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The mean activation time in a group of 24 patients with normal P waves and the mean values in a group of 15 patients with electrocardiographic left atrial enlargement are shown in Figure 4-2A, B, respectively. Obviously detailed atrial activation mapping using the Carto electroanatomic system is most accurate and is necessary for ablation of left atrial tachyarrhythmias. Normal activation is shown in Figure 4-3 in which activation of the left atrium occurs over Bachmann bundle, with additional conduits through the interatrial septum and coronary sinus (and potentially via interatrial bridges). In this patient, delayed activation of the left atrium (P to coronary sinus) and normal intra- right atrium conduction are shown by the atrial map. Intra-atrial delay involving only the right atrium is far less common, but it is seen in the presence of congenital 6 7 heart disease, particularly the endocardial cushion defects and Ebstein anomaly of the tricuspid valve. The prolonged intra-right atrial conduction time was probably due to longer time necessary to traverse the abnormally large right atrium. The demonstration that intra-atrial conduction delay is responsible for prolonged A-V conduction (first-degree A-V block) may alleviate concern that A-V nodal delay, intra-His delay, or infra-His delay is responsible. The vertical line marks the reference point for measurement and is the earliest evidence of atrial electrical activity. Activation times are plotted from various standard sites in the atria, with mean activation time shown with a bar and number. It occasionally occurs spontaneously as Type I second-degree exit block from an automatic atrial focus in the setting of digitalis toxicity (Fig. A similar phenomenon can be precipitated in the laboratory by rapid atrial pacing, which results in progressive increments in the stimulus-to-A 9 interval until the stimulus is not propagated, at which time the process repeats itself. Such types of intra-atrial delays appear to be substrates for intra-atrial reentry (Chapters 8, 9). Interatrial and intra-atrial dissociation have been observed during atrial tachyarrhythmias, particularly atrial flutter and fibrillation. In such instances, all or some part of the atrium manifests one rhythm while the remainder is activated differently.

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The resultant changes mean, with time, that the bladder becomes less compliant with filling (reduced capacity) and also has reduced contractility (poorer emptying). The result of these episodes is a replacement of the injured detrusor muscle fibers with collagen. Collagen is a structural protein that, depending on the degree of cross-linking having flexible characteristics, is not a muscle fiber and does not demonstrate the same ability to distend in a compliant manner as detrusor fibers or more importantly to contract. The net effect of this is the bladder starts to lose the elasticity required for compliant distension. Second, the loss of muscle leads to a net reduction in contractile force so the ability to empty may reduce. Impact of Voiding Dysfunction Many women will have suboptimal voiding, but this remains subclinical until symptoms reach the tipping point. First, symptoms of frequency, urgency, poor stream, double voiding, and nocturia develop related to reduced flow, poor contractility, and delayed/reduced sensation. Second, difficulty with conventional treatment for urgency may occur as the reduction in cholinergic fibers may reduce the effectiveness of anticholinergics, while increasing side effects. As such, the introduction of mirabegron, a beta-3 agonist, gives a medication that has different side effect profile and potentially less impact on voiding function. Finally, problems may develop with sequelae of the poor emptying, such as urinary tract infections (exacerbated by atrophic vaginitis), which can be complicated by upper urinary tract infections and a subsequent effect on renal function. Precipitating Factors Situations affecting voiding include concomitant conditions such as constipation and urinary tract infections as well as comorbidities such as diabetes. Various medications can also impact on bladder function such as antihypertensives including rapid-acting diuretics leading to rapid fill and calcium channel antagonists affecting the sensory thresholds. Urinary Tract Infection Urinary tract infections may precipitate retention/voiding difficulties or be sequelae of it. It is important to examine for this and also to send a sample for culture and sensitivity. The importance of microbiology becomes more relevant in chronic conditions and gives evidence as to whether infections are recurrent (as in frequently occurring) or whether they are resistant to clearance, as a result of altered virulence, e. Voiding problems may occur with prolapse and occasionally presents directly as bladder symptoms such as urgency or voiding difficulties but more commonly subclinically, due to the more direct symptoms of a lump/bulge in the vagina. All patients presenting with prolapse should be asked about voiding function prior to surgery.

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Kan, 65 years: Radionuclide angiography is employed to identify and quantify shunts and analyze distribution of blood to each lung. Six-month follow-up in an early study of the tined lead showed results that seemed comparable to the experience with the original lead [47].

Xardas, 63 years: Validated health-related QoL benefits have been demonstrated for several antimuscarinic medications [48]. It provides great comfort to the patient as there are no tant is in the supra-auricular region.

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8 of 10 - Review by V. Kamak
Votes: 177 votes
Total customer reviews: 177