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Features which indicate a low chance of successful repair These include: • Rheum atic valvular disease • Thickened valve leaflets • M ultiple m echanism s of valve dysfunction • Extensive prolapse of both leaflets • Com m issural regurgitation • Annular calcification • Dissection of valve leaflets com plicating endocarditis buy 5 ml betoptic amex symptoms quit smoking. In general all valves that can be repaired should be cheap betoptic 5ml online medicine reviews, although som e patients m ay opt for valve replacem ent to avoid the (sm all) risk of needing further surgery due to failure of the repair 5ml betoptic with visa medications list form. Because of the low operative risk, absence of the need for anticoagulation and avoidance of the risks of prosthetic valve endocarditis follow ing valve repair, a further group of patients m ay be offered valve repair at an early stage of their disease w here, on the balance of risks, valve replacem ent w ould not yet be justified. Long-term results of m itral valve repair for m yxom atous disease w ith and w ithout chordal replacem ent w ith expanded polytetrafluoroethylene sutures. Superiority of m itral valve repair in surgery for degenerative m itral regurgitation. Cost im plications of m itral valve replacem ent versus repair in m itral regurgitation. The Ross procedure, or pulm onary autograft procedure, w as introduced by M r Donald Ross in 1967. The principle is to replace the diseased aortic valve w ith the autologous pulm onary valve. The pulm onary autograft is placed in the aortic position as a root replacem ent w ith interrupted sutures and the coronary arteries are reim planted. Great care m ust be taken during harvesting of the pulm onary root because of the close proxim ity of the first septal branch of the left anterior descending coronary artery. A hom ograft (preferably pulm onary) is used to restore continuity betw een the right ventricular outflow tract and the pulm onary artery. The Ross procedure is the preferred option for aortic valve replacem ent in the grow ing child due to the grow th potential of the im planted autograft. It should also be considered in any patient w here anticoagulation is com pletely or relatively contraindicated. Another possible indication is active endo- carditis because of its “curative” potential. The likelihood of recurrence of endocarditis and of perivalvar leak is low er in patients after a Ross procedure, com pared to m echanical valve replacem ent. The haem odynam ic perform ance of the autograft valve is superior to m echanical valves, w ith m uch low er transvalvar gradients and better regression in ventricular size and hypertrophy in the m id- term. Anticoagulation w ith w arfarin (a m ajor contributor to m echanical valve-related m orbidity and m ortality) is not required 100 Questions in Cardiology 93 after the Ross procedure. M ore than 90% of all patients are free of any com plications (death, degeneration, valve failure, endo- carditis) after ten years. It is the m ethod of choice for aortic valve replacem ent in the young, w ith excellent early postoperative haem odynam ic results and good m id-term results. Tom Treasure The risk of stroke after valve replacem ent is higher in m echanical than tissue valves (in spite of best efforts at anticoagulation) and is higher after m itral than aortic valve replacem ent. I quote from our ow n prospective random ised trial (in press) of St Jude and Starr-Edw ards valves so the inform ation w as deliberately sought and the follow up w as very near com plete. The annual incident rate of com plications (per 100 patient years) is show n in Table 45. Seamus Cullen Indications for surgical closure of a ventricular septal defect in childhood include congestive cardiac failure, pulm onary hyper- tension, severe aortic insufficiency and prior bacterial endo- carditis. It is unlikely that a significant ventricular septal defect w ill be m issed in childhood and therefore ventricular septal defects seen in adulthood tend to be sm all and isolated. The natural history of sm all congenital ventricular septal defects w as thought to be favourable but longer follow up has dem onstrated that 25% of adults w ith sm all ventricular septal defects m ay suffer from com plications over longer periods of tim e. The com plications docum ented w ere: infective endocarditis, aortic regurgitation, arrhythm ias and m yocardial dysfunction. W hilst closure of a ventricular septal defect protects against infective endocarditis, there are no data to suggest a protective effect against the developm ent of late arrhythm ias, sudden death or ventricular dysfunction. The risk of bacterial endocarditis in patients w ith a ventricular septal defect is low (14. Prior or recurrent endocarditis on a ventricular septal defect w ould be deem ed an indication for surgical closure even though the risks of endocarditis are low. W hilst the m ajority of congenital ventricular septal defects are in the perim em branous or trabecular septum , a sm all percentage are found in the doubly com m itted subarterial position. This sm all sub group m ay be com plicated by aortic valve cusp prolapse into the defect w ith developm ent of subsequent aortic regurgitation w hich m ay be progressive and severe. The detection of aortic regurgitation in such a defect is considered an indication for surgical closure in m ost centres. The m ortality for surgical closure of a post-infarction ventricular septal defect m ay be up to 50%. Cardiogenic shock is exacerbated by the acute left ventricular volum e load from the shunt through the ventricular septal defect. There is a sm all but 96 100 Questions in Cardiology grow ing