Anomalous pH-Dependent Enhancement of p-Methyl Benzoic Acid Sum-Frequency Intensities: Cooperative Surface Adsorption Effects.

Vibrational sum-frequency generation (SFG) spectroscopy is used to determine the surface pKa of p-methyl benzoic acid (pMBA) at the air-water interface by monitoring the carbonyl and carboxylate stretching modes over the pH range of 2 to 12. The SFG intensities of pMBA and its conjugate base, p-methyl benzoate (pMBA-), exhibit an anomalously large enhancement over a narrow pH range (∼0.5) centered at pH 6.3 near the SFG-determined surface pKa, 5.9 ± 0.1. The increase in the surface pKa relative to the bulk value of 4.34 is consistent with the trend previously observed for long chain carboxylic acids in which the surface pKa is higher than the bulk solution pKa. SFG polarization studies help distinguish the orientation and number density contributions to this observed anomalous surface phenomenon. The large SFG intensity increase is attributed to an increase in the pMBA and pMBA- surface concentrations in this narrow pH range due to a cooperative adsorption effect between pMBA and pMBA-. This cooperativity is manifested only on the 2D air-water interface, where the interactions between the acid and base are not as dielectrically screened as in the aqueous bulk phase. Surface effects are critical to understanding and controlling the reactivity, solubility, and behavior of organic acids at interfaces and can have an impact on biomedical applications.

Elective colectomy after acute diverticulitis: an international comparison.

AIM: Routine elective colectomy after acute diverticulitis is not recommended, yet significant numbers are still being performed. Amidst global concern over the rising costs of surgery and the value of healthcare, acute diverticulitis is a disease that is amenable to optimization of strategies for operative intervention. We aim to compare rates of elective colectomy after acute diverticulitis in the USA, England and Australia. METHOD: Index unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2012 for hospitals in the USA, England and Australia. Recurrent unplanned admissions for acute diverticulitis and any subsequent elective admissions for colectomy were found between 2008 and 2014 to allow a minimum 2-year follow-up period. The primary outcome measured was elective colectomy rate. Secondary outcomes included rates of emergency operative intervention and recurrence. Multivariable analysis was performed to control for patient and disease factors. RESULTS: There were 7842 index unplanned admissions for acute diverticulitis over 4 years in selected hospitals from the USA, England and Australia. The elective colectomy rates were 13%, 5.4% and 3.4% for the USA, England and Australia, respectively. The propensity for elective colectomy was higher in the USA (OR 4.2, P < 0.001) and England (OR 1.8, P < 0.001) than in Australia. The recurrence rate in all patients with acute diverticulitis was 10% across the countries. CONCLUSION: There is a higher propensity for elective colectomy after acute diverticulitis in the USA than in England and Australia. This highlights the possibilities for a less aggressive surgical approach to reduce resource utilization, but prospective analysis of information on quality of life is required to support this.

Use of antimicrobial agents in aquaculture.

The aquaculture industry has grown dramatically, and plays an important role in the world's food supply chain. Antimicrobial resistance in bacteria associated with food animals receives much attention, and drug use in aquaculture is also an important issue. There are many differences between aquatic and terrestrial management systems, such as the methods used for administration of drugs. Unique problems are related to the application of drugs in aquatic environments. Residual drugs in fish products can affect people who consume them, and antimicrobials released into aquatic environments can select for resistant bacteria. Moreover, these antimicrobial-resistant bacteria, or their resistance genes, can be transferred to humans. To decrease the risks associated with the use of antimicrobials, various regulations have been developed. In addition, it is necessary to prevent bacterial diseases in aquatic animals by vaccination, to improve culture systems, and to monitor the amount of antimicrobial drugs used and the prevalence of antimicrobial-resistant bacteria.

10-Gb/s transmission over 20-km single fiber link using 1-GHz RSOA by discrete multitone with multiple access.

