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This is not surprising because in patients with concealed bypass tracts antegrade conduction proceeds over the rapidly conducting A-V node buy cheap kamagra effervescent 100mg online, thereby abbreviating that limb of the reentrant circuit generic kamagra effervescent 100mg overnight delivery. In fact generic 100 mg kamagra effervescent otc, enhanced A-V nodal conduction and reciprocating tachycardia using concealed bypass tracts should be considered in any individual with paroxysmal reciprocating tachycardias having cycle lengths ≤250 msec order kamagra effervescent pills in toronto. Patients with short P-R intervals that are due to either enhanced A-V nodal conduction or atrio-His bypass tracts may exhibit atrial flutter or fibrillation with a rapid ventricular response. These patients primarily present with atrial fibrillation or flutter and a rapid ventricular response, which may, in fact, induce ventricular fibrillation (Fig. They found the ventricular response to be directly related to the refractory period. Thus, the functional characteristics of the tissue responsible for A-V conduction is the main determinant of the ventricular response P. Of note, in the group of patients with enhanced A-V nodal conduction who demonstrate dual A-V nodal pathways, the ventricular response is slower. This is a result of the fact that block in the fast pathway frequently occurs with conduction over the slow pathway and repetitive concealment into the fast pathway once conduction proceeds over the slow pathway. A: Atrial flutter with 1:1 A-V conduction is present in a patient with an atrio-His bypass tract. B: 200 mg of lidocaine produced block in the bypass tract, resulting in 2:1 conduction down the normal pathway. Because most of the reciprocating tachycardias are due to A-V nodal reentry or reentry using a concealed A-V bypass tract, treatment should be the same as that for patients with normal P-R intervals with these arrhythmias. With the development of deflectable catheters and increased experience, radiofrequency ablation is the therapy of choice for most patients (see Chapter 14). Patients with atrio-His bypass tracts and atrial flutter and fibrillation with rapid ventricular responses require treatment with drugs that can suppress these bypass tracts and/or prevent the arrhythmia. In the case of atrial flutter (either as a primary arrhythmia or one created from atrial fibrillation by drugs) catheter ablation of flutter is possible and is highly successful (see Chapters 9 and 14). Catheter-delivered radiofrequency energy is the current method of choice to create A-V block (see Chapter 14). Accessory Pathways with Anterograde Decremental Conduction and Fasciculoventricular Pathways At the beginning of this chapter, we assigned all the variants of preexcitation syndromes pathophysiologic names as opposed to the eponyms formerly applied. Thus, fibers initially considered under the rubric “Mahaim” fibers are now recognized as atriofascicular, nodofascicular, nodoventricular, and fasciculoventricular bypass tracts. Nodoventricular bypass tracts were initially described by Mahaim and Benatt in 1937 as conducting tissue 148 extending from the A-V node to the ventricular myocardium. Pathologically, fibers have been described from the node to the ventricle and from the fascicle to the ventricle, usually in or adjacent to the septum. Subsequently 15 17 18 19 it was recognized that bypass tracts can arise in the A-V node and insert in the right bundle branch. Eventually it became clear that the majority of what were assumed to be antegradely conducting nodoventricular and nodofascicular bypass tracts were actually slowly conducting atrioventricular or 18 20 21 22 48 49 148 149 150 atriofascicular bypass tracts. In general if the ventricular insertion of these bypass tracts is in the ventricular myocardium, particularly, near the tricuspid annulus, they will tend to have relatively broader r waves in leads V2-V4 with slurring of the downstroke of the S wave. Although several types of arrhythmias have been described in patients with slowly conducting atrioventricular, nodoventricular, nodofascicular bypass tracts, and atriofascicular bypass tracts, fasciculoventricular bypass tracts have not been 15 16 17 18 19 implicated in any reentrant arrhythmia. Importantly, any of these bypass tracts can act as either participants (with the exception of fasciculoventricular) or bystanders in reentrant arrhythmias. The electrophysiologic studies are critical to establishing the pathophysiologic substrate of these individual fibers and the mechanisms of the arrhythmias with which they are associated. Slowly Conducting Accessory Pathways Anterograde decrementally conducting accessory pathways are not as uncommon as previously thought. In our experience, <3% of patients referred to us for ventricular preexcitation have such a pathway. It is not uncommon for these decrementally conducting accessory pathways to be 17 18 19 151 associated with typical, rapidly conducting A-V accessory connections. Antidromic tachycardia over a slowly conducting A-V bypass tract or nodoventricular-nodal reentry c. Fasciculoventricular bypass tract (no reentrant