experience of transcatheter device closure of such defects w hich avoids the need for cardiopulm onary bypass. In sum m ary, the indications for closure of a ventricular septal defect in an adult include the presence of a significant left to right shunt in the absence of pulm onary vascular disease, progressive aortic valve disease, recurrent endocarditis and acute post- infarction rupture in patients w ith haem odynam ic com prom ise. Currently there is no evidence that closure of a sm all ventricular septal defect w ould prevent the occurrence of arrhythm ias and ventricular dysfunction in the long term. The presence of established pulm onary vascular disease (Eisenm enger syndrom e) is a contraindication to surgical intervention. Transcatheter closure of ventricular septal defect: a nonsurgical approach to the care of the patient w ith acute ventricular septal rupture. Pulm onary vascular disease is a late com plication, rarely seen before the fourth or fifth decade. The presence of tricuspid regurgitation perm its accurate assessm ent of right heart pressures, otherw ise right heart catheterisation is required. Indications for closure include sym ptom s (exercise intolerance, arrhythm ias), right heart volum e overload on echocardiography, the presence of a significant shunt (>2:1) or cryptogenic cerebro- vascular events, especially associated w ith aneurysm of the oval foram en and right to left shunting dem onstrated on contrast echocardiography during a Valsalva m anoeuvre. The results of surgery are excellent w ith little or no operative m ortality in the absence of risk factors, e. How ever, it requires a surgical scar, cardiopulm onary bypass and hospital stay of approxim ately 3–5 days. There is a sm all but definite risk of pericardial effusion w ith the potential for cardiac tam ponade follow ing closure of an atrial septal defect. Their efficacy and ease of deploym ent have been dem onstrated although long term data are lacking. Our policy is to perform a transoesophageal echocardiogram under 98 100 Questions in Cardiology general anaesthesia w ith plans to proceed to device closure if the defect is suitable. Transoesophageal echocardiography is invaluable in guiding correct placem ent of the exposure. Heparin and antibiotics are adm inistered during the procedure and intravenous heparinisation is used for the first 24 hours follow ing deploym ent. Aspirin is adm inistered for six w eeks and then stopped, by w hich tim e the device w ill be covered by endothelial tissue. M echanical problem s seen w ith som e earlier devices have not been encountered w ith the latest range.
Thus buy betoptic 5ml mastercard medications kidney stones, we conclude that increasing the volume of a message beyond soft tends to increase persuasiveness scores in the population order discount betoptic on-line treatment modalities, but this increase occurs for females with medium volume and for males with loud volume discount betoptic 5ml line symptoms youre pregnant. Further, we conclude that dif- ferences in persuasiveness scores occur between males and females in the population but only if the volume of the message is loud. Recall that the greater the effect size, the more important the effect is in determin- ing participants’ scores. Because each of the above has about the same size, they are all of equal importance in understanding differences in persuasiveness scores in this experiment. Such a small 2 indicates that this relationship is very inconsistent, so it is not useful or informative. In essence, if eta squared indicates that an effect was not a big deal in the experiment, then we should not make a big deal out of it when interpreting the experiment. The one exception to the rule of always focusing on the significant interaction is when it has a very small effect size. In such cases, you may focus your interpretation on any significant main effects that had a more substantial effect size. Dividing each mean square between groups by the mean square within groups produces each Fobt. Find Fcrit: For each factor or interaction, if Fobt is larger than Fcrit, then there is a significant difference between two or more means from the factor or interaction. For each significant main effect: Perform post hoc tests when the factor has more than two levels. For a significant interaction effect: Perform post hoc tests by making only uncon- founded comparisons. Graph the effect by labeling the X axis with one factor and using a separate line to connect the cell means from each level of the other factor. Compute eta squared: Describe the proportion of variance in dependent scores accounted for by each significant main effect or interaction. Compute the confidence interval: This can be done for the represented by the mean in any relevant level or cell. Interpret the experiment: Based on the significant main and/or interaction effects and their values of 2, develop an overall conclusion regarding the relationships formed by the specific means from the cells and levels that differ significantly. Say that we added a third factor to the persuasiveness study—the sex of the speaker of the message. Therefore, unless you have a very good reason for including many factors in one study, it is best to limit yourself to two or, at most, three factors. You may not learn about many variables at once, but what you do learn you will understand. In a complete factorial design, all levels of one factor are combined with all levels of the other factor. The main effect means for a factor are obtained by collapsing across (combining the scores from) the levels of the other factor. A significant main effect indicates significant differences between the main effect means, indicating a relationship is