New tools for assessing microvascular obstruction in patients with ST elevation myocardial infarction.
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Blood Pressure Determination↗
Biomedical subjects
J J Warner
Publications and source records attributed to J J Warner.
Comparison of results of percutaneous balloon mitral commissurotomy in patients aged > or = 65 years with those in patients aged < 65 years.
Percutaneous balloon mitral commissurotomy (PBMC) is now first-line therapy in patients with symptomatic mitral stenosis (MS) and favorable valve morphology. Unfortunately, the outcome of Medicare-aged patients undergoing this procedure has not previously been defined. The results of PBMC in 55 patients > or = 65 years old (71 +/- 6 years) with moderate or severe MS were compared with 268 younger patients (47 +/- 10). Preprocedural New York Heart Association functional class and pulmonary pressures did not differ. The older patients had higher blood pressure, were more likely to be in atrial fibrillation and had higher valve scores (9.9 +/- 2.5 vs 8.6 +/- 2.2, p = 0.001). Procedural success was higher in the younger group (71% vs 55%, p = 0.013), with a greater increase in mitral valve area. Complications were similar in both groups and there were no periprocedural deaths. At 6 months a significant improvement in function class was seen in both groups. Restenosis, as assessed by serial echocardiography, occurred at a rate of 0.06 cm(2)/year in both groups, and functional class remained unchanged over 3 years. Event-free survival was similar at 48 months: 76% in the younger group and 69% in the older group. Our data thus demonstrates that PBMC can be safely performed in the Medicare-aged population. Despite less acute success in the older population, complication rates do not differ and decrement in valve area over time occurs at a similar rate. Functional class remains improved and event-free survival over 4 years appears similar in both groups. PBMC should thus be offered to patients with MS and suitable anatomy regardless of their age.
Adult↗
Arthroscopic Bankart repair with the Suretac device for traumatic anterior shoulder instability in athletes.
Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade. Currently, most techniques include the use of suture and suture anchors. However, the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing, and knot tying. Stabilization using the Suretac device (Acufex Microsurgical, Mansfield, MA) simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intra-articular knot tying. However, a successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination under anesthesia, and the pathoanatomy defined by a thorough arthroscopic examination suggest the most effective treatment strategy. The ideal candidate for shoulder stabilization using the Suretac device is an athlete with a relatively pure traumatic anterior instability pattern with detachment pathology (e.g., Bankart lesion) and minimal capsular deformation.
Absorbable Implants↗
Instability of shoulder arthroplasty: balancing mobility and stability.
Avoidance of instability after shoulder arthroplasty is based on an appreciation of normal articular anatomy and its restoration, as well as adequate soft tissue release and secure repair of subscapularis. Errors in restoration of articular anatomy, or disruption of soft tissues about the joint, are the principal reasons for instability. Revision in such cases can be challenging because of difficulties in restoring normal articular position and orientation, as well as reconstruction of deficient soft tissues.
Arthroplasty, Replacement↗
Management of massive irreparable rotator cuff tears: the role of tendon transfer.
The inability to repair a rotator cuff tear is not uncommon, and in practices devoted to the management of shoulder injuries up to 30% of rotator cuff tears may be irreparable. The anterior and posterior components of the rotator cuff are the most important deficient areas. In the case of an irreparable subscapularis tendon tear, pain relief and stability appear to be reliably achieved by a split pectoralis major transfer; however, functional improvement is less certain because the biomechanics associated with this tendon transfer do not appear to be optimal. In the case of an irreparable posterosuperior rotator cuff tear, a latissimus dorsi tendon transfer reliably restores flexion and relieves pain; however, its use after failure of prior rotator cuff surgery makes the outcome less predictable. Both anterior and posterior reconstructions with tendon transfer require precise surgical technique and patient compliance with postoperative rehabilitation.
Biomechanical Phenomena↗
Arthroscopic shoulder reconstruction: fast-track recovery and outpatient treatment.
