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Background and Aim of the Study: Previously, surgery hypertrophic obstructive cardiomyopathy (HOCM) has consisted primarily of septal myectomy and/or resection of the anterior mitral leaflet with low-profile valve replacement. However, recent studies have shown that the anterior papillary muscle and chordal fan can contribute to obstruction, and also that significant mitral regurgitation (MR) may be encountered. Hence, a surgical procedure was devised to address all components of this disorder., Methods: A 37-year-old man had a history of heart murmur and NYHA class IV symptoms, despite beta-blocker therapy. Echocardiography showed severe septal hypertrophy, systolic anterior motion (SAM) of the mitral valve, severe MR and a 185 mmHg resting outflow tract gradient. At surgery, the anterior papillary muscle was found to be medially displaced and contributing to outflow obstruction. The anterior papillary muscle and chordae were resected, a 'traditional' septal myectomy was performed, and a full annuloplasty ring placed. The mitral valve was repaired by connecting the left aspect of the leaflets to the posterior papillary muscles, using Gore-Tex artificial chords., Results: The patient recovered uneventfully. Interval echocardiography at one year showed a negligible outflow gradient, relief of SAM and mild residual MR. The patient currently is active, essentially asymptomatic, and not receiving any medical therapy., Conclusion: Previous approaches to HOCM have been limited by a small incidence of recurrent outflow gradients, pacemaker requirement, persistent MR or complications of the prosthetic valves. By comprehensively addressing all components of outflow obstruction and mitral dysfunction, this combined procedure may produce better results in certain subsets of HOCM, with the excellent late prognosis of artificial chordal replacement.

Achieving a stable repair of mitral valve prolapse can be difficult in complex pathologies, and a 5% to 20% late reoperation rate exists with leaflet resection and reconstruction. During an 8-year period, prolapse was managed uniformly with "adjustable" Gortex (W. L. Gore & Associates Inc, Flagstaff, AZ) artificial chordal replacement and Carpentier ring annuloplasty (Edwards Lifesciences LLC, Irvine, CA), without leaflet resection. Artificial chords were placed initially in the papillary muscles, and then after ring annuloplasty they were adjusted to optimize length to the prolapsing segment(s). Of 52 patients with prolapse, 100% were repaired successfully with artificial chords. Operative mortality was 1.9%, and 4, 6, and 8-year survivals were 87%, 81%, and 71%, respectively. Only 1 of 52 patients (1.9%) experienced late failure, and this patient was re-repaired with artificial chords. Thus, "adjustable" artificial chordal replacement facilitates uniform repair of mitral valve prolapse with a low late failure rate.

A 67-year-old male was scheduled for cadaveric renal transplant. Following rapid sequence anaesthesia, only the tip of the epiglottis was visualized. Mask ventilation was difficult, and therefore an alternative airway device was considered. A size 4 CobraPLA (Engineered Medical System, Indianapolis, IN) was inserted into the hypopharynx, and ventilation was easily accomplished. Then, a size 7 endotracheal tube was threaded over a fiberoptic bronchoscope, through the CobraPLA, into the trachea. The description and insertion technique of the CobraPLA, a new supraglottic airway device is shortly discussed. This is the first report of successful management of difficult mask ventilation with the new CobraPLA, supraglottic airway device.

The authors attempted to favorably manipulate the distribution of pulmonary blood flow during unilateral atelectasis and during unilateral lung lavage by nonocclusive inflation of an ipsilateral pulmonary artery catheter balloon (PAB). Six mongrel dogs were anesthetized, intubated with a double-lumen endotracheal tube, and following a thoracotomy, pulmonary artery and left lung blood flows (Qt and QLL/Qt, respectively) were measured electromagnetically; right lung blood flows (QRL/Qt) were derived by difference. A PAB was positioned in the right main pulmonary artery. The experimental sequence consisted of seven steps: 1) both lungs ventilated; 2) ventilation of the left lung (LL vent), right lung (RL) atelectatic, PAB deflated; 3) LL vent, RL atelectatic, PAB inflated; 4) LL vent, RL lavaged, PAB deflated; 5) LL vent, RL lavaged, PAB inflated; 6) LL vent, RL drained, PAB deflated; and 7) LL vent, RL drained, PAB inflated. At each step the shunt fraction (Qs/Qt) was determined. Inflation of the PAB during LL vent and RL atelectatic (step 3) caused QRL/Qt and Qs/Qt to decrease and QLL/Qt and PaO2 to increase significantly (compared to step 2). There were no significant differences in QRL/Qt, QLL/Qt, Qs/Qt, and PaO2 during RL lavage with the PAB deflated (step 4) compared to RL lavage with the PAB inflated (step 5). Inflation of the PAB during RL drainage (step 7) caused QRL/Qt to decreased and QLL/Qt to increase significantly compared to their values during periods of RL drainage with the PAB deflated (step 6). This resulted in a significant increase in PaO2 and decrease in Qs/Qt. These results demonstrate that the distribution of pulmonary blood flow in dogs can be favorably manipulated by nonocclusive ipsilateral PAB inflation and support a trial of use in selected patients during one-lung anesthesia and ventilation.

Tetanus is caused by the organism Clostridium tetani, which produces tetanospasmin, a neurotoxin responsible for the clinical manifestations of muscle rigidity and reflex spasms. The majority of cases follow an anaerobic wound infection associated with trauma. Incubation period is usually 3 days to 3 weeks. 75% of patients present with trismus. Reflex spasms are seen in 70% of patients and characterize the severity of the disease. Treatment involves removal of the offending organism, neutralization of free neurotoxin, controlling rigidity and reflex spasm, and minimizing complications. Diazepam may be used alone in mild cases. Severe cases require the addition of nondepolarizing neuromuscular blocking agents and mechanical ventilation. Respiratory complications occur early and require aggressive airway management. A serious, late complication is the syndrome of sympathetic nervous system overactivity that is treated with alpha and beta blockade. High mortality rates seen in the United States may be due to delays in diagnosis and lack of familiarity with treatment. The disease is preventable with adequate immunization.

The deliberate reduction of blood pressure in an attempt to reduce intraoperative blood loss has generated significant controversy in the 30 years since its clinical introduction. Numerous series have been reported, but few have met generally accepted, current criteria for controlled studies. In this article, the effect of blood pressure reduction on organ perfusion will be presented together with a review of techniques of achieving hypotension. A summary of results is included and, based on this data, recommendations are offered regarding the application and limits of deliberate hypotension.

A new CPAP device is described which is simple, lightweight, easily constructed, and not functionally dependent on gravity or valves. The device consists of a conventional T-piece into which a small nozzle is placed opposite, but projecting towards, the patient connection. When a flow of oxygen is delivered through the nozzle, continuous positive pressure within the airway results. The device was evaluated with a mechanical lung model, in human volunteers using various breathing patterns and in intubated patients requiring transport within the hospital. In all three situations, the device provided 7-15 torr end-expiratory pressure and an FIO2 of 0.40-0.90 using oxygen flow rates of 10-30 L/min. The device is safe, reliable, and can be easily adapted to provide IMV when required. Clinical applications are discussed.