocity of pulmonary retrograde venous flow at atrial contraction (A) primarily depends on the relative amplitude of the atrial transmitral wave (RA), which is measured from the onset of atrial systole to its peak velocity. We found a highly positive correlation between RA of mitral valve flow (MVF) and A wave of PVF (r = 0.87, P < 0.0001). There was also a highly negative correlation (r = 0.80, P < 0.001) between A of PVF and ratio of early (PE) to late (PA) velocities of MVF. Therefore, the retrograde A wave of PVF is related to the pressure generated in the left atrium during atrial systole. Use of pulmonary vein velocities in conjunction with mitral flow velocities can increase our understanding of the haemodynamics of mitral stenosis and provide a new insight into left atrial performance.

Pulsed Doppler assessment of left ventricular diastolic function in atrial septal defect.

From January 1986 through December 1990, we used pulsed Doppler echocardiography to evaluate left ventricular diastolic function in 43 patients with an ostium secundum atrial septal defect. The study population included 27 females and 16 males, whose ages ranged from 6 to 58 years (mean, 26 years). The patients were grouped according to degree of pulmonary hemodynamic impairment: patients in Group 1 (n = 6) had severe pulmonary hypertension, those in Group 2 (n = 10) had mild-to-moderate pulmonary hypertension, and those in Group 3 (n = 27) had no pulmonary hypertension. For comparison, we also evaluated 30 healthy individuals. All control subjects had a normal left ventricular filling profile. Of the 43 study patients, 8 (19%) showed Doppler echocardiographic signs of impaired left ventricular relaxation, including a prolonged left ventricular isovolumic relaxation time, decreased peak left ventricular diastolic inflow velocity, and a prolonged mean deceleration time of early diastolic flow velocity. Of these 8 patients, 5 were from Group 1, 1 was from Group 2, and 2 were from Group 3. A positive correlation (r = 0.66; standard error of the estimate = 0.32) was found between the late-to-early left ventricular diastolic inflow velocity ratio and the pulmonary-to-systemic vascular resistance ratio. Our results showed impaired left ventricular relaxation in 8 (19%) of patients with atrial septal defect; 5 of these patients had severe pulmonary hypertension. We therefore conclude that left ventricular diastolic dysfunction is closely related to severe pulmonary hypertension.

Use of continuous-wave Doppler echocardiography to evaluate the hemodynamic importance of atrial systole in patients with mitral stenosis.

Continuous-wave Doppler echocardiography was used to assess the hemodynamic role of left atrial systole and its effect on left ventricular performance in 31 patients with pure mitral stenosis. Seventeen (group I) had severe stenosis, and 14 (group II) had mild-to-moderate stenosis. The contribution of atrial systole to cardiac output was 15% in group I and 24% in group II (p < 0.01). This study shows the effectiveness of using continuous-wave Doppler echocardiography to assess the influence of atrial systole on left ventricular performance in patients with mitral stenosis.

[Transient ischemic attacks and coronary disease]. / Tranzitorni ishemicni atak i koronarna bolest.

Taking into consideration data from the literature that the most common cause of mortality of patients with transient ischemic attacks (TIA) is myocardial infarction, the aim of the study was to examine the state of coronary circulation in patients with TIA previously completely asymptomatic to coronary disease. There have been examined 40 patients with TIA previously asymptomatic to coronary disease and 14 patients with general characteristics similar to Parkinson's syndrome, also asymptomatic to coronary disease. All patients were subjected to neurological examination, echocardiography of carotid arteries, standard electrocardiography, X-ray of the heart and ergometry and, if indicated, coronarography. On the basis of the analysis of the results obtained it has been concluded that a significant number of patients with TIA, previously asymptomatic to coronary disease showed signs of coronary disease which imposes the necessity of correction of doctrinaire principles in prevention and follow up of these patients.

Use of continuous wave Doppler echocardiography to evaluate the hemodynamic importance of atrial systole in patients with mitral stenosis.

Continuous wave Doppler echocardiography was used to assess the hemodynamic role of left atrial systole and its effect on left ventricular performance in 31 patients with isolated mitral stenosis. Fourteen of the patients had mild stenosis, whereas the remaining 17 had severe stenosis. The contribution of atrial systole to the cardiac output was 24% in the patients with mild stenosis and 15% in those with severe stenosis (p less than 0.01). This study reveals the importance of continuous wave Doppler echocardiography in assessing the atrial influence on left ventricular performance in patients with mitral stenosis.

Doppler echocardiographic analysis of the transmitral flow velocity profile in patients with ventricular septal defects.

Using continuous-wave Doppler echocardiography, we evaluated the mitral flow velocity pattern in 30 ventricular septal defect patients, 11 of whom had severe pulmonary vascular obstructive disease (Group I); 10 of whom had severe pulmonary hypertension without pulmonary vascular obstructive disease (Group II); and 9 of whom had no pulmonary hypertension and hemodynamically unimportant left-to-right shunts (Group III). In addition, 25 healthy subjects (Group IV) were studied for comparative purposes. The peak velocity of early left ventricular filling (E) was significantly lower in Group I than in all the other groups (p < 0.01). The peak velocity of late left ventricular filling (A) was significantly higher (p < 0.01) in Group I than in Group III, or than in normal individuals (Group IV) (p < 0.01). The ratio A/E was the most prominent difference between Group I patients and the other groups, with Group I having a significantly higher ratio (p < 0.01), which was 1 or greater in 9 of 11 patients. In contrast, none of the remaining ventricular septal defect patients or normal subjects had an A/E ratio of 1 or greater. Group II had increased mitral flow velocities, while Group III had normal mitral flow velocity profiles. A positive correlation between the magnitude of the left-to-right shunt and early mitral flow velocity peak (r = 0.86) and late peak (r = 0.81) was found, regardless of the degree of pulmonary hypertension. These results indicate that significant alterations of the mitral flow velocity pattern, which mimic the abnormalities associated with impaired left ventricular diastolic function (A/E ratio of 1 or greater), occur in ventricular septal defect patients who have severe pulmonary vascular obstructive disease. The transmitral velocity profiles in the ventricular septal defect patients without severe pulmonary vascular obstructive disease were similar to those of the normal patients, although the values relative to the degree of left-to-right shunting were higher in the ventricular septal defect patients.