Arthroscopic shoulder reconstructive surgery has been handled in many different ways. However, there currently is significant evidence and experience to show that doing this surgery on an outpatient basis is not only cost-effective and efficient, but safe and beneficial to patients. New arthroscopic surgical techniques and the use of regional interscalene anesthesia have been shown to provide effective and comfortable intraoperative conditions, while allowing for prolonged analgesia and quicker recovery with minimal side effects. The authors will discuss their approach to surgery, anesthesia, and recovery for outpatient shoulder reconstruction.
Ambulatory Surgical Procedures↗
Superior labral lesions: anatomy, pathology, and treatment.
In 1985, Andrews et al first described superior labral lesions primarily located in the anterosuperior aspect of the labrum in 73 athletes who throw overhead. Subsequently, Snyder et al coined the term superior labrum anterior to posterior lesion by identifying and classifying injury to the labrum that originated posteriorly and extended anteriorly. During the past 15 years, these superior labral injuries have been the source of approximately 70 peer-reviewed publications in the English language literature. Substantial debate continues, however, with reference to the pathogenesis, diagnosis, and treatment of these lesions. The current review defines the anatomy, possible etiologies, diagnosis, and treatment of injuries to the superior labrum.
Algorithms↗
Outcomes following interventions in small coronary arteries with the use of hand-crimped Palmaz-Schatz stents.
Although coronary stenting has been shown to be effective, retrospective studies have suggested that stents do not provide better results than angioplasty in small coronary arteries. We sought to examine procedural, in-hospital, and long-term outcomes of patients undergoing small-vessel stenting with Palmaz-Schatz stents hand-crimped on a balloon catheter <3 mm in diameter. We retrospectively analyzed the outcomes of 117 patients who underwent this type of coronary stent implantation at Duke University Medical Center between January 1, 1997 and May 30, 1998. The clinical indications for percutaneous revascularization included unstable angina in 67.5% of patients, acute myocardial infarction in 4.3%, postinfarct angina in 3.4%, silent ischemia in 3.4%, and stable angina in 1% of patients. Quantitative angiographic analysis was performed immediately before angioplasty and after stent implantation. Stents were used for elective indications in 24%, for suboptimal angiographic result in 61.5%, and for abrupt and/or threatened closure in 14.5% of patients. Reference vessel diameter was similar before and after the procedure. Minimum luminal diameter increased from 0.63 to 2.35 mm, an acute gain of 1.72+/-0.43 mm. Percent stenosis decreased from 74.2% to 4.7%. The clinical composite of death (n = 1, 1%), nonfatal myocardial infarction (n = 6, 5.1%), and revascularization (n = 1, 1%) occurred in-hospital in only 8 patients (6.8%), resulting in clinical procedure success in 109 patients (93%). Our data suggest that stents designed for vessels >3.0 mm can be deployed in small vessels, with a low in-hospital event rate. However, target lesion revascularization in small vessels remains high. Development of antiproliferative strategies could improve long-term outcomes for small-vessel interventions.
Aged↗
Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis.
Pulmonary artery stenosis is an uncommon complication of fibrosing mediastinitis. Previous medical and surgical therapies have provided limited clinical efficacy without objective evidence of clinical improvement. With the advantages of limited invasiveness and absent need for prolonged drug therapy, percutaneous stent deployment to relieve pulmonary artery obstruction represents a novel treatment for this rare disorder.
Adult↗
Selective capsular shift technique for anterior and anterior-inferior glenohumeral instability.
Anterior and anterior-inferior glenohumeral instability is often successfully treated with nonoperative measures, especially in atraumatic instability. In the case of traumatic instability, especially when the labrum is detached from the anteroinferior glenoid rim, surgery is often necessary to stabilize the shoulder and restore function. An anatomic repair that addresses any capsular or labral defect is essential for a successful outcome, and the selective capsular shift technique offers the flexibility necessary to correct these deformities. Several equally important steps must be followed when treating anterior and anterior-inferior glenohumeral instability. These include the correct diagnosis and indications for surgery; a technically successful surgical procedure; and diligent, physician-directed, closely monitored rehabilitation.
