Complex Cesarean Section

The cesarean section, in principle, is not a complex surgical procedure when compared to many others performed in our specialty. However, there is a complex set of physiological and anatomical elements and circumstances that must interact perfectly to obtain an optimal result. Surgical technique is a factor but is often not the primary determinant of a positive outcome; concomitant circumstances interact in a cesarean section such as obstructed labor, abruptio placenta, morbid invasion of the placenta, previous pelvic infection, chorioamnionitis/endometritis, chronic and acute anemia, inadequate blood or insufficient transfusion capacity, oxytocics, anesthetics, lack of (or lack of appropriate administration of) antibiotics, and trained or motivated personnel. In all these cases, and in many other contexts, less-than-optimal results may occur, even in the face of a perfect surgical technique

Hemodynamic Surveillance of Ventricular Pacing Effectiveness with the Transvalvular Impedance Sensor

The Transvalvular Impedance (TVI) is derived between atrial and ventricular pacing electrodes. A sharp TVI increase in systole is an ejection marker, allowing the hemodynamic surveillance of ventricular stimulation effectiveness in pacemaker patients. At routine follow-up checks, the ventricular threshold test was managed by the stimulator with the supervision of a physician, who monitored the surface ECG. When the energy scan resulted in capture loss, the TVI system must detect the failure and increase the output voltage. A TVI signal suitable to this purpose was present in 85% of the tested patients. A total of 230 capture failures, induced in 115 patients in both supine and sitting upright positions, were all promptly recognized by real-time TVI analysis (100% sensitivity). The procedure was never interrupted by the physician, as the automatic energy regulation ensured full patient’s safety. The pulse energy was then set at 4 times the threshold to test the alarm specificity during daily activity (sitting, standing up, and walking). The median prevalence of false alarms was 0.336%. The study shows that TVI-based ejection assessment is a valuable approach to the verification of pacing reliability and the autoregulation of ventricular stimulation energy

Gastric protection in cardiological practice: an Italian survey on the prescriptive attitude

BACKGRO UND : Gastric protection is commonly considered in patients who use medications able to damage gastric mucosa, mainly NSAID s, antiplatelets, and anticoagulants. Therefore, cardiologists may frequently prescribe drugs to protect the stomach from damaging medications. The present survey investigated the attitude toward using gastric protection by a panel of Italian cardiologists. METHOD S: A self-administered questionnaire included three sections concerning practical problems on this issue in clinical practice facing patients with cardiological disorders. The questionnaire was administered in three successive months. RE SULTS: Ninety Italian cardiologists completed the questionnaire. They all consider gastric protection, mainly when prescribing potentially noxious medications. Usually, cardiologists prescribe proton pump inhibitors (PPIs) in 60% of their patients. Alginates and mucosal protectors are less considered. As a rule, cardiologists request investigations if the initial treatment fails. Moreover, the safety issue is carefully assessed. Furthermore, this survey experience significantly affected the approach to managing patients who require gastric protection. The participants carefully considered the prescriptive appropriateness of gastric protectors, mainly concerning the PPIs use. Consequently, PPIs were discontinued when inappropriate. A new medical device with triple action (antacid, mucosal protectors, and anti-reflux) contributed to this new attitude. CON CLUSION S: The present survey underscored that the appropriateness in prescribing gastric protectors is clinically relevant. In addition, a longitudinal survey experience contributed to change the practical approach by highlighting the prescriptive appropriateness of PPIs, and using a new medical device with multiple gastroprotective activities. (Cite this article as: Aragona SE, Margonato A, Felis S, Crisci M, Ciprandi G; the Pirocardio Study Group. Gastric protectio

Long-Term Hemodynamic Performance of the Aortic Valve After David I: An Echocardiographic Study

Despite optimal hemodynamics at rest, the performance of the aortic valve under stress conditions long after David I procedure is still debated. From 2001-2014, 73 patients underwent reimplantation with David I technique. Aortic valve function of 13 patients (age 61.2 ± 8.72) with a follow-up of at least 5 years (6.3 ± 0.9 years) was assessed at exercise echocardiographic stress test on a stationary cycle. Patients who had undergone concomitant procedure, with recurrent aortic insufficiency or mitral valve incompetence, were excluded. In all, 8 healthy volunteers served as controls. Transvalvular gradients progressively increased during the steps in both groups (P-within < 0.001), being higher in David patients (P-between < 0.001), but never reaching a clinical significance (David Peak gradient 23.8 ± 9.3 mmHg; Mean gradient 13.2 ± 5.1 mmHg). Effective orifice area (EOA) and EOA index did not change during the test in David patients, whereas Controls showed a progressive increase of functional valve area to a peak at 50 W (Controls EOA 4.0 ± 0.5 cm(2); EOA index 2.0 ± 0.3 cm(2)/m(2)). In conclusion, David I procedure ensures good hemodynamics during high-flow conditions at long-term follow-up. The reimplantation of the functional aortic annulus inside a rigid tube determines a paradoxical reduction of functional aortic valve area, secondary to the increased stroke volume, without any clinically relevant increase in transvalvular gradients. These data confirm the reliability of David I in the long term, even under physical stress conditions

What can we learn from the histopathology of retained placenta? A 15-year experience at a regional referral center

