Background: Arsenic (As) contamination in groundwater is a severe global health crisis. Inorganic arsenic, a known carcinogen, leads to various health risks, including cancer, increased mortality and arsenicosis, especially in vulnerable populations like children. Studies have explored dose-response relationships between arsenic exposure and health outcomes, linking arsenic in drinking water with biomarkers like hair arsenic content. Nutritional deficiencies, especially low protein intake, exacerbate arsenic toxicity, influencing its metabolism. Aim of the study: This study aims to assess the nutritional status among arsenic-exposed and non-exposed individuals in selected areas, providing essential data to inform health policies and nutritional interventions. Methods: This cross-sectional comparative study focused on Village: Krishno Kathi, Union: Jalalpur, Thana: Tala, District: Satkhira, Bangladesh from July 2001 to December 2002 with varying levels of arsenic contamination in drinking water. Using multistage random sampling, 50 participants were selected from arsenic-exposed areas (>50 ppb) and 50 from non-exposed areas (<10 ppb). Data on demographics, socioeconomic status and nutrition status were collected using a structured questionnaire, anthropometric measurements and dietary intake assessments. Arsenic levels were measured with atomic absorption spectrophotometry. Nutritional status was evaluated using BMI and dietary diversity. Data were analyzed with SPSS, using descriptive statistics and inferential tests. Result: The study enrolled 100 participants, equally divided into arsenic-exposed and non-exposed groups. The mean age was 32.72 years in the exposed group and 35.39 years in the non-exposed group, with no significant differences in age or gender distribution. The exposed group had a significantly lower BMI (19.29kg/m²) than the non-exposed group (20.62kg/m²). Arsenic concentration was much higher in the exposed group (653.54 mg/L vs. 12.4 mg/L). Daily nutrient intake showed no significant differences between groups. The nutritional status revealed that 60% of the exposed group had a low BMI compared to 28% in the non-exposed group. Conclusion: The study reveals significant nutritional disparities between arsenic-exposed and non-exposed individuals in Bangladesh. Arsenic-exposed participants had a lower BMI, with 60% underweight compared to 28% in the non-exposed group. Despite similar nutrient intakes, arsenic exposure was linked to poor nutritional outcomes, highlighting the need for targeted public health interventions.

Background and aim of the study: The study aim was to update the clinical analysis of hemodynamic performance, structural failure and survival in patients undergoing aortic valve replacement (AVR) with a composite aortic, aldehyde tanned, stentless porcine bioprosthesis.

Methods: Between January 1990 and March 2001, 247 patients underwent AVR with aortic stentless valves. Patient demographic and clinical analysis included age, sex, valve lesion, valve size, pre- and postoperative NYHA class, hospital morbidity, mortality, operative data and duration of hospitalization.

Results: Mean patient age was 47.3 years; 71% of patients were males, and 45% had aortic insufficiency. The incidence of rheumatic heart disease requiring surgery was 41.7%. In 23% of patients surgery was indicated due to aortic stented bioprosthetic dysfunction. Preoperatively, 81% of patients were in NYHA classes III and IV. Mean follow up was 5.9+/-2.8 years (range: 1 month to 11.4 years); total follow up was 1,392 patient-years (98% complete). The valve size used was < or =25 mm in 75.3% of patients. The mean intensive care unit stay was 2.6 days; mean hospital stay was 10.7 days. Hospital mortality was 4.0% and late death 6.1%. There were no valve-related deaths. Postoperatively, the mean aortic effective orifice area (EOA) was 1.71 cm2, the mean peak transvalvular gradient 17.1 mmHg, and the mean transvalvular gradient 9.0 mmHg; the left ventricular mass index (g/m2) was 174 and 117 before and after surgery respectively. The rate of leaflet tissue degeneration was 0.9%, and seen as mild by echocardiographic follow up. Actuarial survival at almost 12 years was 91%, and freedom from reoperations was approximately 99%.

Conclusion: Patients with aortic stentless valves have hemodynamic benefits seen as larger aortic EOA, low transvalvular gradients, satisfactory left ventricular remodeling with significant reduction of left ventricular mass, low complication rate, low reoperation rate, lower leaflet tissue degeneration rate, and no valve-related mortality. A longer follow up is required to confirm these benefits.

Background and aim of study: Left ventricular (LV) torsion reduces transmural fiber strain gradients during systole, and torsional recoil in early diastole is thought to assist LV filling. To test the hypothesis that deterioration of torsional dynamics accompanied LV dysfunction during the evolution of mitral regurgitation (MR), torsion was measured during the progression from acute to chronic MR in a canine model.

Methods: Seven dogs underwent cardiopulmonary bypass for LV marker placement and creation of MR by disrupting the posterior leaflet. After 7-10 days, three-dimensional marker coordinates were measured with biplane videofluoroscopy to study LV geometry, size and function, plus maximal torsional deformation, time of maximal torsion relative to end-ejection, and early diastolic torsional recoil during the first 5% of filling. After three months, the animals were re-studied.