We demonstrate a novel 10.5-Gbit/s transmission scheme over 20-km single fiber link by using a remotely fed 1-GHz reflective semiconductor optical amplifier (RSOA). Discrete multitone (DMT) modulation with adaptive bit-/power-loading is applied to overcome the bandwidth limitation of the RSOA. Transmission performance of the proposed scheme is analyzed in terms of various system parameters, such as the nonlinearity of the RSOA, optical signal-to-noise ratio of the optical seed carrier, the overhead size impact on dispersion, the number of DMT subcarriers, and the reflection noise from the single fiber link. We also report flexible-bandwidth-allocated multiple access operation based on the proposed scheme. The throughput for all cases is approximately 10 Gbit/s with BER < 10(-3).

Faecal diversion in the management of perianal Crohn's disease.

AIM: Severe perianal Crohn's disease remains an uncommon but important indication for faecal diversion (FD). The advent of biological therapy such as infliximab for Crohn's disease is considered to have improved the outcome for these patients. The aim of this study was to assess the outcome of patients undergoing FD for perianal Crohn's disease and the impact of biological therapy (infliximab). METHOD: Retrospective chart review was undertaken of patients who underwent FD for management of perianal Crohn's disease at two tertiary centres between 1990 and 2007. Patient demographics, disease extent and use of biological therapy were recorded. Subsequent surgery was assessed. The impact of infliximab on rates of proctocolectomy and restoration of intestinal continuity was assessed. RESULTS: Twenty-one patients (one male, 20 female), median age 34 years (range 21-67 years), underwent FD for perianal Crohn's disease. At a median follow-up time of 22 months (range 4-121 months), four patients had undergone stoma closure, 11 had had proctocolectomy and six had a stoma in situ. The effects of the procedure on severity of perianal disease were no effect in four (19%), temporary improvement in six (29%), initial improvement with later plateau in seven (33%) and healing in four patients (19%). Eleven patients (52%) received infliximab. In this group, four underwent proctocolectomy and two had intestinal continuity restored. This was not significantly different from the noninfliximab group. CONCLUSION: Patients undergoing FD for perianal Crohn's disease have <20% likelihood of restoration of intestinal continuity. This is not improved with biological therapy.

Multi walled carbon nanotube nanocomposites with biodegradable poly(butylene succinate) and their physical characteristics.

In order to examine the influence of multi walled carbon nanotube (MWNT) on physical properties of its biodegradable polymer nanocomposite, biodegradable poly(buthylene succinate) (PBS), which was synthesized from diols and dicarboxylic acids, and MWNT nanocomposites were prepared via a melt-mixing method using a co-rotating intermeshing twin screw extruder. Microstructure of the PBS/MWNT nanocomposites and MWNT were investigated via both scanning electron microscopy and transmission electron microscopy. Their rheological properties were also characterized via rotation and oscillation tests using a rotational rheometer with parallel-plate geometry. It was found that shear viscosity, storage modulus and loss modulus of the nanocomposites examined by a rotational rheometer increased with the MWNT content. Especially their sharp increase for MWNT content of ca. 2.0 wt% was observed, indicating its percolation threshold from the rheological viewpoint which was higher than its electrical percolation threshold (1.0 wt%).

Conjugate Acid-Base Interaction Driven Phase Transition at a 2D Air-Water Interface.

A lattice model is described to explain a recent striking Sum Frequency Generation (SFG) observation of a cooperative surface adsorption effect for an organic acid system at an air-water interface. The reported anomalous pH-dependent enhancement in p-methylbenzoic acid (pmBA) arises from an interaction between the acid (HA) and its conjugate base anion (A-), which competes with strong Coulombic repulsion between the conjugate bases (A--A -). Using a statistical mechanical approach, this lattice gas model reveals an analogy to well-studied magnetic systems in which the attraction between the two different molecular species leads to a phase transition to a two-dimensional checkerboard phase consisting of a network of anion-acid complexes formed at the low-dielectric air-water interface. Cooperative acid-anion interactions that control partitioning at solution and aerosol interfaces are of interest to fields ranging from oceanic and atmospheric chemistry, pharmacology, and chemical engineering.

Nitrous oxide vibrational energy relaxation is a probe of interfacial water in lipid bilayers.

