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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-lynn-garst-md

Asymmetric refractive error can lead to arteria volaris indicis radialis trandate 100 mg mastercard (anisometropic) amblyopia heart attack and vine discount 100 mg trandate with amex, which is detected only by assessing visual acuity blood pressure of 120/80 generic 100 mg trandate overnight delivery. Anterior & Posterior Segment Examination Further examination needs to blood pressure chart different ages buy trandate 100 mg with visa be tailored to each child’s age and ability to cooperate. It is generally easier in neonates and babies than in young children because they can be restrained easily by being wrapped in a blanket, and examination is often easily accomplished by allowing the infant to feed or nurse during the examination. Anterior segment examination in the young child may rely on the use of hand light and loupe, but slitlamp examination is often possible in babies with the cooperation of the mother and in young children with appropriate encouragement. Measurement of intraocular pressure and gonioscopy frequently necessitate examination under anesthesia. The macula has a bright “mother-of-pearl” appearance with a suggestion of elevation, which is more pronounced in heavily pigmented infants. At 3–4 months of age, the macula becomes slightly concave and the foveal light reflection appears. The peripheral 807 fundus in the infant is gray, in contrast to the orange-red fundus of the adult. In white infants, the pigmentation is more pronounced near the posterior pole and gradually fades at the periphery to almost white, which should not be confused with retinoblastoma. In more heavily pigmented infants, a gray-blue sheen is seen throughout the periphery. During the next several months, pigment continues to be deposited in the retina, and usually at about 2 years of age, the adult color is evident. Congenital Abnormalities of the Globe Failure of formation of the optic vesicle results in anophthalmos. Failure of optic vesicle/fissure closure produces colobomas of the iris, retina, and/or choroid. Abnormally small eyes can be divided into nanophthalmos, in which function is normal, and microphthalmos, in which function is abnormal and there may be other ocular abnormalities such as cataract, coloboma, or congenital cyst. Lid Abnormalities Congenital ptosis is commonly due to dystrophy of the levator muscle of the upper lid (see Chapter 4). Severe ptosis can lead to unilateral astigmatism or visual deprivation, and thus cause amblyopia. Palpebral coloboma is a cleft of either the upper or lower eyelid due to incomplete fusion of fetal maxillary processes. Congenital eyelid colobomas are commonly seen in association with craniofacial disorders such as Goldenhar’s syndrome. Megalocornea is an enlarged cornea with normal clarity and function, usually transmitted as an X-linked recessive trait and an isolated anomaly. Iris & Pupillary Defects Displacement of the pupil (corectopia) is usually upward and outward. It may be associated with ectopic lens, when it is usually bilateral, congenital glaucoma, or microcornea. Coloboma of the iris indicates incomplete closure of the fetal ocular cleft and usually occurs inferiorly and nasally. It may be associated with coloboma of the lens, choroid, and optic nerve, and involvement of these structures can be associated with profound reduction of vision. Aniridia (absence of the iris) is a rare abnormality, frequently associated with secondary glaucoma (see Chapter 11) and usually due to an autosomal dominant hereditary pattern. There is a significant association with Wilms’ tumor for which the risk can be determined by genetic testing, thus identifying the children who need to undergo screening by renal ultrasound every 3 months until age 8. Abnormalities in color include albinism, due to the absence of normal pigmentation of the ocular structures and frequently associated with poor visual acuity and nystagmus; and heterochromia, which is a difference in color in the two eyes that may be a primary developmental defect with no functional loss, due to congenital Horner’s syndrome or secondary to an inflammatory process. Lens Abnormalities the lens abnormalities most frequently noted are cataracts (see Chapter 8). Any lens opacity that is present at birth is a congenital cataract, regardless of whether or not it interferes with visual acuity. Maternal rubella during the first trimester of pregnancy is a common cause in emerging countries. Other congenital cataracts have a hereditary background, with autosomal dominant transmission being the most common in developed countries. The innermost fetal nucleus of