produced when we manipulate one indepen- dent variable by itself. A significant two-way interaction effect indicates that the cell means differ signifi- cantly such that the relationship between one factor and the dependent scores depends on the level of the other factor that is present. Perform post hoc comparisons on each significant effect having more than two levels to determine which specific means differ significantly. Post hoc comparisons on the interaction are performed for unconfounded compar- isons only. The means from two cells are unconfounded if the cells differ along only one factor. An interaction is graphed by plotting cell means on Y and the levels of one factor on X. Then a separate line connects the data points for the cell means from each level of the other factor. Usually, con- clusions about the main effects are contradicted when the interaction is significant. Eta squared describes the effect size of each significant main effect and interaction. Identify the following terms: (a) two-way design, (b) complete factorial, and (c) cell. One more time, using a factorial design, we study the effect of changing the dose for one, two, three, or four smart pills and test participants who are 10-, 15-, and 20-years old. For each experiment, compute the main effect means and decide whether there appears to be an effect of A, B, and/or A 3 B. In question 11, if you label the X axis with factor A and graph the cell means, what pattern will we see for each interaction? A 2 3 2 design studies participants’ frustration levels when solving problems as a function of the difficulty of the problem and whether they are math or logic prob- lems. The results are that logic problems produce significantly more frustration than math problems, greater difficulty leads to significantly greater frustration, and difficult math problems produce significantly greater frustration than difficult logic problems, but the reverse is true for easy problems. In question 14, say instead that the researcher found no difference between math and logic problems, frustration significantly increases with greater difficulty, and this is true for both math and logic problems. In an experiment, you measure the popularity of two brands of soft drinks (factor A), and for each brand you test males and females (factor B). The following table shows the main effect and cell means from the study: Factor A Level A1: Level A2: Brand X Brand Y Level B1: 14 23 Males Factor B Level B2: 25 12 Females Application Questions 347 (a) Describe the graph of the interaction when factor A is on the X axis. A researcher examines performance on an eye–hand coordination task as a func- tion of three levels of reward and three levels of practice, obtaining the following cell means: Reward Low Medium High Low Practice Medium High 15 15 15 (a) What are the main effect means for reward, and what do they appear to indicate about this factor? A study compared the performance of males and females tested by either a male or a female experimenter. Here are the data: Factor A: Participants Level A1: Level A2: Males Females 6 Level B1: 11 14 Male Experimenter 10 16 9 Factor B: Experimenter 8 Level B2: 10 6 Female Experimenter 7 10 7 (a) Using 5. You conduct an experiment involving two levels of self-confidence (A1 is low and A2 is high) and examine participants’ anxiety scores after they speak to one of four groups of differing sizes (B1 through B4 represent speaking to a small, medium, large, or extremely large group, respectively). You compute the follow- ing sums of squares (n 5 4 and N 5 32): Source Sum of Squares df Mean Square F Between Factor A 8. You measure the dependent variable of participants’ relaxation level as a function of whether they meditate before being tested, and whether they were shown a film containing a low, medium, or high amount of fantasy. Perform all appropriate sta- tistical analyses, and determine what you should conclude about this study. To select a statistical procedure for an experiment, what must you ask about how participants are selected? For the following, identify the factor(s), the primary inferential procedure to perform and the key findings we’d look for.
In addition betoptic 5 ml cheap symptoms night sweats, use of a beta blocker to reduce cardiac contractility and heart rate is recommended buy discount betoptic 5 ml line symptoms kidney failure dogs. Surgery involves excision of the intimal flap discount betoptic american express symptoms ms women, removal of the intramural hematoma, and placement of a graft. In some cases, replacement of the entire aortic root and aortic valve is necessary when the aortic valve is involved. With prompt surgical intervention, mortality from ascending aortic dis- section is ~15–25%. The differential diagnosis includes pulmonary vascular disease, restrictive cardiomyopathy, constrictive pericarditis, cor pulmonale, and any cause of longstanding left-sided heart failure. Iron stud- ies are a component of the evaluation for hemochromatosis, and fat pad biopsy is a component of the evaluation for amyloidosis, both of which may cause restrictive cardio- myopathy. The tuberculin test is useful for ascertaining the presence of prior infection with Mycobacterium tuberculosis, which is associated with the development of constric- tive pericarditis. A coronary angiogram would not be helpful in a young patient with no physical signs or echocardiographic findings of left-sided heart failure. Hypercalcemia, by shortening the duration of re- polarization, abbreviates the total time from depolarization through repolarization. In this scenario, the hypercalce- mia is due to the rhabdomyolysis and renal failure. These patients with type 2 diabetes and an abnormal lipid