Ultrafast infrared spectroscopy of N 2O is shown to be a sensitive probe of hydrophobic and aqueous sites in lipid bilayers. Distinct rates of VER of the nu 3 antisymmetric stretching mode of N 2O can be distinguished for N 2O solvated in the acyl tail, interfacial water, and bulk water regions of hydrated dioleoylphosphatidylcholine (DOPC) bilayers. The lifetime of the interfacial N 2O population is hydration-dependent. This effect is attributed to changes in the density of intermolecular states resonant with the nu 3 band ( approximately 2230 cm (-1)) resulting from oriented interfacial water molecules near the lipid phosphate. Thus, the N 2O VER rate becomes a novel and experimentally convenient tool for reporting on the structure and dynamics of interfacial water in lipids and, potentially, in other biological systems.

Remote Preconditioning on Rat Hepatic Ischemia-Reperfusion Injury Downregulated Bax and Cleaved Caspase-3 Expression.

OBJECTIVE: Hepatic ischemia-reperfusion injury (IRI) is considered a major cause of hepatic damage in liver surgery. The aim of this study was to investigate the effect of the remote ischemic perconditioning method on hepatic IRI in a rat model. METHODS: Seventeen rats underwent hepatic IRI for 30 minutes followed by reperfusion, and were divided into 3 groups: group I, only hepatic IRI (n = 5); group II, hepatic IRI with remote perconditioning (n = 7); and group III, hepatic IRI with remote postconditioning (n = 5). RESULTS: For Bax/ß-actin, mean values of the 3 groups (±standard deviation) were 1.29 ± 0.26 (group I), 0.89 ± 0.15 (group II), and 1.02 ± 0.23 (group III). The level of Bax/ß-actin in group II was significantly lower than in group I (P < .01). The cleaved Caspase-3/ß-actin ratio for groups I, II, and III was 0.93 ± 0.22, 0.46 ± 0.16, and 0.63 ± 0.22, respectively. The level of cleaved Caspase-3/ß-actin in groups II and III were significantly lower than in group I (P < .01 and P < .05, respectively). The Bcl-2/ß-actin ratio for groups I, II, and III was 1.01 ± 0.09, 1.19 ± 0.39, and 1.20 ± 0.12, respectively. However, there were no significant difference between groups II and III and group I. CONCLUSIONS: The remote perconditioning on rat hepatic IRI downregulated the Bax and cleaved Caspase-3 expression.

Renal denervation for treatment of uncontrolled hypertension in an Asian population: results from the Global SYMPLICITY Registry in South Korea (GSR Korea).

Reports detailing the response of hypertensive patients to renal denervation (RDN) in Asian patients are limited. We evaluated 6- and 12-month outcomes after RDN in an Asian population and compared outcomes to a primarily Caucasian population. The Global SYMPLICITY Registry (GSR) is a prospective, all-comer, worldwide registry that evaluates the safety and effectiveness of RDN and includes the Korean registry substudy (GSR Korea) and a Caucasian subset (GSR Caucasian). Given differences in baseline characteristics among GSR Korea (n=93) as compared with GSR Caucasian (n=169) patients, including lower baseline office systolic blood pressure (SBP), lower body mass index and differences in medications, propensity score adjustment was performed when comparing the change in SBP between subsets. The 6- and 12-month change in SBP in GSR Korea was -19.4±17.2 and -27.2±18.1 mm Hg, respectively (P<0.001 for both vs baseline). GSR Caucasian had a SBP change similar to GSR Korea at 6 months (-20.9±21.4 mm Hg, unadjusted P=0.547, adjusted P=0.998), whereas at 12 months the change was significantly less pronounced (-20.1±23.9 mm Hg, unadjusted P=0.004, adjusted P=0.002). There were no protocol-defined procedure-related adverse events and no chronic adverse events associated with the device in an Asian population. RDN provided a significant reduction in 6- and 12-month office SBP among Asian patients, with a favorable safety profile. The 12-month SBP reduction was larger than that observed in Caucasian patients.

Prognostic significance of cerebral metabolic abnormalities in patients with congestive heart failure.

