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De Hert SG, Rodrigus IE, Haenen LR, Ten Broecke PW, Boeckxstaens CJ, Gillebert TC. Effects of lidoflazine on left ventricular function in patients. J Cardiothorac Vasc Anesth 1997; 11:42-8. [PMID: 9058219 DOI: 10.1016/s1053-0770(97)90251-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The present study evaluated the effects of the nucleoside transport inhibitor, lidoflazine, at a dose of 1 mg/kg, on left ventricular function. DESIGN Patients were randomly assigned to receive either lidoflazine or saline in a double-blind manner. SETTING A university hospital. PARTICIPANTS The study was performed in 32 patients scheduled for elective coronary artery bypass surgery. INTERVENTIONS Left ventricular pressures were measured with fluid-filled catheters. Data were digitally recorded during pressure elevation induced by tilt-up of the legs. Transgastric short-axis echocardiographic views of the left ventricle were simultaneously recorded on videotape. Systolic function was evaluated with the slope (Ees, mmHg/mL) of the systolic pressure-volume relationship. Diastolic function was evaluated with the chamber stiffness constant (Kc, mmHg/mL) of the diastolic pressure-volume relationship. Cardiac function was assessed at baseline and after administration of either lidoflazine (group A [n = 16]) or placebo (group B [n = 16]). Data were compared using two-factor analysis of variance. MEASUREMENTS AND MAIN RESULTS At baseline, diastolic and systolic function were comparable in both groups. Lidoflazine increased Kc from 0.079 +/- 0.015 to 0.125 +/- 0.017 mmHg/mL and decreased Ees from 2.481 +/- 0.213 to 1.217 +/- 0.211 mmHg/mL (p = 0.009 and p = 0.004, respectively). None of these changes occurred when placebo was administered. CONCLUSIONS Administration of lidoflazine before the start of cardiopulmonary bypass impaired left ventricular systolic function but also increased diastolic stiffness.
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Affiliation(s)
- S G De Hert
- Department of Anesthesiology, University Hospital of Antwerp, Belgium
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Niimi Y, Morita S, Watanabe T, Yamamoto S, Rubsamen R, Ichinose F. Effects of nitroglycerin infusion on segmental wall motion abnormalities after anesthetic induction. J Cardiothorac Vasc Anesth 1996; 10:734-40. [PMID: 8910152 DOI: 10.1016/s1053-0770(96)80198-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the effect of intravenous nitroglycerin (NTG) on segmental wall motion abnormalities (SWMAs) and global ventricular function after anesthetic induction in patients undergoing coronary artery bypass grafting (CABG). DESIGN Prospective study. SETTING University hospital. PARTICIPANTS Twenty patients scheduled for elective CABG. INTERVENTIONS Patients demonstrating SWMAs in at least two myocardial segments after induction received intravenous NTG at 2 micrograms/kg/min. MEASUREMENT AND MAIN RESULTS Transesophageal echocardiography (TEE) was performed before and after the NTG infusion for analysis of segmental wall motion abnormalities. Mean arterial pressure (MAP), central venous pressure, and pulmonary capillary wedge pressure decreased significantly after NTG infusion, whereas cardiac index and heart rate remained unchanged. End-diastolic area and end-systolic area decreased, and consequently fractional area change increased significantly. Two of 20 patients (10%) showed electrocardiogram evidence of ischemia after induction. After NTG infusion, 15 of 20 patients (75%) showed an increase in a wall motion score more than two points. In these 15 patients with NTG-responsive wall motion abnormalities, the mean ratio of peak early diastolic filling velocity (E) to peak late diastolic filling velocity (A) increased from 0.89 +/- 0.20 to 1.04 +/- 0.25 (p < 0.01) after NTG infusion despite a decrease in filling pressure. Systolic wall thickening improved in segments with poor preoperative function from a pre-NTG value (mean +/- SD) of -1.0% +/- 7.4% to a post-NTG value of 31.4% +/- 24.9% (p < 0.01). CONCLUSIONS Intravenous NTG improved postinduction SWMAs in 75% of patients with known coronary artery disease. TEE-guided NTG infusion after induction may provide an optimal baseline echocardiogram for monitoring intraoperative myocardial ischemia by improving the reversible portion of postinduction SWMAs.