Humans↗
Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability.
After more than 15 years of experience, arthroscopic shoulder stabilization is becoming less controversial. Historically, recurrence rates following arthroscopic stabilization have been higher than with open stabilization. Although a negligible advantage may exist in terms of expedited postoperative rehabilitation and improved postoperative recovery of motion, critics suggest that its use in contact athletes be limited. The indications for arthroscopic stabilization are expanding, in part, because of improved understanding of the pathophysiology of shoulder instability. Understanding the mechanism of recurrent instability following arthroscopic stabilization offers clues to how physicians can prevent unsatisfactory results in the future. With newer instrumentation and the ability to thermally treat capsular tissue, coexisting pathology, such as capsular plastic deformation, rotator interval lesions, and unrecognized intra-articular pathology, can now be addressed arthroscopically. The judicious use of these techniques is warranted until long-term study results become available. Ideal patients for arthroscopic Bankart repair have a discrete Bankart lesion; a robust, well-developed IGHL; no significant capsular laxity or intraligamentous injury; and an absence of concomitant intra-articular pathology. Additional findings on MR imaging or CT evidence of a discrete labral lesion and pure unidirectional anterior instability during EUA are also good prognostic indicators for arthroscopic Bankart repair. Arthroscopic criteria that render patients less appropriate for an arthroscopic repair include capsular injury, capsular laxity, a bony Bankart lesion, glenohumeral arthritis, and a rotator cuff tear. The authors' believe that either absent or patulous, poorly developed glenohumeral ligaments represent a poor prognostic indicator for a successful outcome following standard arthroscopic Bankart repair. Individuals with poor-quality tissue are more predictably managed using open capsulorrhaphy. Patients with pathologic ligamentous laxity in the absence of a Bankart lesion or any apparent intraligamentous injury to the IGHL are also good candidates for treatment with an open capsulorrhaphy. Findings determined from a thorough physical examination, EUA, and the pathology appreciated during diagnostic arthroscopy help to appropriately choose the surgical procedure that effectively addresses pathology in patients who present with recurrent traumatic anterior instability. Patient preferences and surgical experience are important determinants of procedure selection, and current arthroscopic techniques lack the versatility to uniformly address the entire spectrum of pathology that may be associated with traumatic anterior shoulder instability. Surgeons should always be prepared to convert to an open-stabilization technique if the arthroscopic technique is deficient in addressing all pathology identified at the time of surgery.
Arthroscopy↗
Arthroscopic Bankart repair. Operative technique and surgical pitfalls.
The arthroscopic management of patients with shoulder instability continues to evolve. The obvious benefits include a reduction of operative time, preservation of the subscapularis, improved visualization, and less blood loss. Newer techniques that allow the plastic deformation of the IGHLC to be addressed are emerging, which may yield results as successful as those of open Bankart repair. The ability to adequately tension the IGHLC may result in some loss of external rotation, which may improve results. Capsular tensioning must be critically analyzed at the time of surgery. Adequate stabilization with an arthroscopic approach should provide a convincing postoperative examination of stability. A careful examination after suture placement may indicate residual laxity that must be addressed. Finally, periods of immobilization are similar in open and arthroscopic techniques. The process of biologic healing is not accelerated by arthroscopic techniques, and early return to sport activities that may endanger the repair will likely result in early failure.
Arthroscopy↗
Inhaled nitric oxide selectively dilates pulmonary vasculature in adult patients with pulmonary hypertension, irrespective of etiology.