BACKGROUND: Cerebral metabolic abnormalities were proposed as a potential marker of disease severity in congestive heart failure (CHF), but their prognostic significance remains uncertain. METHODS AND RESULTS: We investigated the prognostic value of cerebral metabolic abnormalities in 130 consecutive patients with advanced CHF (100 men aged 42.6+/-11.9 years; left ventricular ejection fraction, 22.2+/-6.2%). Proton magnetic resonance spectroscopy data were obtained from localized regions ( approximately 8 mL) of the occipital gray matter and the parietal white matter. The primary end point was the occurrence of death after the proton magnetic resonance spectroscopy. During follow-up (18.5+/-14.4 months), 21 patients died and 15 underwent urgent heart transplantation. In the Cox proportional model, occipital metabolites (N-acetylaspartate, creatine, choline, and myoinositol), parietal N-acetylaspartate level, and the duration of CHF symptoms (>12 months) were validated as univariate predictors of death. In multivariate Cox analyses, however, the occipital N-acetylaspartate level was an independent predictor of death (hazard ratio, 0.52; 95% CI, 0.41 to 0.67; P<0.001). An analysis with respect to the combined end point of death or urgent transplantation showed similar results. The best cutoff value (9.0 mmol/kg) for occipital N-acetylaspartate level had 75% sensitivity and 67% specificity to predict mortality. CONCLUSIONS: The occipital N-acetylaspartate level is a powerful and independent predictor of CHF mortality, suggesting that cerebral metabolic abnormalities may be used as a new prognostic marker in the assessment of patients with CHF.

Short- and intermediate-term clinical outcomes from direct myocardial laser revascularization guided by biosense left ventricular electromechanical mapping.

BACKGROUND: Direct myocardial revascularization (DMR) has been examined as an alternative treatment for patients with chronic refractory myocardial ischemic syndromes who are not candidates for conventional coronary revascularization. Methods and Results-We used left ventricular electromagnetic guidance in 77 patients with chronic refractory angina (56 men, mean age 61+/-11 years, ejection fraction 0.48+/-0.11) to perform percutaneous DMR with an Ho:YAG laser at 2 J/pulse. Procedural success (laser channels placed in prespecified target zones) was achieved in 76 of 77 patients with an average of 26+/-10 channels (range 11 to 50 channels). The rate of major in-hospital cardiac adverse events was 2.6%, with no deaths or emergency operations, 1 patient with postprocedural pericardiocentesis, and 1 patient with minor embolic stroke. The rate of out-of-hospital adverse cardiac events (up to 6 months) was 2.6%, with 1 patient with myocardial infarction and 1 patient with stroke. Exercise duration after DMR increased from 387+/-179 to 454+/-166 seconds at 1 month and to 479+/-161 seconds at 6 months (P=0.0001). The time to onset of angina increased from 293+/-167 to 377+/-176 seconds at 1 month and to 414+/-169 seconds at 6 months (P=0.0001). Importantly, the time to ST-segment depression (>/=1 mm) also increased from 327+/-178 to 400+/-172 seconds at 1 month and to 436+/-175 seconds at 6 months (P=0.001). Angina (Canadian Cardiovascular Society classification) improved from 3.3+/-0.5 to 2.0+/-1.2 at 6 months (P<0.001). Nuclear perfusion imaging studies with a dual-isotope technique, however, showed no significant improvements at 1 or 6 months. CONCLUSIONS: Percutaneous DMR guided by left ventricular mapping is feasible and safe and reveals improved angina and prolonged exercise duration for up to a 6-month follow-up.

Creatine kinase-MB enzyme elevation following successful saphenous vein graft intervention is associated with late mortality.

BACKGROUND: Although the risk for development of creatine kinase (CK-MB) elevation after saphenous vein graft (SVG) intervention is high, its prognostic significance remains unknown. This study evaluated the impact of periprocedural CK-MB elevation on late clinical events following successful SVG angioplasty. METHODS AND RESULTS: We studied 1056 consecutive patients with successful (defined by angiographic success and absence of major complications) intervention of 1693 SVG lesions. These patients were grouped as normal CK-MB (n=556), minor CK-MB rise (CK-MB 1 to 5 times normal, n=339), and major CK-MB rise (CK-MB >5 times normal, n=161). There were no differences in major clinical events at 30-day follow-up among the 3 groups. However, 1-year mortality was 4.8%, 6.5%, and 11. 7%, respectively, P<0.05 (ANOVA). Even within a population without any intraprocedure or in-hospital complications (n=727, 69% of the overall cohort), 1-year mortality remained significantly higher with CK-MB elevation: 2.4%, 5.5%, and 10.7%, respectively, P<0.05 (ANOVA). Multivariate analysis revealed major CK-MB elevation as the strongest independent predictor of late mortality (odds ratio 3.3, with 95% CI 1.7 to 6.2), followed by diabetes mellitus (odds ratio 2. 6, with 95% CI 1.5 to 4.5). CONCLUSIONS: Major CK-MB elevation occurs after 15% of otherwise successful SVG interventions and is associated with increased late mortality.