Results: Progression from acute to chronic MR was associated with a significant decrease in maximum LV dP/dt (1,574+/-213 to 1,300+/-252 mmHg/s, p <0.01) and an increase in LVEDP from 11+/-5 to 15+/-5 mmHg (p <0.01). After three months of MR, maximum torsional deformation decreased from 6.3+/-1.9 to 4.7+/-2.0 degrees (p = 0.04), as did early diastolic recoil (-3.8+/-1.0 to -1.5+/-1.7 degrees, p = 0.03).

Conclusion: Progression from acute to chronic MR is accompanied by decreased and delayed systolic LV torsional deformation and a decline in early diastolic recoil, which may contribute to LV dysfunction by increasing transmural strain gradients during systole and impairing diastolic filling. As torsional deformation and recoil can be measured non-invasively with MRI in humans, such measurements might prove useful in patients with progressive MR as an adjunct to determine the timing of surgical repair.

Background and aim of the study: Although, in theory, the mitral annulus with the Duran flexible ring should change size and shape during the cardiac cycle, no clinical reports are available of such flexibility several years after surgery. The study aim was to evaluate mitral annulus flexibility at medium-term follow up after surgery.

Methods: Eleven patients (mean age 60+/-8 years) were enrolled for this study. All were in sinus rhythm and had less than mild residual mitral regurgitation. The mean time between study and mitral valve repair was 6.0+/-2.4 years. Three sizes of Duran ring were used (three size 27, six size 29, and two size 31). All patients were studied with transesophageal echocardiography. The mitral annulus was reconstructed 10 times around a single axis of rotation during the cardiac cycle, using published methods. The area, circumferential length and shape of the mitral annulus were analyzed at various times during the cardiac cycle.

Results: A significant change in mitral annular area occurred during the cardiac cycle; the maximum to minimum reduction was 23+/-8% (p <0.001). The area and circumferential length of the mitral annulus in patients with size 29 Duran rings changed from 8.2+/-1.3 to 6.2+/-1.3 cm2 (p <0.001) and from 11.8+/-1.1 to 9.9+/-0.8 cm (p <0.001), respectively. Three-dimensional reconstruction of the mitral annulus showed it to retain its non-planar shape, but the shape to change significantly during the cardiac cycle.

Conclusion: The mitral annulus with a Duran ring remained flexible and retained its non-planar configuration at six years after implantation.

Background and aim of the study: Acute papillary muscle rupture (PMR) is a rare but fatal complication of myocardial infarction (MI). Surgery represents the best treatment option, but carries a high risk. Our experience of emergency mitral valve surgery in patients with acute PMR following MI during the past 22 years is reviewed.

Methods: Between 1978 and 2000, 33 patients (20 males, 13 females; mean age 64 years; range: 46-80) underwent emergency surgery for acute post-infarct PMR in our institution. The site of MI was anterior in three patients and inferior in 30. Preoperatively, 17 patients had an intra-aortic balloon pump (IABP) inserted, 26 were on inotropic support, and 17 were ventilated. Twenty patients (61%) underwent concomitant coronary bypass grafting (CABG). The valve was replaced in 31 patients and repaired in two. Mean (+/- SD) duration of follow up was 63+/-54 months (range: 0-183 months).

Results: Early mortality (in-hospital) was 21% (n = 7). Factors associated with significant risk of early mortality included raised preoperative serum creatinine (p = 0.02), need for preoperative inotropic support (p = 0.03) and preoperative ventilation (p = 0.03). Raised preoperative serum creatinine remained significant on multiple logistic regression (p = 0.04). Postoperatively, 21 patients required an IABP. Mean duration of intensive care unit stay was 4+/-2.5 days (range: 0-10 days). Survival, including in-hospital mortality, at one, five and 10 years was 75+/-7.4, 65+/-8.6 and 32+/-9.7%, respectively. Four patients required valve-related reoperation (three for a paraprosthetic leak, one for failed repair).

Conclusion: Patients with acute post-infarct PMR present in a severely compromised state. Early mortality is high, but the intermediate outcome is encouraging for operative survivors.

Background and aim of the study: Acute myocardial infarction associated with mitral papillary muscle rupture and cardiogenic shock carries a high mortality. Data relating to early and late survival after emergency mitral valve surgery and concomitant complete coronary artery revascularization in this patient population were analyzed.