profile have insulin resistance and a marked increase in cardiovascular risk. Elevated serum endothelin levels may contribute to hypertension, and elevated homocysteine levels have been suggested as a cardiovascular risk factor. Clinical Identification of the Metabolic Syndrome—Any Three Risk Factors Risk Factor Defining Level a Abdominal obesity b Men (waist circumference) >102 cm (>40 in. They should benefit from life-style changes, similarly to men with categorical in- creases in waist circumference. The presence of a widened pulse pressure and diastolic murmur heard best along the lower sternal border suggests aortic regurgitation. The figure shown below in panel C shows a typical bisfer- iens pulse that is characteristic of aortic regurgitation. With a bisferiens pulse, there are two distinct pulsations that can be palpated with systole. The initial pulse represents an exaggerated percussion wave reflecting the increased stroke volume that occurs in aortic regurgitation, with the second peak reflecting the tidal, or anacrotic, wave. A2, aortic component of the second heart sound; S1, first heart sound; S4, atrial sound. These features suggest fixed left ventricular outflow obstruc- tion, such as occurs with valvular aortic stenosis. Pulsus bisfe- riens with both percussion and tidal waves occurring during systole. This type of carotid pulse contour is most frequently ob- served in patients with hemodynamically significant aortic regur- gitation or combined aortic stenosis and regurgitation with dominant regurgitation. In hypertrophic obstructive cardiomyopathy, the pulse wave upstroke rises rapidly and the trough is followed by a smaller slowly rising positive pulse. A dicrotic pulse results from an accentuated dicrotic wave and tends to occur in patients with sepsis, severe heart failure, hypovolemic shock, cardiac tam- ponade, and aortic valve replacement. Of the other options, both mitral regurgitation and tricuspid regurgitation (choice E) would cause systolic and not diastolic murmurs. A hyperkinetic pulse may occur in these conditions, particularly if associated with fever or sepsis. Mitral steno- sis causes a diastolic murmur but is not a common lesion associated with infective endo- carditis, unless underlying valvular stenosis was present prior to acquiring the infection. Aortic stenosis is associated with pulsus parvus et tardus, with a delayed and prolonged carotid upstroke as shown here in panel B of the fig- ure. These patients often have distant heart sounds and on examination typically have pulsus para- doxus. Jugular veins are distended and typically show a prominent x descent and an ab- sent y descent, as opposed to patients with constrictive pericarditis. In addition, Kussmaul’s sign is absent in tamponade but present in constrictive pericarditis. Echocardiographic findings typically reveal right atrial collapse and right ven- tricular diastolic collapse. Cardiac catheterization will reveal equalization of diastolic pressures across the cardiac chambers. Therefore, the pulmonary capillary wedge pres- sure will be equal to the diastolic pulmonary arterial pressure, and this will be equal to the right atrial pressure. These catheterization findings are also present in a patient with constrictive pericarditis. When beta blockers are ineffective or poorly tolerated, calcium channel blockers are in- dicated for the treatment of stable angina. Adverse effects of the calcium channel block- ers include hypotension, conduction disturbances, and the propensity to exacerbate heart failure due to the negative inotropic effects. In general, verapamil should not be used in conjunction with beta blockers because of the combined effect on heart rate and contractility. Diltiazem should not be used in patients taking beta blockers with conduc- tion disturbances and a low ejection fraction. Immediate-release nifedipine and other short-acting dihydropyridines should be avoided due to the increased risk of precipitat- ing myocardial infarction. Amlodipine and other second-generation dihydropyridines dilate coronary arteries and decrease blood pressure. In conjunction with beta blockers, which slow heart rate and decrease contractility, amlodipine has a favorable effect in the treatment of angina. High-risk cardiac lesions include prosthetic heart valves, a history of bacterial endocarditis, complex cyanotic congenital heart disease, patent duc- tus arteriosus, coarctation of the aorta, and surgically constructed systemic portal shunts. Moderate-risk patients include those with congenital cardiac malformations other than high-risk or low-risk lesions, acquired aortic or mitral valve dysfunction, hypertrophic cardiomyopathy with asymmetric septal hypertrophy, and mitral valve prolapse with valve thickening or regurgitation. Her procedure is an esophageal dilation, which, like dental pro- cedures, calls for prophylaxis in the moderate- to high-risk groups. Generally, men older than 50 are at risk for this condition, and it classically presents with syncope in the setting of shaving, wearing a tight collar, or turning the head to one side. Diagnosis is suggested by carotid sinus mas- sage with prolonged (more than 3 s) asystole. Due to further vasospasm, cold water ingestion may exacerbate the patient’s symptoms. Many infectious, inflammatory, and inherited conditions have been associated with this finding, including syphilis, tubercu- losis, mycotic aneurysm, Takayasu’s arteritis, giant cell arteritis, rheumatoid arthritis, and the spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, Behçet’s disease). In addition, it can be seen with the genetic disorders Marfan’s syn- drome and Ehlers-Danlos syndrome.
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