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T RANSESOPHAGEAL echocardiography (TEE) is useful for intraoperative monitoring of cardiac function 1,z and for evaluating valve repair. 3 Recently, TEE has been proposed as a useful intraoperative tool improving diagnostic accuracy and assisting in surgical repair of pediatric congenital heart malformations. 4 Its role in the diagnosis of congemtal cardiac malformations in adults has not been widely discussed. The sinus venosus variant of atrial septal defect (SVASD) occurs in up to 20% of adults with an atrial septal defect (ASD) and is the most difficult to Identify. 5 This defect is frequently associated with anomalous connection of the right pulmonary veins to the junction of the right atrium and the superior vena cava. 6 The authors describe two cases of adult cardmc surgery where intraoperative TEE helped to diagnose previously unsuspected SVASD associated with partial anomalous pulmonary venous connections (PAPVC) and discuss how the echocardiography results led to modification of the planned operation.

The excellent long-term patency rates achieved with use of the internal mammary artery (IMA) to bypass the left anterior descending coronary artery have stimulated a variety of approaches to expand the use of this conduit in coronary bypass surgery. In this report we document our results using the two terminal branches of the IMA to bypass two arteries in a Y configuration. Sixty-seven patients received IMA Y grafts during a 6-month period in 1987. A total of 150 IMA branch anastomoses were performed (8 patients received bilateral IMA Y grafts). Fourteen of 67 patients were revascularized using IMA grafts only. Operative mortality was 2 of 67 (3%), and follow-up mortality was 5 of 67 (7.5%). Fifty-eight patients could be evaluated 37 +/- 2.7 months later. Clinically 36% of patients reported some recurrence of angina and 12 of 47 (25%) had a positive electrocardiographic stress test. Four patients were reoperated on (2 redo coronary artery bypass grafting, 2 transplants). Sixty (40%) of the 150 branch anastomoses could be evaluated objectively and 30 (50%) were patent. Five (8.5%) were stenotic and 25 (41.5%) were occluded (overall patency rate, 58.5%). We conclude that although the use of IMA Y grafts is a technically feasible means to increase IMA usage, extended application of this technique cannot be recommended unless improved patency rates can be demonstrated.

To determine the relative impact of each category-based TEE indication according to the ASA guidelines.In 851 patients undergoing cardiac surgery, TEE clinical indications were classified as category I or II according to the ASA guidelines. Category I indications are patients in which TEE is considered useful and category II are those where TEE is potentially useful but indications are less clear. All TEE examinations were reviewed by two anesthesiologists with advanced training in TEE. For each patient, the clinical impact of TEE in the clinical management was assessed using five criteria: 1) change of medical therapy; 2) change in the surgical procedure; 3) confirmation of a suspected diagnosis; 4) positioning of an intravascular device, and 5) substitute to a pulmonary artery catheter (PAC).TEE had greater utility in category I than in category II indications (15/53 (28%) vs. 110/798 (14%) respectively) (P0.01). The nature of the clinical impact was as follows: modification of medical therapy in 67/125 (53%), modification of planned surgical intervention in 38/125 (30%), confirmation of a diagnosis in 34/125 (27%). The impact on therapy was higher in complex surgical procedures (39%) than in valvular replacement (19%) (P0.01) and coronary artery bypass surgery (10%) (P0.001).Our findings validate the usefulness of the ASA practice guidelines demonstrating a greater impact of TEE on clinical management for category I indications than for category II. TEE also had a greater clinical impact in complex surgical procedures and in valvular replacement.

Background. Bradyarrhythmia has been reported with vecuronium when given with high dose narcotics. We hypothesized that if the bradycardic response is dependent on a vagal reaction mediated by narcotics, it should be independent of the vecuronium dose. A dose-related response of vecuronium on heart rate (HR) would be in favour of a chronotropic action of this agent. Methods. We examined three induction techniques using high doses of fentanyl in which vecuronium was given in increasing doses. In addition, a reference group received a low dose of atracurium. Forty patients scheduled for elective CABG surgery were anaesthetized with fentanyl (50 μg) given over 5 min, and were randomly assigned to receive either 0.056, 0.14, 0.28 mg/kg of vecuronium or 0.28 mg/kg of atracurium. Haemodynamic measurements were obtained at the following intervals: before induction (time 0), after the administration of fentanyl (at 5 min), and 1, 2 and 5 min after tracheal intubation (at 10, 11 and 15 min). Results. In vecuronium-treated groups, there were significant decreases in HR, mean arterial pressure, and cardiac output (P

Clinical information on the Medtronic-Hall valve prosthesis was obtained by reviewing the records of 379 patients, 164 of whom had aortic valve replacement (AVR), 163 of whom had mitral valve replacement (MVR), and 52 of whom had double valve replacement over 90 months (1,225 patient-years) (mean follow-up, 42.01 ± 1.3 months [± standard error]). Mean age was 53.8 ± 12 years. One hundred ninety-three patients (50.9%) had some type of concomitant operation, such as tricuspid annuloplasty, coronary artery bypass grafting, or resection of ascending aortic aneurysm. Ninety-one percent were in New York Heart Association (NYHA) Functional Class III or IV pre-operatively. Early mortality and late mortality were 7.7% (29 patients) and 13.5% (51 patients), respectively. The actuarial survival at 7 1/2 years was 74.1 ± 2.7% for the total group and 69.0 ± 4.5% for those having AVR, 81.0 ± 3.2% for those having MVR, and 67.0 ± 8.9% for those having double valve replacement. All patients but 2 were maintained on a regimen of chronic anticoagulation with warfarin sodium. Twenty-six thromboembolic episodes occurred (2.1/100 patient-years): 13 after MVR (2.3/100 patient-years), 11 after AVR (2.1/100 patient-years), and 2 after double valve replacement (1.4/100 patient-years). Four thromboembolic episodes were fatal; no valve thrombosis occurred. There were no structural failures. Of the 350 late survivors, 92% were in NYHA Functional Classes I and II. Total valve-related complications have been minimal. Our 7 1/2-year experience with the Medtronic-Hall valve prosthesis reveals a low thromboembolic rate of 2.1/100 patient-years in anticoagulated patients, a well-engineered and resistant valve structure, an acceptable hemolysis, and an acceptable rate of valve-related complications.

The combination of idiopathic cystic medial necrosis and congenital aortic stenosis in a 12-year-old boy is described. The patient presented with acute dissecting aneurysm of the ascending aorta. Successful emergency surgery included replacement of the ascending aorta and aortic valve with prostheses by means of cardiopulmonary bypass and hypothermia. Considerations in the management of this lesion (cystic medial necrosis associated with congenital aortic stenosis) are discussed.

After coronary bypass surgery, a 40-year-old man developed disruption of the site of cannulation of the ascending aorta. The false aneurysm which ensued presented as recurrent episodes of spontaneous angina and myocardial infarction ending in coronary death 48 days after surgery. The aortic origin of all three permeable coronary bypasses were strangulated by the hematoma. Awareness of this unusual potential hazard is essential, since an early suspicion would lead to proper diagnostic interventions and reoperation.