tachycardias) Electrophysiologic Manifestations Electrocardiographic and electrophysiologic characteristics of decrementally conducting bypass tracts depend on the sites of insertion: either the atrium or the A-V node and the site of insertion in the ventricle. Those pathways that arise in the atrium more closely resemble a typical A-V bypass tract. Both atriofascicular and slowly conducting atrioventricular pathways demonstrate greater preexcitation when atrial stimulation is performed closer to the bypass tract, whereas the degree of preexcitation observed over bypass tracts that arise from the A-V node is not influenced by the site of atrial stimulation. The conduction velocity down the bypass tract is an additional critical determinant of the degree of preexcitation. If the conduction time over the bypass tract to the ventricle (by whatever route) approximates that of the normal conduction system, little or no preexcitation may be present in the basal state (Fig. Any perturbation – such as changing autonomic tone, or electrical or pharmacologic maneuvers that prolong conduction to the ventricles over the normal A-V normal conducting system (primarily the A-V node) to a greater degree than in the slowly conducting accessory pathway – will increase the degree of preexcitation. Since all of these accessory pathways exhibit decremental conduction, the P-delta (or P-R) will increase in response to atrial pacing. During sinus rhythm (left), the degree of preexcitation depends on the relative conduction time down the decrementally conducting bypass tract and conduction time down the normal conducting system below the “takeoff” of the bypass tract. The increase in P-delta interval is due to conduction delay above the site of the takeoff. Electrophysiologic studies are critical to document the presence and type of these slowly conducting accessory pathways and their participation in clinical arrhythmias. The H-V interval may be normal or decreased, depending on whether any evidence of preexcitation exists. Normalization of the H-V by His bundle pacing proves that the takeoff is from the node or the atrium and excludes a fasciculoventricular pathway (see below). Electrophysiologic studies have demonstrated that the vast majority (probably greater than 90%) of these decrementally conducting accessory pathways are atriofascicular or long atrioventricular pathways. Slowly conducting short atrioventricular pathways are a distant second with pathways arising in the A-V node being least common. Sites of 34 atriofascicular or long atrioventricular and 9 short atrioventricular pathways that I have studied are shown in Figure 10-110. Atriofascicular and Long Atrioventricular Bypass Tracts As shown in Figure 10-113, atriofascicular and/or long atrioventricular pathways have their atrial insertion at the 22 48 49 149 150 free wall of the right atrium. In the baseline state minimal or no preexcitation may be present; thus, the H-V interval may be normal (∼60%) or short. The A-H interval will show a greater degree of prolongation than the A-V interval regardless of the morphology. The fixed V-H interval, despite shorter atrial paced cycle lengths and/or coupling intervals (Fig. In my opinion, whenever the V-H is <20 msec insertion into the right bundle branch is likely. Long atrioventricular bypass tracts inserting 20 near the right bundle branch have been described by Haissaguerre et al. In my experience and that of others, most of these 18 20 21 22 48 49 149 150 153 long fibers are consistent with slowly conducting atriofascicular tracts. Decrementally conducting atriofascicular and long atrioventricular pathways are located along the anterior and lateral free wall of the right ventricle (solid line, 35 patients). Short atrioventricular pathways are more variably located (dots, 12 at the right free wall and 3 at a left lateral site). The first is a normal sinus complex with no evidence of conduction over the atriofascicular tract. In the third and fourth complexes, conduction over the atriofascicular tract is present, and there is a reversal of activation sequences, with the right bundle potential occurring before the His bundle potential. This suggests that the atriofascicular bypass tract inserts into the right bundle branch and conducts retrogradely to the His bundle. Careful mapping of the tricuspid annulus and the anterior free wall of the right ventricle has demonstrated discrete potentials with complexes comparable to those recorded P. It is recorded as a single long structure, analogous to the right bundle branch, which in most cases appears to join the distal right bundle branch at the insertion of the moderator band at the apical third of the free wall (Fig. In essence, it functions as an auxiliary conducting system in parallel to the normal conduction system. During preexcitation propagation is traced anterogradely over the accessory pathway and retrogradely up the right bundle branch to the His bundle to give rise to the short V-H interval (Fig. In this instance, the His bundle is activated prior to the proximal right bundle branch, with anterograde conduction down the right bundle branch to the site of block. This is the mechanism of long and short V-H tachycardias (see subsequent discussion).

