Massive intrapericardial fibroma presenting with palpitations.
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Arrhythmias, Cardiac↗
Biomedical subjects
C Ratnatunga
Publications and source records attributed to C Ratnatunga.
Traumatic innominate artery transection.
Blunt innominate artery injury is a rare but often lethal complication of severe deceleration trauma. We report the case of a 38-year-old man with such an injury who was successfully operated on an emergency basis. In cases of brachiocephalic vessel trauma, a high index of suspicion in chest deceleration injuries may lead to a proper investigative process and an accurate diagnosis. Clinical signs as blood pressure gradient between the arms and widening of the mediastinum on chest X-ray is highly suggestive of trauma of the thoracic aorta and its great vessels. A chest CT scan may contribute to the diagnosis and can rule out major trauma of the aorta, but the procedure of choice for the definite diagnosis is usually the angiography. Subsequent early repair is favorable to avoid complications and fatal events. Cardiopulmonary bypass use in selected cases favors the outcome.
Accidents, Traffic↗
Relationship between the G894T polymorphism (Glu298Asp variant) in endothelial nitric oxide synthase and nitric oxide-mediated endothelial function in human atherosclerosis.
Nitric oxide (NO), produced by endothelial nitric oxide synthase (eNOS), plays important roles in normal vascular homeostasis, and reduced endothelial NO bioactivity is an important feature of vascular disease states. The Glu298Asp (G894T) polymorphic variant of eNOS has been associated with vascular disease, but functional data are lacking. Accordingly, we examined the relationships between NO-mediated endothelial function, the presence of the eNOS Glu298Asp variant, and clinical risk factors for atherosclerosis. Endothelium-dependent vasorelaxations to different agonists were determined in human saphenous veins obtained from patients with coronary artery disease and identified risk factors (n = 104). Patients were genotyped for the eNOS G894T polymorphism. Nitric oxide-mediated endothelial vasorelaxations were highly variable between patients. Reduced vasorelaxations were associated with increased number of clinical risk factors for atherosclerosis (r = - 0.54, P < 0.001), whereas the Glu298Asp variant was not associated with any differences in contractions to phenylephrine, NO-mediated vasorelaxations to acetylcholine, bradykinin or calcium ionophore, or relaxations to the NO donor sodium nitroprusside. Increased atherosclerotic risk factors, but not the presence of the eNOS Glu298Asp variant, are associated with impaired nitric oxide-mediated endothelial vasomotor function, suggesting that this polymorphism does not have a major direct functional effect on vascular eNOS activity in human atherosclerosis.
Aged↗
Minimally invasive saphenous vein harvesting: effects on endothelial and smooth muscle function.
BACKGROUND: The long saphenous vein remains the commonest conduit used in coronary artery bypass grafting procedures. Surgical trauma during vein harvesting can cause endothelial and smooth muscle injury that has important implications for vein graft longevity. Minimally invasive vein harvesting is advocated to reduce wound morbidity. However, the functional consequences of increased handling and traction, with potentially detrimental effects, remain unknown. METHODS: Forty patients were prospectively randomized into either a minimally invasive (minimal) or traditional (open) saphenous vein harvest group. Smooth muscle contractile function was assessed by responses to potassium chloride and phenylephrine. Endothelial cell function was assessed by responses to serial escalations in concentration of acetylcholine, bradykinin, calcium ionophore, sodium nitroprusside, and N-nitro-L-arginine using isometric tension studies. RESULTS: Harvest times were similar for both groups. The total incision length in the minimal group was significantly shorter than in the open group. There were no differences in smooth muscle contractions to either receptor-independent or receptor-mediated agonists between the two groups. Similarly, vasorelaxation in response to both endothelium-dependent and endothelium-independent agonists were similar in both groups. CONCLUSIONS: Minimally invasive saphenous vein harvesting is associated with similar medial smooth muscle and endothelial function as open harvesting. These findings suggest that minimally invasive harvesting techniques can be used without major detrimental effects on vascular integrity.
Aged↗
Coronary artery bypass grafting in non-dialysis-dependent mild-to-moderate renal dysfunction.