the lens forms early in embryonic life and is surrounded by the embryonic nucleus. If a congenital cataract is too small to occlude the pupil, adequate visual acuity is attained by viewing around it. If the pupil is occluded, normal sight does not develop and visual deprivation may lead to nystagmus and profound irreversible amblyopia. Good visual results have been reported with both unilateral and bilateral cataracts treated by early surgery with prompt correction of aphakia and amblyopia therapy. Aphakic correction is done by using extended-wear contact lenses with the power changed frequently to maintain optimal correction as the globe grows and the refractive status changes or by implantation of an intraocular lens, but determining the appropriate power is difficult. Whether this can be dealt with adequately is the major determinant in deciding whether early surgery for monocular congenital cataract is justified. In the case of bilateral congenital cataracts, the time interval between operating on the two eyes must be as short as possible if amblyopia in the second eye is to be avoided. If early surgery is to be undertaken for congenital cataracts, it is best done within the first 2 months of life, and thus prompt referral to an ophthalmologist is essential. Developmental Anomalies of the Anterior Segment Failure of migration or subsequent development of neural crest cells produces abnormalities involving the anterior chamber angle, iris, cornea, and lens. Glaucoma is a major clinical problem that often requires surgical intervention, as good control 810 of intraocular pressure is required before considering corneal transplantation. Congenital Glaucoma Congenital glaucoma (see Chapter 11) may occur alone or in association with many other congenital lesions. Early diagnosis and treatment are essential to preserve useful vision and prevent permanent blindness. Early signs are corneal haze or opacity, increased corneal diameter, and increased intraocular pressure. Since in childhood the outer coats of the eyeball are not rigid, the increased intraocular pressure expands the cornea and sclera, producing an eye that is larger than normal (buphthalmos). The major differential diagnoses are forceps injuries at birth, developmental anomalies of the cornea or anterior segment, and mucopolysaccharidoses such as Hurler’s syndrome, of which none produce enlargement of the globe. Vitreous Abnormalities In premature infants, remnants of the tunica vasculosa lentis are frequently visible, in front of and/or behind the lens. Usually they have regressed by term, but rarely, they remain permanently and appear as a complete or partial “cobweb” in the pupil. At other times, remnants of the primitive hyaloid system fail to absorb completely, leaving either a cone on the optic disk that projects into the vitreous (Bergmeister’s papilla) or a gliotic tuft on the posterior lens capsule (Mittendorf’s dot). Persistent hyperplastic primary vitreous is an important cause of leukocoria that must be differentiated from retinoblastoma, congenital cataract, and retinopathy of prematurity. Posterior polar chorioretinal scarring is a feature of toxoplasmosis and other maternally acquired intrauterine infections. They are usually benign, such as minor abnormalities of the retinal vessels at the nerve head and tilted disks due to an oblique entrance of the nerve into the globe, but they may be associated with severe visual loss in the case of optic nerve hypoplasia or the rare central coloboma of the disk (morning glory syndrome) (see Chapter 14). Optic nerve hypoplasia is a nonprogressive congenital abnormality of one or both optic nerves in which the number of axons in the involved nerve is reduced. Previously regarded as rare, it is now recognized to be a major cause of visual loss in children. The degree of visual impairment varies from normal acuity with a wide variety of visual field defects to no perception of light. Clinical diagnosis is hampered by the difficulties of examining young children and the subtlety of the clinical signs. In more marked cases, the optic disk is obviously small and the circumpapillary halo of the normal-sized scleral canal produces the characteristic “double ring sign. Optic nerve hypoplasia is frequently associated with midline deformities, including absence of the septum pellucidum, agenesis of the corpus callosum, dysplasia of the third ventricle, pituitary and hypothalamic dysfunction, and midline facial abnormalities. Jaundice and hypoglycemia in the neonatal period and growth retardation, hypothyroidism, and diabetes insipidus during childhood are important consequences. More severe intracranial abnormalities such as anencephaly and porencephaly also occur.