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It usually occurs Subcutaneous Nodules about 3 months after the acute rheumatic fever purchase kamagra effervescent with amex. Tough infrequent kamagra effervescent 100 mg lowest price, they are more likely to be clumsiness cheap kamagra effervescent 100mg mastercard, and it can be elicited by enquiring from the observed in patients with severe carditis order cheap kamagra effervescent on line. Tey In school going children, deterioration of the hand- appear on bony prominence, like knees, elbows, shins, over writing is the best sign suggestive of chorea (Fig. Te characteristic chorea movement consists of pur- Tey are better palpated than seen (Figs 27. Erythema Marginatum Emotional liability is usually seen and child may develop It is a very infrequent fnding and difcult to diagnose. As a result of chorea, the child may not be may start as a nonspecifc pink macules over the trunk. Prolonged P-R interval on electrocardiogram is also a nonspecifc fnding and may occur in many conditions. Among them, the most reliable is estimation of antibodies against the group A streptococci. High titers are considered more signifcant in making the diagnosis, but low titers do not exactly rule out the diagnosis. Positive throat swab culture is the gold standard for confrmation of the presence of groups A streptococcal infection. All patients with acute rheumatic fever should have at least one throat swab culture before the initiation Fig. It could be positive even in an individual without blanching, evanescent rash and difcult to identify in the evidence of acute rheumatic fever. Other Investigations Minor Criteria Chest roentgenogram may show evidence of cardio- Minor criteria include both clinical and laboratory param- megaly. Role of echocardiography in acute rheumatic fever: Tough echocardiography fndings has not been Fever included in the criteria for diagnosing acute rheumatic It is seen in almost all cases of acute rheumatic fever, and usually fever, it has a major role to play in the diagnosis of it is of mild-to-moderate grade. However it is very nonspecifc subclinical and mild carditis cases which are usually and could be a manifestation of any other infection. It also helps in Polyarthralgia assessing the severing of the cardiac abnormalities and subsequently in assessing and follow-up of Pain in joints without any other signs of infammation, like patients with chronic valvular disease. Te dose is 100 mg/kg/day in four divided Echocardiography Of remarkable utility in diagnosing subclinical doses. Tis dosage is expected to maintain a blood or mild carditis (mild valvular regurgitation) that is usually missed by clinical examination. If the facilities are available to estimate blood salicylate level, the dosage is adjusted Artifcial Appearance of artifcial subcutaneous nodules subcutaneous 4–10 days after injection of auto-test logous to achieve and maintain this blood level. Te full dosage Endomyocardial A positive biopsy showing Aschof nodules should be continued for about 10 weeks and then tapered biopsy or histiocytes establishes the diagnosis but a and stopped over next 2 weeks. When the patient is on negative biopsy (which is more often the case) aspirin therapy, it is very important to monitor for drug does not rule out carditis. When patient complains of tinnitus, look for other manifestations of salicylism, stop the drug and ask Differential Diagnosis for blood salicylate level. If patient develops toxicity, the Rheumatic fever has to be diferentiated from various oth- dosage has to be reduced and continued with monitoring. Tese disorders include rheumatoid arthritis, viral benefcial in the treatment of acute rheumatic fever. Diferentiating rheu- z Carditis with heart failure matoid arthritis becomes more important when a patient z Severe carditis with impending heart failure. Diferen- Steroids are helpful in controlling the acute tiating from infective endocarditis is most crucial in the infammatory process, but do not modify the incidence or management of acute carditis. At times, it is very difcult, severity of the residual chronic rheumatic heart disease. Echocardiogram and Steroid that is most commonly used is prednisolone in a blood culture are useful investigations in these situations. Tis Te only complication and long-term squeal of acute helps in preventing rebound rheumatic activity and rheumatic fever is rheumatic valvular heart disease. Approximately, a course of 12 weeks combined steroid– Treatment aspirin therapy (steroid 4 weeks, aspirin 9 weeks; 4th Te treatment of acute rheumatic fever includes week common, i. Start with Bed rest: All patients with acute rheumatic fever, diuretics and use digoxin as and when required. Ideally, and they may not respond to even the additional the bed rest should be given for 6–8 weeks period, medical therapy. In these cases, surgical therapy in the period generally needed for rheumatic activity to the form of valve replacement with prosthetic valve subside. In the absence of carditis, Treatment of chorea: Reassure the parents that it is there is no need for restricting the salt. Consider using drugs if the Anti-infammatory drug therapy: Anti-infammatory symptoms are severe. Te drugs used are phenobarbi- agents are the mainstay in the management