OBJECTIVES: The effect of mild-to-moderate elevation of preoperative serum creatinine levels on morbidity and mortality from coronary artery bypass grafting has not been investigated in a large multivariable model incorporating preoperative and intraoperative variables. Our first objective was to ascertain the effect of a mild-to-moderate elevation in the preoperative serum creatinine level on the need for mechanical renal support; the duration of special care and total postoperative stay; the occurrence of infective, respiratory, and neurologic complications; and hospital mortality. Our second objective was to ascertain which patient variables contributed to an increase in the serum creatinine level in association with coronary artery bypass grafting. METHODS: A total of 1427 patients who had no known pre-existing renal disease and who were undergoing first-time coronary artery bypass grafting with cardiopulmonary bypass were recruited for the study. Patients were divided, on the basis of preoperative serum creatinine level, into 3 groups as follows: creatinine level of less than 130 micromol. L(-1); creatinine level of 130 to 149 micromol. L(-1); and creatinine level of 150 micromol. L(-1) or greater. A multivariable stepwise logistic regression analysis was used, and variables significant at the 5% level were included when developing the final multivariable models. RESULTS: Multivariable analysis showed that elevation of the preoperative serum creatinine level to 130 micromol. L(-1) or greater increased the likelihood of needing mechanical renal support postoperatively (P <.001), as well as the need for postoperative special care (P <.001) and total hospital stay (P <.001). In-hospital mortality was also significantly elevated as the preoperative creatinine level rose to 130 to 149 micromol. L(-1) (P =.045) and to 150 micromol. L(-1) or greater (P <.001). It was further observed that patients with preoperative serum creatinine levels of 130 to 149 micromol. L(-1) (P =.02), patients with preoperative serum creatinine levels of 150 micromol. L(-1) or greater (P =.001), hypertensive patients (P =.007), patients with angina of New York Heart Association class III or greater (P =.001), patients having a nonelective operation (P =.002), and patients having a prolonged cardiopulmonary bypass time (P =.008) had a significantly greater increase in the serum creatinine level as a result of coronary artery bypass grafting. Of particular note was the finding that the method of myocardial protection (cardioplegia or crossclamp fibrillation) did not significantly influence in-hospital mortality, need for mechanical renal support, or special care or total postoperative hospital stay. CONCLUSIONS: A mild elevation (130-149 micromol. L(-1)) in the preoperative serum creatinine level significantly increases the need for mechanical renal support, the duration of special care and total postoperative stay, and the in-hospital mortality. As the preoperative serum creatinine level increases further (> or =150 micromol. L(-1)), this effect is more pronounced. No significant difference in outcome was observed between the use of cardioplegia or crossclamp fibrillation for myocardial protection.
Aged↗
Prosthetic valve endocarditis in a patient with Marfan's syndrome following acupuncture.
Active prosthetic valve endocarditis (PVE) as a complication of acupuncture requiring valve surgery has not been reported previously. We report a case of PVE in a patient with Marfan's syndrome as a complication of acupuncture, who underwent emergency redo aortic root and valve replacement with a homograft. This report highlights the need for prophylactic antibiotics before acupuncture in patients with prosthetic valves, and also describes the use of a homograft as an effective surgical strategy.
Acupuncture Therapy↗
Performance of Edwards prima stentless aortic valve over eight years.
Long-term clinical and hemodynamic performance is a key consideration in using a stentless aortic bioprosthesis. This study reports clinical and hemodynamic performance of Prima stentless aortic valve during our 8-year follow-up. In the study, 85 patients underwent aortic valve replacement (Edwards Prima or Prima plus stentless valve) and had follow-up at discharge and then annually up to 8 years. The mean age at operation was 72 +/- 5 yrs, 49 were male and 25% underwent concomitant CABG. Doppler Echo studies were performed to determine mean pressure gradient (mPG), effective orifice area (EOA) and the degree of regurgitation of stentless valves. Aortic root geometry was assessed by the ratio of sinotubular junction to valve size at peak systole. Patient survival rate was 82% +/- 5% at 5th year and 72% +/- 6% at 8th year. The freedom from valve structure failure was 97% +/- 2% at 5th and 8th year. Valve mPG and EOA at 8 years remained significantly better than those at discharge (6.8 +/- 4.4 mm Hg v 9.7 +/- 6.2 mm Hg; 1.91 +/- 0.54 cm(2) v 1.63 +/- 0.71 cm(2), both P <.01), and did not differ from those at 3-year follow-up. Mean sinotubular junction diameter remained below valve size (0.96 +/- 0.14). Mild degree of valvular regurgitation was present in 17% of patients, but this did not progress over the period of follow-up. After aortic valve replacement with the Prima stentless valves, excellent valve hemodynamics and normal root geometry were well maintained up to 8 years, but longer-term follow-up of a larger cohort remains essential.