Methods: Between January 1988 and December 1998, 21 consecutive patients (mean age 62+/-9.7 years) underwent emergency coronary and concomitant mitral valve surgery for acute myocardial infarction and mitral papillary muscle rupture associated with cardiogenic shock. Mitral valve replacement was performed in 19 patients (90%), and mitral valve repair in two (10%). An average of 2.2 distal anastomoses per patient was performed. Revascularization was complete in 19 patients (90%). Preoperatively, intra-aortic balloon pumping was used in 11 patients (52%), and two (10%) had salvage surgery when arriving at the operating room under cardiopulmonary resuscitation. Early and late follow up was complete; mean follow up was 5+/-3 years (range: 16 months to 12 years).

Results: Thirty-day mortality was 19% (4/21), with two cardiac-related early deaths (10%). Early morbidity included perioperative stroke in 6% (1/17), myocardial infarction in 6% (1/17), and need for hemodialysis in 18% (3/17). There were three late deaths; one was cardiac-related. Actuarial survival at one, five and 10 years was 81, 68 and 56%, respectively. All survivors were in NYHA class I or II.

Conclusion: Emergency surgery for acute post-infarction mitral papillary muscle rupture is justified, even as a salvage procedure. Concomitant mitral valve surgery and complete coronary artery revascularization achieve acceptable survival rates and satisfactory functional results.

Background and aim of the study: Functional ischemic mitral regurgitation (MR) can occur secondary to coronary artery disease. Controversy exists regarding management of these patients. Mitral valve annuloplasty in conjunction with coronary artery bypass grafting (CABG), accepted as the best treatment for severe MR, has been disputed for lesser degrees of regurgitation due to higher mortality. The results of a combined procedure approach were reviewed.

Methods: Between February 1992 and June 1999, 100 consecutive patients (mean age 67+/-11 years) with functional ischemic MR underwent mitral valve repair + CABG. The repair was limited to a Duran flexible annuloplasty ring. Among patients, 72% had a preoperative myocardial infarction and 51% required perioperative intra-aortic balloon pump. NYHA functional class was III-IV in 72%; preoperative MR by transesophageal echocardiography (TEE) was grade 3-4+ in 80% and grade 2+ in 20%.

Results: Intraoperative completion TEE indicated 0-1+ MR in 98%. Early mortality was 12% and late mortality 14%, for an overall survival of 74%. The mean follow up was 35.8 months. Follow up TEE on 82% of patients showed zero to trivial MR in 42% of patients, grade 1+ MR in 29%, 2+ MR in 24%, and 3-4+ MR in 5%. Follow up NYHA class was I-II in 81% of patients and III-IV in 19%. A significant correlation was found between recurrent MR and declining left ventricular function on follow up only, as well as the occurrence of preoperative myocardial infarction.

Conclusion: Functional ischemic MR remains a difficult problem to treat, and has a poor long-term outcome. Ring annuloplasty for functional ischemic MR with coronary artery disease achieves immediate valve competence. However, a significant number of patients develop recurrent MR at intermediate follow up.

Background and aim of the study: Septal-lateral (S-L) mitral annular diameter reduction is thought to be central to the efficacy of ring annuloplasty in correcting functional mitral regurgitation (MR), but rings perturb mitral annulus (MA) dynamic motion and limit posterior leaflet excursion. The effects of S-L annular cinching ('SLAC'), a novel method for mitral annular reduction, were investigated.

Methods: Eight adult sheep had multiple radioopaque markers placed on the left ventricle, leaflet edges, and around the MA. The S-L trans-annular suture was anchored to the mid-septal MA and externalized through the mid-lateral MA and left ventricular wall. Animals were studied immediately postoperatively with biplane videofluoroscopy before and after suture cinching to reduce annular size. MA area (MAA) and S-L dimension were calculated throughout the cardiac cycle from the annular marker coordinates. MAA contraction (AMAA) was expressed as percentage decrease from maximum to minimum MAA. Anterior (AML) and posterior (PML) leaflet angular excursion were calculated as the change in angle between each leaflet edge marker and the S-L annular dimension during the cardiac cycle. MA folding was calculated as the change in distance during systole of the mid-septal annular marker from a plane fitted to the lateral MA markers.

Results: SLAC reduced end-diastolic (ED) S-L diameter (21.6+/-2.8 versus 17.1+/-2.6 mm; p = 0.0005) and ED MAA (618+/-126 versus 525+/-114 mm2; p = 0.0004), but did not perturb normal AMAA (15.8+/-4.1 versus 15.1+/-4.8%; p = 0.4), annular flexion (2.0+/-0.7 versus 1.8+/-0.7 mm; p = 0.3) or AML excursion (55+/-7 versus 53+/-7 degrees; p = 0.1). PML excursion was decreased only slightly (52+/-11 versus 44+/-12 degrees; p = 0.002).

Conclusion: SLAC substantially reduced S-L annular size, but without perturbing normal MA contraction dynamics, MA flexion, or anterior leaflet excursion. This novel surgical method might represent an alternative to mitral annuloplasty for patients with certain types of mitral pathology.