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Affiliation(s)
- Y Niimi
- Department of Anesthesiology, Teikyo University School of Medicine, Ichihara Hospital, Chiba, Japan
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Koide Y, Keehn L, Nomura T, Long T, Oka Y. Relationship of regional wall motion abnormalities detected by biplane transesophageal echocardiography and electrocardiographic changes in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 1996; 10:719-27. [PMID: 8910150 DOI: 10.1016/s1053-0770(96)80196-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND It has been demonstrated that new regional wall motion abnormalities (RWMAs) are infrequently associated with electrocardiographic (ECG) ischemic changes during coronary artery bypass graft (CABG) surgery. The evaluation of apical or basal areas by biplane transesophageal echocardiography (TEE) may clarify the relationship between RWMA and ECG changes. METHODS Biplane TEE and ECG (leads II and V5) were continuously monitored in a total of 98 patients undergoing CABG surgery to determine the incidence and characteristics of RWMAs and to relate these findings to ECG changes. RESULTS Twenty-four new RWMAs were detected in 21 (21%) patients. Incidences of new RWMAs in each view were found to be as follows: 12 (50%) in short-axis view (SAV); 5 (21%) in long-axis view (LAV); and 7 (29%) in both views. Ten of the 24 new RWMA episodes (42%) corresponded to ECG ischemic changes. These new ECG changes were significantly more common when the new RWMAs appeared on both views (86%) as compared with the LAV alone (0%) (p < 0.01) or with SAV alone (33%). Moreover, in patients with a greater number of abnormal segments (> 3), new RWMAs were significantly (p < 0.05) associated with ECG changes. CONCLUSION Biplane TEE provides additional information about spatial distribution of new RWMAs. This study was the first to demonstrate that a clear relationship between TEE and ECG ischemia exists. When these new RWMAs exhibited a large spatial distribution, the frequency of ECG ischemic changes increased.
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Affiliation(s)
- Y Koide
- Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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54
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Jopling MW. Pro: automated electrocardiogram ST-segment monitoring should be used in the monitoring of cardiac surgical patients. J Cardiothorac Vasc Anesth 1996; 10:678-80. [PMID: 8841878 DOI: 10.1016/s1053-0770(96)80148-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- M W Jopling
- Department of Anesthesiology, Ohio State University, Columbus 43210-1228, USA
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55
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ACC/AHA task force report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Cardiothorac Vasc Anesth 1996; 10:540-52. [PMID: 8776655 DOI: 10.1016/s1053-0770(05)80022-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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56
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Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH, Spittell JA, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A, Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 1996; 27:910-48. [PMID: 8613622 DOI: 10.1016/0735-1097(95)99999-x] [Citation(s) in RCA: 210] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- K A Eagle
- Educational Services, American College of Cardiology, Bethesda, Maryland 20814-1699, USA
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Affiliation(s)
- D T Mangano
- Department of Anesthesiology, University of California, San Francisco 94143, USA
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59
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Kozàkovà M, Palombo C, Pittella G, Distante A. Transesophageal echocardiography in myocardial ischemia: a review. Echocardiography 1995; 12:479-94. [PMID: 10172641 DOI: 10.1111/j.1540-8175.1995.tb00840.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This article reviews established as well as emerging fields in the application of transesophageal echocardiography (TEE) in the investigation of myocardial ischemia. TEE already has a well defined and established role in stress echocardiography in patients with poor transthoracic acoustic window, and in the detection of intraoperative myocardial ischemia in cardiac and noncardiac surgery. The evaluation of right ventricular ischemia and infarction and the assessment of coronary flow reserve (CFR) are relatively new fields in the application of TEE and the potential of this technique has not yet been fully evaluated. The evidence collected and reviewed in this article is still preliminary but it presupposes a significant role of TEE in the diagnosis and pathophysiological assessment of myocardial ischemia.