Aged↗
Functional effect of the C242T polymorphism in the NAD(P)H oxidase p22phox gene on vascular superoxide production in atherosclerosis.
BACKGROUND: Increased superoxide anion production increases oxidative stress and reduces nitric oxide bioactivity in vascular disease states. NAD(P)H oxidase is an important source of superoxide in human blood vessels, and some studies suggest a possible association between polymorphisms in the NAD(P)H oxidase CYBA gene and atherosclerosis; however, no functional data address this hypothesis. We examined the relationships between the CYBA C242T polymorphism and direct measurements of superoxide production in human blood vessels. METHODS AND RESULTS: Vascular NAD(P)H oxidase activity was determined in human saphenous veins obtained from 110 patients with coronary artery disease and identified risk factors. Immunoblotting, reverse-transcription polymerase chain reaction, and DNA sequencing showed that p22phox protein, mRNA, and 242C/T allelic variants are expressed in human blood vessels. Vascular superoxide production, both basal and NADH-stimulated, was highly variable between patients, but the presence of the CYBA 242T allele was associated with significantly reduced vascular NAD(P)H oxidase activity, independent of other clinical risk factors for atherosclerosis. CONCLUSIONS: Association of the CYBA 242T allele with reduced NAD(P)H oxidase activity in human blood vessels suggests that genetic variation in NAD(P)H oxidase components may play a significant role in modulating superoxide production in human atherosclerosis.
Aged↗
UltraRapid communications : vascular superoxide production by NAD(P)H OxidaseAssociation with endothelial dysfunction and clinical risk factors
Superoxide anion plays important roles in vascular disease states. Increased superoxide production contributes to reduced nitric oxide (NO) bioactivity and endothelial dysfunction in experimental models of vascular disease. We measured superoxide production by NAD(P)H oxidase in human blood vessels and examined the relationships between NAD(P)H oxidase activity, NO-mediated endothelial function, and clinical risk factors for atherosclerosis. Endothelium-dependent vasorelaxations and direct measurements of vascular superoxide production were determined in human saphenous veins obtained from 133 patients with coronary artery disease and identified risk factors. The predominant source of vascular superoxide production was an NAD(P)H-dependent oxidase. Increased vascular NAD(P)H oxidase activity was associated with reduced NO-mediated vasorelaxation. Furthermore, reduced endothelial vasorelaxations and increased vascular NAD(P)H oxidase activity were both associated with increased clinical risk factors for atherosclerosis. Diabetes and hypercholesterolemia were independently associated with increased NADH-dependent superoxide production. The association of increased vascular NAD(P)H oxidase activity with endothelial dysfunction and with clinical risk factors suggests an important role for NAD(P)H oxidase-mediated superoxide production in human atherosclerosis. The full text of this article is available at http://www.circresaha.org. Key Words:atherosclerosis endothelium superoxide nitric oxide diabetes Two Distinct Congenital Arrhythmias Evoked by a Multidysfunctional Na(+) Channel Marieke W. Veldkamp, Prakash C. Viswanathan, Connie Bezzina, Antonius Baartscheer, Arthur A.M. Wilde, Jeffrey R. Balser Abstract-The congenital long-QT syndrome (LQT3) and the Brugada syndrome are distinct, life-threatening rhythm disorders linked to autosomal dominant mutations in SCN5A, the gene encoding the human cardiac Na(+) channel. It is believed that these two syndromes result from opposite molecular effects: LQT3 mutations induce a gain of function, whereas Brugada syndrome mutations reduce Na(+) channel function. Paradoxically, an inherited C-terminal SCN5A mutation causes affected individuals to manifest electrocardiographic features of both syndromes: QT-interval prolongation (LQT3) at slow heart rates and distinctive ST-segment elevations (Brugada syndrome) with exercise. In the present study, we show that the insertion of the amino acid 1795insD has opposite effects on two distinct kinetic components of Na(+) channel gating (fast and slow inactivation) that render unique, simultaneous effects on cardiac excitability. The mutation disrupts fast inactivation, causing sustained Na(+) current throughout the action potential plateau and prolonging cardiac repolarization at slow heart rates. At the same time, 1795insD augments slow inactivation, delaying recovery of Na(+) channel availability between stimuli and reducing the Na(+) current at rapid heart rates. Our findings reveal a novel molecular mechanism for the Brugada syndrome and identify a new dual mechanism whereby single SCN5A mutations may evoke multiple cardiac arrhythmia syndromes by influencing diverse components of Na(+) channel gating function. The full text of this article is available at http://www.circresaha.org. Key Words: Na(+) channel inactivation long-QT syndrome Brugada syndrome
Journal Article↗
Vascular superoxide production by NAD(P)H oxidase: association with endothelial dysfunction and clinical risk factors.