OBJECTIVES: We sought to compare the responses of patients with pulmonary hypertension from primary and secondary causes (PPH and SPH, respectively) to inhaled nitric oxide (iNO) in the cardiac catheterization laboratory. BACKGROUND: Pulmonary hypertension can lead to right ventricular pressure overload and failure. Although vasodilators are effective as therapy in patients with PPH, less is known about their role in adults with SPH. Inhaled nitric oxide can accurately predict the response to other vasodilators in PPH and could be similarly utilized in SPH. METHODS: Forty-two patients (26 to 77 years old) with pulmonary hypertension during cardiac catheterization received iNO. Demographic and hemodynamic data were collected. Their response to iNO was defined by a decrease of > or =20% in mean pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). RESULTS: Mean PA pressures and PVR were lower during nitric oxide (NO) inhalation in all patients with pulmonary hypertension. Seventy-eight percent of patients with PPH and 83% of patients with SPH were responders to iNO. A trend was seen toward a greater response with larger doses of NO in patients with SPH. Nitric oxide was a more sensitive predictor of response (79%), compared with inhaled oxygen (64%), and was well tolerated, with no evidence of systemic effects. Elevation in right ventricular end-diastolic pressure appeared to predict poor vasodilatory response to iNO. CONCLUSIONS: Nitric oxide is a safe and effective screening agent for pulmonary vasoreactivity. Regardless of etiology of pulmonary hypertension, pulmonary vasoreactivity is frequently demonstrated with the use of NO. Right ventricular diastolic dysfunction may predict a poor vasodilator response.
Administration, Inhalation↗
Recognition and treatment of refractory capsular contracture of the shoulder.
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Contracture↗
Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study.
BACKGROUND: Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift. METHODS: Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery. RESULTS: There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures. CONCLUSIONS: Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.
Adolescent↗
In situ force distribution in the glenohumeral joint capsule during anterior-posterior loading.
Our objective was to examine the function of the glenohumeral capsule and ligaments during application of an anterior-posterior load by directly measuring the in situ force distribution in these structures as well as the compliance of the joint. We hypothesized that interaction between different regions of the capsule due to its continuous nature results in a complex force distribution throughout the glenohumeral joint capsule. A robotic/universal force-moment sensor testing system was utilized to determine the force distribution in the glenohumeral capsule and ligaments of intact shoulder specimens and the joint kinematics resulting from the application of external loads at four abduction angles. Our results suggest that the glenohumeral capsule carries no force when the humeral head is centered in the glenoid with the humerus in anatomic rotation. However, once an anterior-posterior load is applied to the joint, the glenohumeral ligaments carry force (during anterior loading, the superior glenohumeral-coracohumeral ligaments carried 26+/-16 N at 0 degrees and the anterior band of the inferior glenohumeral ligament carried 30+/-21 N at 90 degrees). Therefore, the patient's ability to use the arm with the humerus in anatomic rotation should not be limited following repair procedures for shoulder instability because the repaired capsuloligamentous structures should not carry force during this motion. Separation of the capsule into its components revealed that forces are being transmitted between each region and that the glenohumeral ligaments do not act as traditional ligaments that carry a pure tensile force along their length. The interrelationship of the glenohumeral ligaments forms the biomechanical basis for the capsular shift procedure. The compliance of the joint under our loading conditions indicates that the passive properties of the capsule provide little resistance to motion of the humerus during 10 mm of anterior or posterior translation with anatomic humeral rotation. Finally, this knowledge also enhances the understanding of arm positioning relative to the portion of the glenohumeral capsule that limits translation during examination under anesthesia.
Aged↗
An analytical approach to determine the in situ forces in the glenohumeral ligaments.
The purpose of this study was to use an analytical approach to determine the forces in the glenohumeral ligaments during joint motion. Predictions from the analytical approach were validated by comparing them to experimental data. Using a geometric model, the lengths of the four glenohumeral ligaments were determined during anterior-posterior loading simulations and forward flexion-extension. The corresponding force in each structure was subsequently calculated based on length data via load-elongation curves obtained experimentally. During the anterior loading simulation at 0 deg of abduction, the superior glenohumeral ligament carried up to 71 N at the maximally translated position. At 90 deg of abduction, the anterior band of the inferior glenohumeral ligament had the highest force of 45 N during anterior loading. These results correlated well with those found in previous experimental studies. We believe that this validated analytical approach can be used to predict the forces in the glenohumeral ligaments during more complex joint motion as well as assist surgeons during shoulder repair procedures.
Aged↗
Intracoronary thrombus: an ongoing challenge.
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Animals↗