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Progression to atrial flutter treatment order 100 mg trandate with amex liver toxicity is exceedingly rare and is likely due to arrhythmia heart episode buy generic trandate 100 mg on-line idiosyncratic or immunoallergic reactions blood pressure good range cheap trandate 100 mg online. The presence of chronic liver disease other than cirrhosis is not a contraindication for statin use arrhythmia jokes order trandate 100 mg on line. Check creatine kinase only if patient has symptoms of myopathy, an extremely rare side effect. As part of our improvement process, the Kaiser Permanente Washington guideline team is working towards updating our clinical guidelines every 2–3 years. To achieve this goal, we are adapting evidence-based recommendations from high-quality external guidelines, if available and appropriate. The external guidelines must meet several quality standards to be considered for adaptation. In addition to identifying the recently published guidelines that meet the above standards, a literature search was conducted to identify studies relevant to the key questions that are not addressed by the external guidelines. Fasting Is Not Routinely Required for Determination of a Lipid Profile: Clinical and Laboratory Implications Including Flagging at Desirable Concentration Cutpoints (Nordestgaard 2016) 2016 U. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. November 2016 2014 Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U. Cardiovascular disease: risk assessment and reduction, including lipid modification. This may not be optimal if the risk score is used for other purposes, such as the use of aspirin for primary prevention (Ridker 2016). There have been no studies to date that examine the predictive value of lipids measured in the fasting and nonfasting states in the same individual. There were, however, a statistically significant higher rate of injection site reactions and a statistically insignificant higher rate of adjudicated cases of new-onset diabetes in the evolocumab group. This might be due to chance as the study was not powered to detect a difference in mortality, but the early termination of the study does not allow examining the long-term risks or benefits of evolocumab. Evolocumab was tested against a placebo and not against a statin-plus-ezetimibe combination therapy, which would be the appropriate comparator. The elderly patients were analyzed as one group with no categorization or subanalyses according to age. The authors performed an exploratory secondary analysis to examine modification of the treatment effect by frailty status, which was a specified outcome in the trial protocol. The results of the analysis stratified by baseline frailty status showed higher event rates with increasing frailty in both treatment groups. However, within each frailty stratum, absolute event rates were lower for the intensive treatment group. Key question 6 What is the safety and tolerability of the long-term use of high-intensity statins. The association appears to be stronger with atorvastatin 80 mg and rosuvastatin compared to lower-intensity atorvastatin and other statins used. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin. Overall, the systematic reviews included 11 major aspirin primary prevention trials (N=118,445 participants). Aspirin dose ranged between the trials from 50 to 325mg in all but one; eight trials used a dose of 100 mg/day. Subgroup analysis based on age, sex, and diabetes status suggests that older age groups have greater benefits than younger ages, and that there was insufficient evidence to determine any sex difference. The estimates showed that the benefits were greatest with initiating aspirin at 50–59 years and continuing it unless contraindicated by adverse bleeding events. The relative risk reduction was similar across age, sex, race/ethnicity, lipid level, and other risk factors. Trials that stratified participants according to a baseline global cardiovascular risk score showed similar risk reduction estimates in participants at a higher versus lower risk. The task force evidence report estimated that 244 individuals would need to take a statin daily to prevent one death from any cause in 5 years. The review suggested that statins were not associated with increased risk of withdrawal due to adverse events, serious adverse events, myalgia, cancer, or liver-related harms compared to controls. The pooled analysis showed a higher but statistically insignificant risk of diabetes with statins. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U. Statin Use for the Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Risk of hospitalized rhabdomyolysis associated with lipid-lowering drugs in a real-world clinical setting. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Use of high potency statins and rates of admission for acute kidney injury: multicenter, retrospective observational analysis of administrative databases. Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for management of dyslipidemia and prevention of cardiovascular disease. Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Safety Profile of Atorvastatin 80 mg: A Meta-Analysis of 17 Randomized Controlled Trials in 21,910 Participants. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents Cardiovascular Disease Risk. Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations. Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Wanner C, Krane V, Marz W, et al for the German Diabetes and Dialysis Study Investigators. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Floaters are • Floaters (mobile blurry shadows that obscure the vision) most bothersome when near the • Flashes (streaks of light, usually at the side of the vision) center of vision and less annoying these symptoms usually become less intense over several weeks. Clear vitreous fuid flls hole, the fashes and foaters may the space between the condensed be accompanied by decreased vitreous gel and the retina. These conditions can lead to further complications, such as retinal detachment or epiretinal membrane, which can result in permanent vision loss. When light enters the eye, it passes through the iris to the retina Diagnostic Testing: Posterior vitreous detachment is usually diagnosed with where images are focused and a dilated eye examination. However, if the vitreous gel is very clear, it may be converted to electrical impulses that continued next page are carried by the optic nerve to the brain resulting in sight. Once surgery is complete, a gas bubble or silicone oil may be injected into the vitreous gel to help hold the retina in position. Drop Time Action Chloramphenicol One drop, Antibiotic four times a day for: 2 weeks / 3 weeks / 4 weeks (delete as applicable) Dexamethasone One drop, Anti (Maxidex) four times a day for: infammatory 2 weeks / 3 weeks / 4 weeks (delete as applicable) Cyclopentolate One drop, Enlarges pupil two times a day for: 2 weeks / 3 weeks / 4 weeks (delete as applicable) • When putting the eye drops into your eye do not allow the bottle tip to touch the eye. Holding the bottle on the bridge of your nose or on your forehead, squeeze one drop into the eye. Positioning after surgery • Keep your head either: Face down * Right cheek to pillow * Left cheek to pillow * Alternate cheeks to pillow for 5* / 14* days * delete as appropriate • Take a ten minute break from positioning every hour Page 4 Instructions after your operation • Try not to rub or touch the eye. If you are posturing after surgery often this swelling can get worse after the frst day and can affect the fellow eye. The regular use of pain killing tablets such as Paracetamol or Ibuprofen is recommended for the frst 3-4 days after surgery.

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The veins are darker and wider than their paired arteries (anatomically arterioles) blood pressure medication hctz purchase trandate 100 mg on line. The vessels are examined for color pulse pressure vs heart rate order trandate 100mg fast delivery, tortuosity pulse pressure sensor cheap trandate 100 mg with mastercard, and caliber blood pressure log printable discount 100 mg trandate mastercard, as well as for associated abnormalities, such as aneurysms, hemorrhages, or exudates. The green “red free” filter assists in the examination of the retinal vasculature and the subtle striations of the nerve fiber layer as they course toward the disk (see Chapter 14). To examine the retinal periphery, which is greatly enhanced by dilating the pupil, the patient is asked to look in the direction of the quadrant to be examined. Thus, the temporal retina of the right eye is seen when the patient looks to the right, while the superior retina is seen when the patient looks up. As the patient looks up, the superior retina rotates downward into the examiner’s line of vision. Since it requires wide pupillary dilation and is difficult to learn, this technique is used primarily by ophthalmologists. A bright adjustable light source attached to the headband is directed toward the patient’s eye. As with direct ophthalmoscopy, the patient is told to look in the direction of the quadrant being examined. A convex lens is hand-held several inches from the patient’s eye in precise orientation so as to simultaneously focus light onto the 94 retina and an image of the retina in midair between the patient and the examiner. Using the preset head-mounted ophthalmoscope lenses, the examiner can then “focus on” and visualize this midair image of the retina. Comparison of Indirect & Direct Ophthalmoscopy Indirect ophthalmoscopy is so called because one is viewing an “image” of the retina formed by a hand-held “condensing lens. Compared with the direct ophthalmoscope (15 magnification), indirect ophthalmoscopy provides a much wider field of view (Figure 2–16) with less overall magnification (approximately 3. Thus, it presents a wide panoramic fundus view from which specific areas can be selectively studied under higher magnification using either the direct ophthalmoscope or the slitlamp with special auxiliary lenses. Comparison of view within the same fundus using the indirect ophthalmoscope (A) and the direct ophthalmoscope (B). The field of view with the latter is approximately 10°, compared with approximately 37° using the indirect ophthalmoscope. One is the brighter light source that permits much better visualization through cloudy media. A second advantage is that by using both eyes, the examiner enjoys a stereoscopic view, allowing visualization of elevated masses or retinal detachment in three dimensions. Finally, indirect ophthalmoscopy can be used to examine the entire retina, even out to its extreme periphery, the ora serrata. Optical distortions caused by looking through the peripheral lens and cornea interfere very little with the indirect ophthalmoscopic examination compared with the direct ophthalmoscope. In