Stenting of unprotected left main coronary artery stenoses: immediate and late outcomes.

OBJECTIVES: We examined the immediate and long-term outcomes after stenting of unprotected left main coronary artery (LMCA) stenoses in patients with normal left ventricular (LV) function. BACKGROUND: Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area. METHODS: Forty-two consecutive patients with unprotected LMCA stenoses and normal LV function were treated with stents. The post-stent antithrombotic regimens were aspirin and ticlopidine; 14 patients also received warfarin. Patients were followed very closely with monthly telephone interviews and follow-up angiography at 6 months. RESULTS: The procedural success rate was 100%, with no episodes of subacute thrombosis regardless of anticoagulation regimen. Six-month follow-up angiography was performed in 32 of 34 eligible patients. Angiographic restenosis occurred in seven patients (22%, 95% confidence interval 7% to 37%); five patients subsequently underwent elective coronary artery bypass graft surgery (CABG), and two patients were treated with rotational atherectomy plus adjunct balloon angioplasty. The only death occurred 2 days after elective CABG for treatment of in-stent restenosis. The other patients (without angiographic follow-up) remain asymptomatic. CONCLUSIONS: Stenting of unprotected LMCA stenoses may be a safe and effective alternative to CABG in carefully selected patients with normal LV function. Further studies in larger patient populations are needed to assess late outcome.

In-stent restenosis: contributions of inflammatory responses and arterial injury to neointimal hyperplasia.

OBJECTIVES: We examined the relative contributions of inflammation and arterial injury to neointimal formation in a porcine coronary overstretch restenosis model. BACKGROUND: Previous studies established that stents cause neointimal proliferation proportional to injury. Although inflammation has been postulated to be a major contributor to restenosis after angioplasty, there is a paucity of data on the relation between inflammation and subsequent neointimal formation. METHODS: Twenty-one pigs underwent balloon injury followed by implantation of oversized, tubular, slotted stents (stent/artery ratio 1.2:1) in the left anterior descending coronary artery. Morphometric analysis of the extent of injury (graded as injury score 0 to 3) and inflammation (graded as inflammation score 0 to 3) 1 month later was assessed and correlated with neointimal formation. RESULTS: An inflammatory reaction was observed in 20 of 21 pigs, and significant positive correlations were found between the degree of arterial injury and the extent of the inflammatory reaction (r = 0.80, p < 0.01) and between the extent of inflammatory reaction and the neointimal thickness (r = 0.75, p < 0.01), neointimal area (r = 0.53, p = 0.01) and percent area stenosis (r = 0.66, p < 0.01) within the stents. Importantly, there were areas with inflammation only in the absence of injury, and vice versa, that were also associated with neointimal hyperplasia. CONCLUSIONS: These data suggest that the inflammatory reaction plays an equally important role as arterial injury in neointimal formation after coronary stenting, and that anti-inflammatory approaches may be of value to reduce in-stent restenosis.

Ergonovine echocardiography as a screening test for diagnosis of vasospastic angina before coronary angiography.

