Chest
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The survival of subjects with postmyocardial infarction cardiogenic shock treated with intra-aortic balloon pumping (IABP) differs significantly among various reports. Differences in the criteria for IABP application and in the timing of its initiation have been considered as the main reasons for variations in survival. This study examines whether the way patients in cardiogenic shock are treated prior to IABP may affect their survival. Fifty-five patients in severe postmyocardial infarction cardiogenic shock were classified into three groups according to the rate of dobutamine infusion prior to IABP: the "nondobutamine" (group A, n = 31), the "high-dose dobutamine" (8 to 20 micrograms.kg-1.min-1, group B, n = 17), and the "low-dose dobutamine" (up to 7 micrograms.kg-1.min-1, group C, n = 7). All subjects seen from 1978 to 1983 were recruited for group A, from 1986 to 1990 for group B, and in years 1984, 1985, and 1991 for group C, without using any other classification criteria. It was shown a posteriori that the three groups did not differ in the features of the subjects, in the severity of shock, and in the time length between onset of shock and pumping initiation. None of the 17 subjects of group B could survive under pumping, while 10 of the 31 subjects in group A and 4 of the 7 subjects in group C were weaned off pumping. ⋯ A protracted, high-dose pre-IABP administration of dobutamine may adversely affect the survival of patients with postmyocardial infarction cardiogenic shock.
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Case Reports
Diagnosis of circumferential dissection of the ascending aorta by transesophageal echocardiography.
A 28-year-old woman with Marfan's syndrome presented with chest pain; transesophageal echocardiography showed circumferential dissection of the ascending aorta. Both aortic angiography with digital subtraction and computed tomography scanning with contrast were negative for dissection. Circumferential dissection of the ascending aorta was confirmed by surgery at which time replacement of the aorta and aortic valve were performed. Transesophageal echocardiography may become the most practical and reliable procedure for the diagnosis of aortic dissection.
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The Epworth Sleepiness Scale (ESS) is a simple questionnaire measuring the general level of daytime sleepiness, called here the average sleep propensity. This is a measure of the probability of falling asleep in a variety of situations. The conceptual basis of the ESS involves a four-process model of sleep and wakefulness. ⋯ ESS scores significantly distinguished patients with primary snoring from those with obstructive sleep apnea syndrome (OSAS), and ESS scores increased with the severity of OSAS. Multiple regression analysis showed that ESS scores were more closely related to the frequency of apneas than to the degree of hypoxemia in OSAS. ESS scores give a useful measure of average sleep propensity, comparable to the results of all-day tests such as the multiple sleep latency test.
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To assess the prevalence and severity of Doppler-detected valvular regurgitation, as assessed by multiple Doppler modalities, in patients with structurally normal hearts, we analyzed Doppler echocardiograms in a consecutive sample of 206 referred patients who were found to have completely normal M-mode and two-dimensional echocardiograms. Valvular regurgitation was detected by Doppler in 94 percent, and 56 percent had regurgitation in at least two valves (mitral, tricuspid, and/or aortic). Mitral, tricuspid, and aortic regurgitation was detected in 73 percent, 68 percent, and 12 percent, respectively, with moderate regurgitation occurring in 6 percent, 5 percent, and 2 percent, respectively. ⋯ Estimated right atrial pressure was > 10 mm Hg in only 7 percent, and only 13 percent had estimated pulmonary artery systolic pressure > or = 40 mm Hg. These data indicate a very high prevalence of trivial and mild mitral and tricuspid regurgitation in patients with otherwise "normal" hearts, suggesting that these findings are physiologically normal. These data should be considered when addressing management in patients with Doppler-detected valvular regurgitation in order to prevent "iatrogenic heart disease."
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Recurrent spontaneous pneumothorax often requires surgical treatment following variable periods of chest tube therapy. A limited axillary thoracotomy provides sufficient exposure to isolate or excise pulmonary blebs and perform a pleurodesis. Prompt use of this surgical approach in lieu of the initial placement of a thoracostomy tube avoids prolonged hospitalization and a significant failure rate of thoracostomy tubes to resolve this problem. ⋯ A limited axillary thoracotomy corrected the underlying pathology, hastened hospital discharge, limited pain, prevented short-term recurrence, and was cosmetically acceptable. A limited axillary thoracotomy is the operation of choice when a spontaneous pneumothorax requires surgery. This surgical approach has become our primary treatment for recurrent pneumothorax, avoiding the use of a preoperative thoracostomy tube and unnecessary delay, with excellent results for the patient.