addition, the adjunct technique of scleral depression 96 (Figure 2–17) can be used to enhance examination of the peripheral retina. A smooth, thin metal probe is used to gently indent the globe externally through the lids at a point just behind the corneoscleral junction (limbus). As this is done, the ora serrata and peripheral retina are pushed internally into the examiner’s line of view. By depressing around the entire circumference, the peripheral retina can be viewed in its entirety. Diagrammatic representation of indirect ophthalmoscopy with scleral depression to examine the far peripheral retina. Indentation of the sclera through the lids brings the peripheral edge of the retina into visual alignment with the dilated pupil, the hand-held condensing lens, and the head-mounted ophthalmoscope. Because of all of these advantages, indirect ophthalmoscopy is used preoperatively and intraoperatively in the evaluation and surgical repair of retinal detachments. A disadvantage of indirect ophthalmoscopy, which also applies to the Volk-style of lenses for examination of the posterior segment with a slitlamp, is that it provides an inverted image of the fundus, which requires a mental adjustment on the examiner’s part. A general medical examination would often include many of these same testing techniques. Assessment of pupils, extraocular movements, and confrontation visual fields is part of any complete neurologic assessment. Direct ophthalmoscopy should always be performed to assess the appearance of the disk and retinal vessels. Separately testing the visual acuity of each eye (particularly with children) may uncover either a refractive or a medical cause of decreased vision. The three most common preventable causes of permanent visual loss in developed nations are amblyopia, diabetic retinopathy, and glaucoma. All can remain asymptomatic while the opportunity for preventive measures is gradually lost. During this time, the pediatrician or general medical practitioner may be the only physician the patient visits. By testing children for visual acuity in each eye, examining and referring diabetics for regular dilated fundus ophthalmoscopy, and referring patients with suspicious disks to the ophthalmologist, the nonophthalmologist may indeed be the one who truly “saves” that patient’s eyesight. This represents both an important opportunity and responsibility for every primary care physician. They will be grouped according to the function or anatomic area of primary interest. Usually 98 performed separately for each eye, it assesses the combined function of the retina, the optic nerve, and the intracranial visual pathway. It is used clinically to detect or monitor field loss due to disease at any of these locations. Damage to specific parts of the neurologic visual pathway may produce characteristic patterns of change on serial field examinations. Measurement of degrees of arc remains constant regardless of the distance from the eye that the field is checked. The sensitivity of vision is greatest in the center of the field (corresponding to the foveola) and least in the periphery. Perimetry relies on subjective patient responses, and the results will depend on the patient’s psychomotor as well as visual status. The Principles of Testing Although perimetry is subjective, the methods discussed below have been standardized to maximize reproducibility and permit subsequent comparison. Perimetry requires (1) steady fixation and attention by the patient; (2) a set distance from the eye to the screen or testing device; (3) a uniform, standard amount of background illumination and contrast; (4) test targets of standard size and brightness; and (5) a universal protocol for administration of the test by examiners. As the patient’s eye fixates on a central target, test objects are randomly presented at different locations throughout the field. If they are seen, the patient responds either verbally or with a hand-held signaling device. Varying the target’s size or brightness permits quantification of visual sensitivity of different areas in the field. The smaller or dimmer the target seen, the higher is the sensitivity of that location. There are two basic methods of target presentation—static and kinetic—that can be used alone or in combination during an examination. In static perimetry, different locations throughout the field are tested one at a time. A dim stimulus, usually a white light, is first presented at a particular location. If it is not seen, the size or intensity is incrementally increased until it is just large enough or bright enough to be detected. This sequence is repeated at a series of other locations, so that the sensitivity of multiple points in the field can be evaluated and combined to form a profile of the visual field. The object is slowly moved toward the center from a peripheral area until it is first spotted. By moving the same object inward from multiple directions, a boundary called an “isopter” can be mapped out that is specific for that target. The isopter outlines the area within which the target can be seen and beyond which it cannot be seen. By repeating the test using objects of different size or brightness, multiple isopters can then be plotted for a given eye. Methods of Perimetry the tangent screen is the simplest apparatus for standardized perimetry. It uses different-sized pins on a black wand presented against a black screen and is used primarily to test the central 30° of visual field.

