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To investigate whether prophylactic amiodarone infusion prevents ventricular fibrillation after aortic cross-clamp release and attenuates cytokine production in patients with left ventricular hypertrophy undergoing cardiac surgery.Prospective, randomized controlled trial.A public hospital.The study comprised 68 patients undergoing aortic valve replacement for severe aortic stenosis.Patients were randomly assigned to receive a 150mg bolus then 30mg/h continuous infusion of amiodarone (amiodarone group) or a 1 mg/kg bolus then 1 mg/kg/h continuous infusion of lidocaine (lidocaine group). The primary outcome was the ventricular fibrillation incidence rate after aortic cross-clamp release. Secondary outcomes included perioperative serum interleukin-6 and tumor necrosis factor-alpha levels.The ventricular fibrillation incidence rate was significantly lower in the amiodarone than in the lidocaine group (20.6% v 50%, relative risk 0.41; 95% confidence interval [CI] 0.20-0.86; p = 0.021). Interleukin-6 levels 1hour after aortic cross-clamp release and at intensive care unit admission were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 117.4pg/mL [87.1-158.4] v 339.5pg/mL [210.6-547.2]; p0.01 and 211.1pg/mL [162.8-73.6] v 434.1pg/mL [293.7-641.5]; p0.01, respectively). Tumor necrosis factor-alpha levels 1hour after aortic cross-clamp release were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 1.624pg/mL [1.359-1.940] v 2.283pg/mL [1.910-2.731]; p = 0.02).Amiodarone prevented reperfusion ventricular fibrillation in patients with left ventricular hypertrophy undergoing aortic valve replacement to a greater extent than did lidocaine. Furthermore, amiodarone inhibited postoperative interleukin-6 and tumor necrosis factor-alpha production.

Objectives To clarify the relationship between right and left ventricular (RV and LV) diastolic function and postoperative atrial fibrillation (POAF). The early effects of major lung surgery on cardiac function in the intraoperative period during lung surgery were evaluated, using transesophageal echocardiography. Design Single-center prospective observational study. Setting A public hospital. Participants Patients undergoing elective lobectomy with lymph node dissection for lung cancer (n = 116). Interventions Transesophageal echocardiography examination was performed under general anesthesia before skin incision (preoperative) and after chest closure (postoperative). According to measured echocardiographic variables, ventricular systolic and diastolic functions were classified at each time point. Measurements and Main Results Of the 116 patients, 24 (20.7%) experienced POAF. Preoperative RV and LV diastolic dysfunction were more common in patients with POAF than in those without POAF (58.3 v 28.3%, p = 0.008; 54.2 v 19.6%, p = 0.001, respectively). Among patients without preoperative diastolic dysfunction, a small number developed RV and LV diastolic dysfunction immediately after surgery (9.2% and 16.5%, respectively) and these distributions were comparable between patients with POAF and those without POAF. RV systolic dysfunction was observed in 6.5% of patients immediately after surgery and was not related to the occurrence of POAF. Multivariate analysis revealed older age, chronic obstructive pulmonary disease (COPD), and preoperative biventricular diastolic dysfunction as risk factors for POAF. Conclusions Preoperative biventricular diastolic dysfunction, as well as older age and COPD, are associated with POAF in patients undergoing lobectomy. Major lung surgery has minimal early effects on postoperative systolic and diastolic functions.

A 77-year-old patient suffering from a giant right coronary artery aneurysm with coronary arteriovenous fistula was admitted to our hospital. The fistula could not be documented preoperatively by computed tomography or coronary angiography but was documented intraoperatively by transesophageal echocardiography (TEE). However, TEE was unable to visualize the draining site of the fistula. Direct palpation by the surgeon ultimately confirmed that the fistula was draining into the coronary sinus. The fistula was closed and the volume of the aneurysm reduced by partial resection. The postoperative course of the patient was uneventful. Giant aneurysms occasionally displace cardiac structures. In such cases, combined imaging technologies, including TEE, may be needed for precise assessment of the giant aneurysm and fistula.

Background: Changes in heart position are occasionally observed on the transesophageal echocardiography (TEE) image screen after changing the body position from supine to lateral, although the magnitude of change in cardiac position varies individually. We hypothesized that this variation is associated with certain patient characteristics and evaluated how lateral positioning affects visualization of the heart on TEE and whether the magnitude of change in the heart position correlates with patient characteristics. Methods: Fifty-three lung resection patients were enrolled. Two angle and two length parameters (DqTV , DqAP , DL TV , and DL AP ) were defined to describe location change of the lateral tricuspid annulus and right ventricular apex on the TEE image between supine and lateral position. The correlation coefficients were calculated between these four parameters and patient characteristics, including age, body mass index (BMI), epicardial fat thickness, and pulmonary function variables. Results: The DqTV correlated positively and inversely with BMI in both right and left lateral patients (right: r = 0.6365, P = 0.0034; left: r = −0.6616, P < 0.0001, respectively). In left lateral patients, the DqTV correlated inversely with epicardial fat thickness (r = −0.4879, P = 0.0182), and the DL AP correlated positively with the forced vital capacity percent predicted (r = 0.5736, P = 0.0082). Conclusions: Lateral body positioning affects cardiac visualization on TEE, and the BMI, epicardial fat thickness, and pulmonary function moderate this effect.

