AimsWe present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR).
Methods and resultsTwo hundred and fifty-one patients (aged 68.4 + 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5-51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision (n ¼ 3) or at discharge (n ¼ 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years (P , 0.001) and 5 years (P , 0.001). Fiveyear actuarial survival was 83.2 + 4.4. Five-year freedom from re-operation for failed repair was 78.2 + 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge (P ¼ 0.001 and P ¼ 0.01, respectively) and at early follow up (P ¼ 0.004 and P ¼ 0.02) but raised at 3 years (P , 0.001) and 5 years (P , 0.001). Systolic and diastolic sphericity indexes improved at discharge (P , 0.001) remained stable at 1 year but they re-increased at 3-year control (P ¼ 0.006 and P ¼ 0.03, respectively) with a late raise exceeding the pre-operative value (P , 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume 145 mL, systolic sphericity index 0.7, myocardial performance index 0.9, and wall motion score index 1.5 were predictors of recurrent MR.
ConclusionOur findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.--
This randomized double-blind placebo-controlled study was designed to evaluate the effects on postoperative pain of the local anesthetic, 0.5% bupivacaine with epinephrine, sprayed hepatodiaphragmatically under the surgeon's direct view during laparoscopic cholecystectomy. Metabolic endocrine responses to surgery (glucose and cortisol) and nonsteroidal anti-inflammatory drug requirements were investigated, as well as the presence of nausea, vomiting, and sweating. Local anesthetics or placebo solutions were given as follows. Immediately following the creation of a pneumoperitoneum, surgeons sprayed the first 20 mL of solution (S1), and an additional 20 mL of solution (S2) was sprayed at the end of the operation. Patients were classified into three groups (14 patients per group). Group A received 20 mL of saline during both S1 and S2, group B received 20 mL of saline during S1 and 20 mL of bupivacaine during S2, and group C received 20 mL of bupivacaine during both S1 and S2. The degree of postoperative pain was assessed using the visual analogue scale (VAS) and the verbal rating scale (VRS) on arrival in the recovery room and subsequently at time intervals of 4 h, 8 h, 12 h, and 24 h. The results of this study indicate a significant decrease of postoperative pain in patients treated with local anesthetic. VAS and VRS pain scores, as well as respiratory rate and analgesic requirements, were significantly lower in group C. The postoperative plasma cortisol level in group C was significantly lower than in groups A and B.
Farm tractors are large, heavy, powerful vehicles with a high center of gravity. When driven carelessly on sloping, irregular, or slippery ground, tractors can overturn sideways and cause the death by crush asphyxia of the driver or passengers, especially if appropriate safety equipment is not fitted or used. The aim of this review is to focus on the diagnostic difficulties with which coroners and forensic pathologists have to cope when a confirmation of crush asphyxia after tractor side rollover is required by judicial authorities. Forensic investigations in such cases must involve the meticulous analysis of the death scene and the mechanical characteristics of the vehicle together with accurate postmortem and toxicological examination.
Open-heart operations can be performed with acceptable short- and long-term results in patients with CRF on dialysis. Adequate preoperative management with identification of high-risk patients and a more aggressive approach before the onset of symptoms of cardiac failure are advisable.
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