OBJECTIVES: In patients with chest pain suggestive of variant angina, we performed this prospective study to test the specificity and diagnostic validity of ergonovine echocardiography (detection of regional wall motion abnormality during bedside ergonovine challenge) as a screening procedure before coronary angiography. BACKGROUND: Spasm provocation test outside the catheterization room has generally not been accepted as a safe diagnostic method. METHODS: Ergonovine echocardiography was performed in 80 consecutive patients with chest pain syndrome after confirmation of negative treadmill or normal stress myocardial perfusion scan results using thallium-201. A bolus of ergonovine maleate was injected at 5-min intervals up to a total cumulative dosage of 0.35 mg with echocardiographic monitoring of left ventricular wall motion. A 12-lead electrocardiogram (ECG) was also recorded every 3 min after each ergonovine injection. Positive test results were development of regional wall motion abnormalities or transient ST segment elevation or depression >0.1 mV in any single lead of the 12-lead ECG. Coronary angiography was undertaken within 2 +/- 4 days (mean +/- SD) after ergonovine echocardiography, and the spasm provocation test with acetylcholine or ergonovine was performed in patients with normal angiographic findings or lumen diameter narrowing <70%. RESULTS: On the basis of angiographic criteria, 56 patients had coronary vasospasm; this finding was later ruled out in 19 patients with near-normal angiographic results by a negative response on the spasm provocation test. In the remaining five patients, coronary spasm provocation was not performed because they revealed a high degree of fixed stenosis (lumen diameter narrowing 97 +/- 4%). Ergonovine echocardiography could diagnose coronary vasospasm before angiography, with a sensitivity of 91% (51 of 56 patients, 95% confidence interval [CI] 84% TO 98%) and specificity of 88% (21 of 24 patients, 95% CI 75% to 100%). Of 53 patients showing regional wall motion abnormalities during ergonovine echocardiography, characteristic ST segment elevation in the simultaneously recorded ECG was observed in only 20 (38%). There were no complications, including myocardial infarction or fatal arrhythmia, during the test. CONCLUSIONS: Ergonovine echocardiography before coronary angiography is safe and can be used as a reliable diagnostic screening test for coronary vasospasm in patients with negative treadmill or normal stress myocardial perfusion scan results. These findings suggest that invasive coronary angiography can be avoided in selected patients for the diagnosis of vasospastic angina.

Long-term clinical events following creatine kinase--myocardial band isoenzyme elevation after successful coronary stenting.

OBJECTIVE: We sought to evaluate the impact of intermediate creatine kinase-myocardial band isoenzyme (CK-MB) elevation on late clinical outcomes in patients undergoing successful stent implantation in native coronary arteries. BACKGROUND: Elevations of CK-MB after percutaneous coronary interventions are frequent. An association between high level of CK-MB elevation (>5 times normal) and late mortality after balloon and new device angioplasty has been reported previously. However, significant controversy remains on the long-term clinical importance of lower CK-MB elevations (one to five times normal) after percutaneous coronary revascularization. Moreover, the incidence and prognostic importance of cardiac enzyme elevation after coronary stenting have not been well established. METHODS: Prospectively collected data from 900 consecutive patients (1,213 lesions) undergoing successful stenting in native vessels were analyzed. Based on the CK-MB levels after coronary stenting, patients were classified into three groups: normal group 1 (n = 585), elevation of >1 to 5 times normal group 2 (n = 238) and elevation of >5 times normal group 3 (n = 77). RESULTS: Patients in group 3 had more in-hospital recurrent ischemia (p = 0.001) and pulmonary edema (p = 0.01) than patients in groups 1 and 2. Long-term clinical end points were similar between groups 1 and 2. However, patients in group 3 had an increased incidence of late mortality compared with patients in groups 2 and 1 (6.9%, 1.2% and 1.7%, respectively, p = 0.01). Multivariate analysis showed that patients with CK-MB >5 times normal after coronary stenting had an increased risk of major adverse clinical events (relative risk: 1.70, p < 0.05) and death (relative risk: 3.25, p < 0.05) that was not observed in patients with lower CK-MB rise. CONCLUSIONS: Patients with CK-MB elevation >5 times normal had higher late mortality and more unfavorable event-free survival than those patients with normal or lower CK-MB rise after coronary stenting. While intermediate CK-MB elevation (>1 to 5 times normal) is frequent after coronary stenting (26%), this was not associated with an increased risk of late mortality or major adverse clinical events.

Safety and clinical impact of ergonovine stress echocardiography for diagnosis of coronary vasospasm.