Superoxide anion plays important roles in vascular disease states. Increased superoxide production contributes to reduced nitric oxide (NO) bioactivity and endothelial dysfunction in experimental models of vascular disease. We measured superoxide production by NAD(P)H oxidase in human blood vessels and examined the relationships between NAD(P)H oxidase activity, NO-mediated endothelial function, and clinical risk factors for atherosclerosis. Endothelium-dependent vasorelaxations and direct measurements of vascular superoxide production were determined in human saphenous veins obtained from 133 patients with coronary artery disease and identified risk factors. The predominant source of vascular superoxide production was an NAD(P)H-dependent oxidase. Increased vascular NAD(P)H oxidase activity was associated with reduced NO-mediated vasorelaxation. Furthermore, reduced endothelial vasorelaxations and increased vascular NAD(P)H oxidase activity were both associated with increased clinical risk factors for atherosclerosis. Diabetes and hypercholesterolemia were independently associated with increased NADH-dependent superoxide production. The association of increased vascular NAD(P)H oxidase activity with endothelial dysfunction and with clinical risk factors suggests an important role for NAD(P)H oxidase-mediated superoxide production in human atherosclerosis. The full text of this article is available at http://www.circresaha.org.
Acetylcholine↗
Late presentation of tension chylothorax following blunt chest trauma.
We describe the case of tension chylothorax in a 29-year-old man following blunt chest trauma sustained in a road traffic accident. This presented with respiratory and haemodynamic compromise. Conservative treatment was attempted but definitive surgical intervention was required.
Accidents, Traffic↗
Forearm fasciotomy post cardiac surgery.
Compartment syndrome is an uncommon diagnosis in the field of cardiac surgery. Early diagnosis and prompt operative decompression are essential for a successful outcome in terms of functional status of the limb concerned and mortality. The management of a compartment syndrome of the forearm is identical to that of the leg.
Aortic Valve↗
Chronic peripheral occlusive arterial disease in Sri Lanka.
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Adult↗
Should business management training be part of medical education?
The introduction of modern business management practices in the National Health Service has exposed different levels of management training and expertise between clinicians and hospital managers. This is undesirable and frequently unproductive. This article puts the case for the inclusion of business management training within undergraduate and postgraduate curricula.
Commerce↗
Endemic multinodular goitre--management strategies.
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Goiter, Endemic↗
Skeletal fluorosis with neurological complications.
A case of skeletal fluorosis with spinal cord compression from Kekirawa following consumption of water with high fluoride content for about 20 years is described. The observations of other workers (4,5) and the present case report show that more extensive field studies among vulnerable populations is indicated in this region. The need to search for a cost effective method of defluoridation of water is stressed.
Adult↗
Increase in middle cerebral artery velocity on breath holding: a simplified test of cerebral perfusion reserve.
Resting middle cerebral artery velocity (Vmca) as well as its rate of increase on breath holding was measured on both sides in 11 age matched controls (Group I), in six symptomatic patients with unilateral internal carotid artery occlusion (Group II) and in nine symptomatic patients with unilateral internal carotid stenosis of greater than 75% (Group III), using a transcranial doppler velocimeter. There was a significantly lower resting Vmca in Group II patients on the occluded side, but not on the stenosed side in Group III, but there was considerable overlap of results. However, during breath holding, the rate of increase of Vmca allowed better separation of the occluded side (Group II) from the contralateral normal side as well as from controls, and from the stenosed side in Group III. Also there was a lower rate of rise of Vmca on the stenosed side in Group III than controls. As a test in symptomatic patients with a relevant carotid occlusion, values of less than 2.4 mm/sec2 were found in 100% of patients and only 4.5% of controls. Reactivity to breath holding promises to be a useful test in the evaluation of symptomatic patients with extra cranial carotid artery disease.
Aged↗
Ureteric re-implantation in the neuropathic bladder.
During the last 5 years 174 children with neuropathic bladder were studied, and only 7 required urinary diversions. A total of 31 ureteroneocystostomies were performed in 17 patients, 16 of whom had gross vesico-ureteric reflux. Revisionary surgery was required in four children and two underwent pyeloplasty. Deterioration followed ureteroneocystostomy in two patients, but 13 (76 per cent) of the children were significantly improved.
Adolescent↗