of acute tone, chlorpromazine, diazepam and haloperidol. Tese agents are required to suppress with phenobarbitone and consider using other drugs the ongoing infammation and provide symptomatic as required. Tis is to eradicate the z Rheumatic fever with carditis: For 10 years after the last attack, streptococcal infection. Alternatively use oral penicillin 4 lakh units (250 mg), every 4–6 hourly for 10 days. Te mitral prophylaxis every 21 days with benzathine penicillin regurgitation may spontaneously disappear over a period of 1. Ideal is to prevent occurrence of rheumatic fever with early diagnosis and treatment. It is the most common acquired heart the acquisition of group A streptococcal infection disease in children. Te disease is basically valvular heart (through implementing actions and measures that disease afecting the heart valves either in isolation or in target environmental, economic, social and behavioral combination. Mitral valve is the commonly involved fol- conditions, cultural patterns of living) and adequate lowed by aortic valves. In practice, primary Mitral Regurgitation prophylaxis focuses on identifcation and treatment of streptococcal sore throat with penicillin therapy. Mitral regurgitation is the most common and earliest mani- Beside penicillin therapy, primary prophylaxis requires festation of rheumatic carditis. Varying degree of mitral educating the public on the dangers of streptococcal regurgitation occur in almost all cases of acute carditis. Ten full days therapy is a must, high volume overload results in enlargement of the left especially when oral drugs are used. Te mitral regurgitation that occurs once in every 21 days for 27 kg weight and more, and during acute rheumatic fever usually subsides by about a 0. Most often the mitral regurgitation is mild to prophylaxis, include penicillin V, 250 mg twice daily, moderate and remains asymptomatic for a longer time. Ideally, the secondary prophylaxis should be continued Clinical Features lifelong. However, some experts recommend it till 40 years Clinical manifestations are dependent on the severity. In patients with no residual lesion, one Patients with moderate to severe regurgitation develop may consider giving secondary prophylaxis for a limited easy fatigability and dyspnea on exertion. Appropriate prophylaxis against infective endocarditis is On examination, heart is enlarged; apex is displaced very much essential. Te frst heart Prognosis sound is normal, second heart sound is accentuated Prognosis depends upon the severity of the disease, with augmented pulmonary component, a pansystolic especially the carditis. Children with severe carditis are at murmur is heard at the apex with radiation to the left axilla increased risk of chronic sequelae in the form of rheumatic (Fig. Mortality rate is high in patients indicating increased early rapid flling of the left ventricle. Infective endocarditis can complicate In severe mitral regurgitation, diastolic murmur may be describe rapid occurrence of mitral stenosis in children, 489 occur rapidly within few years after the carditis. It is more common in children in South Indian, Sri Lanka and some other parts in Asia.

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The role of anti-incontinence surgery for occult stress incontinence during surgery for pelvic organ prolapse remains the subject of ongoing debate purchase kamagra effervescent overnight delivery. In this study buy genuine kamagra effervescent line, 53 women without preoperative stress urinary incontinence or occult stress incontinence were assessed [21] order kamagra effervescent with amex. The prevalence of de novo postoperative urinary incontinence is approximately 15%–18% [49] cheap 100 mg kamagra effervescent. However, the different study methodologies employed make the outcome data difficult to collate. A prior vaginal hysterectomy had been performed in 48% of cases and prior abdominal hysterectomy in 52%. Prolene mesh was used in all cases and fixed to the sacrum by either sutures or staples. Of the 140 women, 66 were available for follow-up examination and 92% (objective success rate) of these demonstrated good long-term vault support. A total of 103 women completed follow-up questionnaires and the subjective success rate was 62% with 64 of the 103 women reviewed reporting no “presence of a lump. A polyester mesh, silicone coated on one side, was used with anterior and posterior mesh extensions. The mesh was sutured onto the sacral promontory and the peritoneum closed over the mesh. The average age of the 363 subjects was 63 years and the average operating time 97 minutes. Complications in association with all the various procedures used to treat prolapse occurred in only 5. In women who underwent laparoscopic surgery to manage pelvic organ prolapse, complications were identified in only 6. Women treated laparoscopically had a significantly higher risk of pulmonary edema but a lower risk of urinary complications [58]. When the mesh was introduced vaginally, the erosion rate was 20% but only 6% when introduced laparoscopically. The transvaginal introduction of the mesh was performed in 20 cases but abandoned in favor of laparoscopic introduction after the authors noticed a high erosion rate with this technique. The goals of surgery when