BACKGROUND: The aim of this study was to retrospectively review the histopathology reports of retained placentas in search of potential histologic pathogenetic markers and clinical predictive factors. METHODS: Clinical and histopathological features of 86 cases of retained placenta over a 15-years period in a large regional referral center were retrospectively examined and compared. RESULTS: Retained placenta is a complication occurring in less than 0.4% of the total assisted deliveries and is mainly seen in primiparae/primigravidae in their mid-thirties. No relevant alterations of maternal health were observed during pregnancy. Several of our patients had positive family history for hypertension and metabolic diseases (37.21% and 33.72%, respectively). No cases of severe fetal disease or twin pregnancies were observed. Superficial placental accretion (8.3%) and chorioamnionitis (33.73%), usually associated with retained placenta, resulted uncommon and too mild to justify the onset of the condition. On the contrary, we observed an increased frequency of hypoxic/ischemic lesions (46.51%) or lesions related to maternal hypertension (15.12%). CONCLUSIONS: Retained placenta would appear to be caused by pathological adhesion of the chorionic disc to the decidua that seems to be unrelated to maternal or fetal disease but that is more likely linked to an adaptive hypoxic and/or ischemic state, which often coexists with maternal hypertension

Hemodynamic Surveillance of Ventricular Pacing Effectiveness with the Transvalvular Impedance Sensor

The Transvalvular Impedance (TVI) is derived between atrial and ventricular pacing electrodes. A sharp TVI increase in systole is an ejection marker, allowing the hemodynamic surveillance of ventricular stimulation effectiveness in pacemaker patients. At routine follow-up checks, the ventricular threshold test was managed by the stimulator with the supervision of a physician, who monitored the surface ECG. When the energy scan resulted in capture loss, the TVI system must detect the failure and increase the output voltage. A TVI signal suitable to this purpose was present in 85% of the tested patients. A total of 230 capture failures, induced in 115 patients in both supine and sitting upright positions, were all promptly recognized by real-time TVI analysis (100% sensitivity). The procedure was never interrupted by the physician, as the automatic energy regulation ensured full patient’s safety. The pulse energy was then set at 4 times the threshold to test the alarm specificity during daily activity (sitting, standing up, and walking). The median prevalence of false alarms was 0.336%. The study shows that TVI-based ejection assessment is a valuable approach to the verification of pacing reliability and the autoregulation of ventricular stimulation energy

Hemodynamic Surveillance of Ventricular Pacing Effectiveness with the Transvalvular Impedance Sensor

The Transvalvular Impedance (TVI) is derived between atrial and ventricular pacing electrodes. A sharp TVI increase in systole is an ejection marker, allowing the hemodynamic surveillance of ventricular stimulation effectiveness in pacemaker patients. At routine follow-up checks, the ventricular threshold test was managed by the stimulator with the supervision of a physician, who monitored the surface ECG. When the energy scan resulted in capture loss, the TVI system must detect the failure and increase the output voltage. A TVI signal suitable to this purpose was present in 85% of the tested patients. A total of 230 capture failures, induced in 115 patients in both supine and sitting upright positions, were all promptly recognized by real-time TVI analysis (100% sensitivity). The procedure was never interrupted by the physician, as the automatic energy regulation ensured full patient&apos;s safety. The pulse energy was then set at 4 times the threshold to test the alarm specificity during daily activity (sitting, standing up, and walking). The median prevalence of false alarms was 0.336%. The study shows that TVI-based ejection assessment is a valuable approach to the verification of pacing reliability and the autoregulation of ventricular stimulation energy

Efficacy and Safety of Two Dosages of Canrenone as Add-On Therapy in Hypertensive Patients Taking Ace-Inhibitors or Angiotensin II Receptor Blockers and Hydrochlorothiazide at Maximum Dosage in a Randomized Clinical Trial: The ESCAPE-IT Trial

To evaluate the effects of canrenone as add-on therapy in patients already treated with angiotensin converting-enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARBs) and hydrochlorothiazide at the maximum dosage (25 mg/day)

Ambulatory blood pressure parameters after canrenone addition to existing treatment regimens with maximum tolerated dose of angiotensin-converting enzyme inhibitors/angiotensin II type 1 receptor blockers plus hydrochlorothiazide in uncontrolled hypertensive patients

Background: Blockade of the renin\ue2\u80\u93angiotensin\ue2\u80\u93aldosterone system is a cornerstone in cardiovascular disease prevention and hypertension treatment. The relevance of ambulatory blood pressure monitoring (ABPM) has been widely confirmed for both increasing the accuracy of blood pressure (BP) measurements, particularly in pharmacological trials, and focusing on 24 h BP prognostic parameters. The aim of this study was to assess the effects of canrenone addition on ambulatory BP in uncontrolled hypertensive patients already treated with the highest tolerated dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor (AT1R) antagonists plus hydrochlorothiazide (HCT). Methods: ABPM was performed at baseline and after 3 months of combination therapy in 158 outpatients with stage 1 or 2 hypertension who were randomized to add canrenone (50 or 100 mg) to the pre-existing therapy with ACE inhibitors or AT1R antagonists plus HCT. Twenty-four-hour systolic and diastolic BPs were considered normalized when the values were,130 and,80 mmHg, respectively. Results: The addition of canrenone was associated with a reduction in systolic and diastolic BPs (24 h and daytime and nighttime; P,0.001), mean arterial pressures (P,0.001), and pulse pressures (P,0.01). The \uce\u94 24 h systolic/diastolic BPs were -13.5\uc2\ub111.2/-8\uc2\ub18 mmHg and -16.1\uc2\ub113.5/-11.2\uc2\ub18.3 mmHg (50 and 100 mg/day, respectively). In the 50 mg arm, the 24 h systolic and diastolic BPs were normalized in 67.5% and 74% of the patients, respectively, and in 61.6% and 68.5% of the patients in the 100 mg arm, respectively (P,0.05; P= not significant for 50 vs 100 mg). The percentage of patients whose nocturnal decrease was.10% with respect to diurnal values did not change during combination therapy. Conclusion: Canrenone addition to ACE inhibitors or AT1R antagonists plus HCT was associated with a significant reduction of 24 h BP and to an increased number of patients meeting 24 h ABPM targets in a clinical setting of uncontrolled stage 1 or 2 hypertension