Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy:One-year follow-up

Objective: Follow-up of patients with treatment-resistant Raynaud's phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS). Methods: Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillary microscopy were performed. Results: One year after SPTS the duration of the attacks of was reduced with 1.9 h in the left hand versus 0.3 h in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p = 0.017), pain (p = 0.027) and physical functioning (p = 0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75–140) at baseline versus 118 (95–190) one year post-operatively, p = 0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1–41) at baseline versus 38 (24–43) one year post-operatively, p = 0.028). Conclusion: One year after unilateral R3 SPTS the benefit with regard to the majority of outcome variables persisted, though some effects seem to attenuate. Long-term effects and long-term follow-up results will be investigated in an on-going study. Clinical trial registration number: NCT02680509

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy:a novel minimally invasive endoscopic technique

OBJECTIVE: To assess the minimally invasive single-port thoracoscopic sympathicotomy feasibility and efficacy in patients with treatment-resistant RP. METHODS: Single-port thoracoscopic sympathicotomy was performed unilaterally on the left side in eight patients with RP (six males, two females, with a median age of 45.2 years). Five patients had primary and three had secondary RP. Perfusion effects in the hands were assessed at baseline and after 1 month by using a cooling and recovery procedure, and by using laser speckle contrast analysis. Number and duration of RP attacks were reported over a 2-week period. RESULTS: Patient satisfaction was 100% after surgery. After surgery, a unilateral improvement in perfusion was observed in the left hand compared with the right hand, with cooling and recovery (P = 0.008) and with laser speckle contrast analysis (P = 0.023). In addition, the number and duration of the attacks in the left hand decreased compared with the right hand (both P = 0.028). No serious adverse events occurred in a follow-up period of at least 10 months. CONCLUSION: Single-port thoracoscopic sympathicotomy is feasible and can be effective in improving hand perfusion in patients with RP. However, long-term efficacy needs to be established. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509

Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials

<p>Abstract</p> <p>Background</p> <p>The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina.</p> <p>Methods</p> <p>We searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units.</p> <p>Results</p> <p>Seven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, <it>p </it>= 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, <it>p </it>= 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up.</p> <p>Conclusion</p> <p>SCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.</p

Spinal cord stimulation in refractory angina pectoris - Clinical results and mechanisms

Patients with therapeutically refractory angina pectoris do not respond to adequate anti-anginal medication and are not suitable anymore for revascularisation procedures. This group of patients has a poor quality of Life, since their exercise capacity is severely afflicted. A new additional therapy for patients with refractory angina is neurostimulation. The concept of neurostimulation is based on the ''gate control theory'', a model in which nociceptive unmyelinated fiber afferents (C and A delta) are inhibited by non-nociceptive myelinated fiber afferents. Patients treated with spinal cord stimulation (SCS) show an increase in exercise capacity and a concomitant reduction in myocardial ischemia. A reduction in anginal attacks and nitroglycerin intake is also reported. The mechanisms of action of SCS are unclear, although there is evidence of an increase in myocardial oxygen supply, as is shown in peripheral vascular disease. Sympathetic nervous activity, prostaglandins, and endogenous opiates may also play a role in pain suppression by SCS. As soon as the safety and the complication rate are established, SCS may be commonly used as an additional therapy in patients with so-called ''intractable angina pectoris''

Electrical neuromodulation improves myocardial perfusion and ameliorates refractory angina pectoris in patients with syndrome X:fad or future?

At present, there is no reliable antianginal drug therapy for patients with cardiac syndrome X. Therefore, the effect of electrical neuromodulation on refractory angina pectoris and myocardial perfusion in cardiac syndrome X was assessed. Eight patients (aged 55 +/- 7 years) with heterogeneous myocardial perfusion and no esophageal abnormalities were included. The subjects were nonresponders to antianginal drug therapy. Angina pectoris attacks and myocardial perfusion dynamics were evaluated by positron emission tomography at baseline and following 4 weeks of (transcutaneous electrical nerve stimulation) TENS. Following TENS there was a reduction of angina pectoris episodes (baseline 20 +/- 3, TENS 3 +/- 1; p = 0.012), and short acting nitroglycerin intake per week (baseline 10 +/- 3, TENS 2 +/- 1; p = 0.008). The rate pressure product (mmHg min(-1)) during the cold pressor test (CPT) was reduced during TENS (baseline 12 800 +/- 1200, TENS 11500 +/- 900; p = 0.02). Following TENS, the perfusion reserve ratio between rest and dipyridamole flow increased (baseline 1.59 +/- 0.15, TENS 1.90 +/- 0.11 ml min(-1) x 100g; p = 0.05). The coronary vascular resistance had a trend towards a reduction (baseline 0.96 +/- 0.04, TENS 0.85 +/- 0.06 mmHg min(-1) x 100g/ml; p = 0.06) during CPT. This observation may suggest that neurostimulation improves angina pectoris with a concomitant improvement of myocardial perfusion in cardiac syndrome X. (C) 2003 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved

Analytical aspects of the automated CKMB1,2 and CKMM1,2,3 isoform determination and its relation to other biochemical markers

The automated (CK)MB1,2/MM1,2,3 isoform measurement, based on electrophoresis, has been simplified to the point that it has become possible to perform this analysis on a 24-h routine basis. We studied analytical aspects of this analysis and its clinical relevance in relation to other biochemical markers (CK total, CKMB activity, CKMB mass, myoglobin, Troponin I and Troponin T) in patients with acute myocardial infarction (AMI), patients with unstable angina pectoris (UAP), and healthy donors. Furthermore, the additional significance of the analysis was evaluated in patients with clinically unexpected, raised CKMB/CK total activities. The storage of serum at 4 degrees C does not influence the MB2/MB1 ratios, whereas storage at 20 degrees C changes them significantly. MM3/MM1 and normal MB2/MB1 ratios show lower coefficients of variation than increased MB2/MB1 ratios. Between 2 and 30 h after myocardial tissue damage, AMI patients showed a characteristic change in CK isoform patterns. At a mean time of 3.6 h after the onset of symptoms we found raised MB2/MB1 ratios in 94% of these patients. With the information of the CK isoform analysis unexpected abnormal CK activities could be explained by CK macro enzymes (Ig-bound and mitochondrial), insufficient CE; clearance capacity, enzyme activities 4 h after (re-)infarction, and raised CK activity 15 h after skeletal muscle damage. We conclude that the CK isoforms are relatively simply to assess; they are adequate tools with which to indicate the CK kinetics over a period lasting between 2 and 30 h after tissue damage with a single blood sample and a single analysis; the CK isoform analysis has additional value in explaining inappropriate CKMB/CK total activities, and the MB2/MB1 ratios show to be one of the best early parameters for discriminating patients with AMI on admission to hospital