We sought to examine what factors, including cerebrovascular carbon dioxide (CO(2)) reactivity, are related to a decrease in internal jugular venous oxygen saturation (SjvO(2)) during normothermic cardiopulmonary bypass (CPB) in patients with diabetes mellitus.Twenty-three diabetic patients scheduled to undergo elective coronary artery bypass grafting were studied. As a control, 27 age-matched control patients without diabetes mellitus were also examined. After the induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to continuously monitor SjvO(2). Arterial and jugular venous blood gases were measured during CPB. The cerebrovascular CO(2) reactivity was measured after the induction of anesthesia and before the start of surgery using a 2.5-MHz pulsed transcranial Doppler probe.The SjvO(2) values in the diabetic group were lower than those in the control group at the initiation of CPB and at 20, 40, and 60 min after the start of CPB. The values for pre- and post-CO(2) reactivity in the control group did not significantly differ (pre-CPB: 4.8% +/- 2.3% mmHg(-1); post-CPB: 5.9% +/- 4.4% mmHg(-1)). In contrast, the values for CO(2) reactivity were lower post CPB than pre-CPB in the diabetic group (Pre-CPB: 6.3% +/- 2.9% mmHg(-1); post-CPB: 4.7% +/- 2.6% mmHg(-1); P0.05). In the diabetic group, glycosylated hemoglobin A1c (HbA1c) is considered to be a factor related to a decrease in SjvO(2) during CPB.Cerebrovascular CO(2) reactivity in diabetic patients decreased after the cessation of CPB but not in the control patients. In addition, HbA1c is also thought to be a factor related to a decrease in SjvO(2) in diabetic patients.

An 84-year-old woman with pulmonary hypertension (PH) secondary to chronic pulmonary thromboembolism suffered from continuous warfarin dependent bleeding from sigmoid colon cancer. Sigmoidectomy was scheduled to control continuous bleeding. Six hours after discontinuation of anticoagulant therapy for elective sigmoidectomy, the patient showed hypoxia, pulmonary thromboembolism and pulmonary hypertension with right ventricular systolic pressure (RVSP) of 81 mmHg. The operation was postponed and heparin was infused. Since two-day heparinization therapy did not improve PH, oral administration of sildenafil citrate 60 mg daily was initiated. Seven days after initiation of sildenafil administration, RVSP decreased to 49 mmHg without improvement of hypoxia. Sigmoidectomy was performed under general anesthesia. The patient showed severe hypotension managed with noradrenaline and dopamine infusion during and after surgery, resulting from interaction between sildenafil and vasodilators. The patient was discharged 36 days after the operation without complications.

Electroconvulsive therapy (ECT) increases neuronal energy consumption and alters systemic hemodynamics.We examined the effects of ECT on regional cerebral oxygen saturation (rSO2) using a near-infrared spectrophotometer. Heart rate (HR), mean arterial blood pressure (MAP), and rSO2 were continuously monitored throughout ECT under general anesthesia in 43 patients. In all subjects, rSO2 changed in a consistent pattern during ECT, initially decreasing (-9.4% +/- 0.9%) just after application of the electrical current and subsequent increasing (8.7% +/- 0.9%) beyond the pre-ECT value. A close correlation was demonstrated between the increase in rSO2 and the mean blood pressure after the electrical shock (r2 = 0.832, P < 0.0001). We conclude that ECT initially may increase cerebral metabolic rate of oxygen more than cerebral blood flow and that rapidly increasing blood pressure transiently may overwhelm cerebral pressure autoregulation. (Anesth Analg 1996;83:726-30)

Gastric bleeding during cardiopulmonary bypass (CPB) is a rare but life-threatening complication for patients undergoing cardiac surgery. We present a case of a patient undergoing coronary bypass grafting in whom we detected gastric bleeding by transesophageal echocardiography (TEE) during CPB. After separation from CPB, bleeding was stopped by endoscopic clipping of the mucosa. If a fluid deficit is noted and TEE reveals a hypoechoic space within the stomach, gastric bleeding might be suggested.