The role of cryoabla limitation is the ability to blood pressure kit cvs discount 100 mg trandate otc perform and confirm that lesions are tion will continue to blood pressure chart newborn buy generic trandate 100mg online be endocardial even with new variable length transmural hypertension uncontrolled icd 9 code discount trandate 100 mg on line. Lesions are formed by local tissue technology for laser ablation is the fiberoptic delivery devices heating prehypertension due to anxiety buy trandate 100mg cheap. They must be shown to ates a unidirectional linear ablation of 2 cm to 5 cm with a be safe, reliable and effective with no added morbidity and flexible configuration. The mechanism is wavelength depend mortality, and should be satisfactory for ablation of paroxys ent by creating harmonic oscillation in water molecules with mal, persistent or intermittent chronic atrial fibrillation. The wavelength technologies should be optimal for either nonbeating or beat chosen for good penetration is a 980 nm diode laser. Laser ablation can be applied to the epicardium, as well as endocardium Special surgical considerations because transmural lesions pass even through epicardial fat. Microwave ablation: this is considered to cause effective and Mitral regurgitation with posterior annular calcification is best controlled heating of large tissue volumes without causing char managed by excision of the bar of calcium and reconstruction ring of either the endocardial or epicardial surfaces (282-284). The valve is repaired or replaced depending on the frictional heating by induction of dielectric ionic movements. The same technique is used the method spares the endocardial surface, and local tissue for atrioventricular groove repair. The deeper penetration with microwave ment with preservation of the posterior leaflet. Ultrasound ablation: this technology uses an ultrasound the mechanism of mitral regurgitation in ischemic disease transducer to deliver mechanical pressure waves at high fre is often extremely difficult to precisely determine preopera quency. The tissue destruction is thermal and lesion depth cor tively and intraoperatively. Annuloplasty alone emitted from the transducer and resulting wave travels through may be adequate over time for control of ischemic mitral regur tissue causing compression, refraction and particle movement, gitation in some patients. There is the potential that ultrasound may both ischemic mitral regurgitation is best managed with techniques ablate and image, thus providing confirmation that the lesion for both abnormalities and recurrence may not be different is transmural. The course of mitral stenosis Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy. Newer advances in the diagnosis and management of patients with valvular heart disease: Executive treatment of mitral stenosis. Percutaneous Heart Association Task Force on Practice Guidelines (Committee on mitral balloon valvotomy for recurrent mitral stenosis after surgical Management of Patients with Valvular Heart Disease). Predictors of long-term application of transvenous mitral commissurotomy by a new balloon outcome after percutaneous balloon mitral valvuloplasty. Percutaneous balloon assessment of commissural calcium: A simple predictor of outcome valvuloplasty compared with open surgical commissurotomy for after percutaneous mitral balloon valvotomy. Catheter balloon commissurotomy long-term results of mitral valve repair in 254 young patients with for mitral stenosis: Complications and results. Catheter balloon valvuloplasty for severe calcific of chordal preservation versus chordal resection in mitral valve aortic stenosis: A limited role. Comparison of open versus surgical closed and open mitral commissurotomy: Seven-year mitral commissurotomy with mitral valve replacement with or follow-up results of a randomized trial. Mid-term results of mitral valve from the National Heart, Lung, and Blood Institute Balloon replacement combined with chordae tendineae replacement in Valvuloplasty Registry. Prediction of outcome after percutaneous mitral commissurotomy: Six year results of the valve replacement for rheumatic mitral regurgitation in the