treating vaginal vault prolapse are The relief of patients’ symptoms The correction of vaginal vault prolapse by restoring the normal pelvic anatomy where feasible The correction of coexisting urinary, coital, and lower bowel dysfunction The avoidance of the development of urinary, coital, and lower bowel dysfunction The achievement of a durable result, which in some cases may require the use of prosthetic materials The “best” operation for treating vaginal vault prolapse remains the subject of ongoing debate. In treating vaginal vault prolapse, vaginal, abdominal, and laparoscopic approaches should not be viewed as competing procedures [59]. The choice of operation to treat vaginal vault prolapse depends on many factors: the surgeon’s training and experience will influence the choice of surgery, and a recommendation for a specific operation can only be made after careful clinical assessment and after taking into consideration the patient’s age, medical condition, coital activity, level of physical activity, and a history of failed prior surgery. These benefits include superior surgical visualization, less pain, and quicker return to activities of normal daily living. Changes in pelvic organ prolapse surgery in the last decade among United States urologists. Urogynecologic surgical mesh: Update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse, 2011. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: Experience with 363 cases. Abdominal–retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Abdominal sacral colpopexy with mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic 1497 support defects: A prospective randomized study with long-term outcome evaluation. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. The structure of the bladder neck, urethra and pelvic floor in relation to female urinary incontinence. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Laparoscopic sacrocolpopexy with two separate meshes along the anterior and posterior vaginal walls for multicompartment pelvic organ prolapse. Laparoscopic sacrocolpopexy, hysterectomy, and Burch colposuspension: Feasibility and short-term complications of 77 procedures. Laparoscopic promontory sacral colpopexy: Is the posterior, recto-vaginal, mesh mandatory? Classification of biomaterials and their related complications in abdominal wall hernia surgery. Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures. Porcine dermis compared with propylene mesh for laparoscopic sacral colpopexy: A randomized controlled trial. Long-term results of robotic assisted laparoscopy: Sacrocolpopexy for the treatment of high grade vaginal vault prolapse. Basic science and clinical studies coincide: Active treatment approach is needed after a sports injury. Laparoscopic Burch colposuspension versus tension-free vaginal tape: A randomized trial. Tension-free vaginal tape and laparoscopic mesh colposuspension in the treatment of stress urinary incontinence: Immediate outcome and complications—A randomised clinical trial. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage 3 or 4 pelvic organ prolapse. Laparoscopic sacrocolpopexy with Gynemesh as graft material—Experience and results. A comparison of laparoscopic and abdominal sacral colpopexy: Objective outcome and perioperative differences. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Vaginal sacrospinous colpopexy and laparoscopic sacral colpopexy for vaginal vault prolapse. The absolute indication is fertility preservation in women who have not yet completed childbearing. However, this is a small group of patients; most women presenting requiring surgery for prolapse have no desire for further children, indeed the majority are postmenopausal. In the authors’ experience, the other more prevalent indications for hysteropexy include patient request and superior outcome. The latter is a contentious statement; clinical data is still sparse and will be discussed in this chapter. However, when there is loss of apical support, traditional vaginal hysterectomy will not correct defects. This is most readily apparent when women present with procidentia; it is self-evident that hysterectomy will not treat vaginal eversion. If hysterectomy is performed, additional vaginal suspension needs to be provided, usually either by sacrospinous fixation or sacrocolpopexy. Hysteropexy, in our view, offers a more logical approach, and furthermore avoids vaginal mesh, with the attendant extrusion risk it carries. While it has served the gynecologist well for many years, its continued use raises some significant questions. Vaginal hysterectomy fails to address the underlying deficiency in connective tissue pelvic floor support [1] that causes prolapse; indeed, the uterosacral ligaments are cut during the operation—it is hardly surprising that recurrent prolapse rates are so high, with rates of up to 40% described in the literature [2,3]. Recurrence can manifest with vaginal vault eversion, or more commonly recurrent enterocoele/cystocele. We know that cystocele commonly arises because of loss of apical type 1 vaginal support [4], and until apical support is established, it will recur. Furthermore, hysterectomy removes a healthy organ which may play a role in patients’ individual and sexual identity.

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