OBJECTIVES: We sought to address the issues of safety, feasibility and clinical impact of noninvasive diagnosis of coronary vasospasm (CVS). BACKGROUND: The safety of ergonovine provocation for CVS performed outside the catheterization laboratory has been questioned. METHODS: We performed a retrospective analysis of the results of bedside ergonovine provocation testing by monitoring left ventricular regional wall motion abnormalities (RWMAs) using two-dimensional echocardiography (Erg Echo). RESULTS: After confirming that there was no significant epicardial coronary stenosis, Erg Echo was performed on 1,372 patients from July 1991 to December 1997. Ergonovine echocardiography was terminated prematurely in 13 patients (0.9%) because of limitations caused by side effects unrelated to myocardial ischemia. Among 1,359 completed tests, 31% (n = 421) showed positive results, with development of RWMAs in 412 tests (98%) or ST displacement in electrocardiograms of nine tests (2%). Arrhythmias developed in 1.9% (26/1,372), including transient ventricular tachycardia (n = 2) and atrioventricular block (n = 4), which were promptly reversed with nitroglycerin. There was no mortality or development of myocardial infarction. Based on the angiographic criteria of 218 patients, the sensitivity and specificity of Erg Echo for the diagnosis of CVS were 93% and 91%, respectively. Since 1994, Erg Echo has become a more popular diagnostic method than invasive spasm provocation testing in the catheterization laboratory and has comprised more than 95% of all spasm provocation tests during the last three years. In the outpatient clinic, 453 patients underwent Erg Echo safely. CONCLUSIONS: Although this is a retrospective study in a single center, we believe that Erg Echo is highly feasible, accurate and safe for the diagnosis of CVS and can replace invasive angiographic spasm provocation testing in the catheterization laboratory.

Long-term clinical and echocardiographic outcome of percutaneous mitral valvuloplasty: randomized comparison of Inoue and double-balloon techniques.

OBJECTIVES: The purpose of the present study was to compare the long-term clinical and echocardiographic results of the Inoue and the double-balloon techniques. BACKGROUND: The large randomized trial comparing the extent of commissurotomy and the long-term results between the double-balloon and Inoue balloon techniques has not been reported. METHODS: We conducted a prospective, randomized trial comparing two procedures in 302 consecutive patients who underwent percutaneous mitral valvuloplasty (PMV) using Inoue (n = 152; group I) or double-balloon technique (n = 150, group D) between 1989 and 1995. The sample size was planned to provide the study with approximately 80% power for the detection of a 10% difference between the two groups. RESULTS: There were no significant differences in baseline characteristics between the two groups. Immediately after PMV, mitral valve area (MVA) increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2 in group I and from 0.9 +/- 0.2 to 1.9 +/- 0.3 cm2 in group D. No significant differences existed between the two groups in terms of development of commissural splitting, commissural mitral regurgitation (CMR), moderate to severe mitral regurgitation (MR) and MVA after PMV. The successful immediate results (MVA > or =1.5 cm2 and MR < or =2) were achieved in 127 (84%) patients of group I and 122 (81%) patients of group D (p = NS). Annual clinical and echocardiographic evaluation was completed for 290 (96%) patients with mean follow-up of 51 +/- 27 months. Adverse events occurred in 19 (13%) patients of group I (3 deaths, 7 mitral valve replacements, 5 repeat PMV, 2 NYHA class > or =3, 2 technical failures) and 16 (11%) patients of group D (2 deaths, 10 mitral valve replacements, 3 repeat PMV, 1 NYHA class > or =3). Estimated actuarial seven-year event-free survival was 75 +/- 7% in group I and 82 +/- 6% in group D (p = NS). Estimated actuarial seven-year restenosis-free survival was 67 +/- 7% in group I and 76 +/- 6% in group D (p = NS). On multivariate analysis, unsuccessful immediate result (p < 0.001) and absence of CMR (p < 0.01) were independently related with events. Absence of CMR and smaller mitral valve area after PMV were independently related with restenosis (p < 0.001). CONCLUSIONS: The Inoue and double-balloon techniques were equally effective in commissurotomy and produced similar, excellent long-term results. The achievement of complete commissurotomy with development of CMR or larger post-PMV mitral valve area is important to optimize the long-term results of PMV.