era of N. Functional results 5 years valvotomy in reducing the severity of associated tricuspid valve after successful percutaneous mitral commissurotomy in a series of regurgitation. A predictive model on a regurgitant lesions of the aortic or mitral valve in advanced left series of 1514 patients. Mechanics of left ventricular contraction in chronic severe mitral Circulation 1992;85:448-61. Cathet Cardiovasc Diagn Determinants of pulmonary hypertension in left ventricular 1998;43:42. Echocardiographic results of balloon valvotomy in mitral stenosis with versus without prediction of left ventricular function after correction of mitral mitral regurgitation. J Am Coll Cardiol ejection fraction on postoperative left ventricular remodeling after 1996;27:1225-31. Am Heart J follow-up of patients undergoing percutaneous mitral balloon 1996;131:974-81. American Society and long-term outcome of percutaneous mitral valvotomy in of Echocardiography. J Thorac preoperative symptoms on survival after surgical correction of Cardiovasc Surg 1998;115:381-8. Cardiol Rev Echocardiographic predictors of survival after surgery for mitral 2001;9:137-43. Surgical treatment of angiographic predictors of operative mortality in patients undergoing asymptomatic and mildly symptomatic mitral regurgitation. Mitral regurgitation hemodynamic effects of the preserved papillary muscles during mitral due to ruptured chordae tendineae: Early and late results of valve valve replacement. Late outcomes of postoperative ventricular performance following valve replacement mitral valve repair for floppy valves: Implications for asymptomatic for chronic mitral regurgitation. Mitral valve replacement with and without chordal preservation in Current concepts of mitral valve reconstruction for mitral patients with chronic mitral regurgitation: Mechanisms for insufficiency. Valve repair improves the outcome of surgery for mitral invasive and conventional mitral valve surgery using premeasured regurgitation. Preoperative left mitral valve reconstruction with mitral valve replacement: ventricular peak systolic pressure/end-systolic volume ratio and Intermediate-term results. Lorusso R, Borghetti V, Totaro P, Parrinello G, Coletti G, mitral valve reconstruction with Carpentier techniques in 148 Minzioni G. Ann Thorac Surg Mechanism of outflow tract obstruction causing failed mitral valve 2001;71:1464-70. Curr Opin without chordal replacement with expanded polytetrafluoroethylene Cardiol 2002;17:179-82. New York: on the surgical treatment of ischemic mitral regurgitation: Operative McGraw Hill, 1997:991-1024. Mitral regurgitation: Basic pathophysiologic J Thorac Cardiovasc Surg 1996;112:287-92. Ischemic mitral regurgitation: Long-term outcome and prognostic Ann Thorac Surg 1999;68:820-4. Leaflet restriction versus coapting force: In vitro the posterior tricuspid leaflet and chordae: Technique and results. Mitral stenosis after mitral valve repair for strategy in mitral valve regurgitation based on echocardiography. Ann Thorac Surg mitral regurgitation due to severe myxomatous disease: Surgical 1998;66:1277-81. The edge-to-edge technique: Intraoperative transesophageal Doppler color flow imaging used to A simplified method to correct mitral insufficiency. Eur J guide patient selection and operative treatment of ischemic mitral Cardiothorac Surg 1998;13:240-6. Effects of valve surgery on left ventricular contractile valve repair for mitral valve prolapse. J Thorac Determinants of the degree of functional mitral regurgitation in Cardiovasc Surg 1991;101:495-501. Incidence, clinical detection, and prognostic the restricted posterior mitral leaflet motion in chronic ischemic implications. Is repair preferable the mitral valvular-ventricular complex in chronic ischemic mitral to replacement for ischemic mitral regurgitation Mitral valve reconstruction than 2,000 patients after coronary artery bypass grafting. Am J and replacement for ischemic mitral insufficiency: Seven years’ Cardiol 1986;58:195-202. Ischemic mitral regurgitation redux – to repair or to outcomes in patients with moderate ischemic mitral regurgitation replace

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