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Affiliation(s)
- M Kozàkovà
- Institute of Clinical Physiology, University of Pisa, Italy
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60
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Ellis JE, Klock PA, Klafta JM, Laff SP. Choice of anesthesia and intraoperative monitoring for lower extremity revascularization. Surg Clin North Am 1995; 75:665-78. [PMID: 7638712 DOI: 10.1016/s0039-6109(16)46689-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The prevalence of significant coronary artery disease re-enforces the importance of careful preoperative and intraoperative management in patients undergoing lower extremity revascularization. This article presents a practical approach toward the evaluation of anesthetic risk and the proper use of anesthetic agents and monitoring devices to minimize morbidity. The role of general and regional anesthetic agents is discussed, and complications of both techniques are presented.
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Affiliation(s)
- J E Ellis
- Department of Anesthesia and Critical Care, University of Chicago, Illinois, USA
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Pieper EP, Hellemans IM, Hamer HP, Ravelli AC, van den Brink RB, Ebels T, Lie KI, Visser CA. Additional value of biplane transesophageal echocardiography in assessing the genesis of mitral regurgitation and the feasibility of valve repair. Am J Cardiol 1995; 75:489-93. [PMID: 7863995 DOI: 10.1016/s0002-9149(99)80587-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To determine the additional diagnostic value of biplane transesophageal echocardiography (TEE) in patients undergoing mitral valve surgery, we studied 48 patients with severe mitral regurgitation. Transesophageal echocardiographic video recordings were reorganized in separate transverse and longitudinal sections to allow independent evaluation. Mechanism of mitral regurgitation and anatomic abnormalities of the mitral valve were assessed by all 3 transesophageal echocardiographic modalities and were related to surgical findings. Biplane TEE detected increased leaflet mobility with a sensitivity of 91% and a specificity of 84%, and restricted leaflet mobility with a sensitivity of 100% and a specificity of 97%. Biplane TEE was accurate in the diagnosis of most of the anatomic abnormalities associated with these mechanisms. However, the sensitivity for detecting subvalvular abnormalities (including papillary muscle abnormalities) was poor, and measurement of the annular diameter had a poor correlation with annular dilatation. Although the yield of biplane TEE was better than either transverse or longitudinal TEE alone, the differences did not reach statistical significance, because of the size of the patient group. The surgical procedure (either valve repair or replacement) was correctly predicted with transverse TEE in 71%, with longitudinal TEE in 69%, and with biplane TEE in 79% of the patients. All 3 transesophageal echocardiographic modalities are very capable of assessing the anatomic abnormalities and mechanism of mitral regurgitation, as well as predicting the feasibility of valve repair.
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Affiliation(s)
- E P Pieper
- Department of Cardiology, University Hospital Groningen, The Netherlands
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63
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Hohner P, Backman C, Diamond G, Friedman A, Häggmark S, Johansson G, Karp K, Reiz S. Anaesthesia for abdominal aortic surgery in patients with coronary artery disease, Part II: Effects of nitrous oxide on systemic and coronary haemodynamics, regional ventricular function and incidence of myocardial ischaemia. Acta Anaesthesiol Scand 1994; 38:793-804. [PMID: 7887100 DOI: 10.1111/j.1399-6576.1994.tb04007.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This study examines the effects of nitrous oxide on haemodynamics, anterior left ventricular (LV) function and incidence of myocardial ischaemia in abdominal vascular surgical patients with coronary artery disease. Forty-seven patients were randomly assigned to isoflurane-fentanyl anaesthesia with nitrous oxide-oxygen vs air-oxygen (control). Systemic and coronary haemodynamics, 12-lead ECG, LV anterior wall motion by cardiokymography (CKG) and myocardial lactate balance were recorded at four intervals: before and during anaesthesia and 10 and 30 minutes into surgery. Systemic haemodynamics were controlled by anaesthetic dose, and, when insufficient, by i.v. nitroglycerine (NG) in case of LV failure (PCWP > 18 mmHg) and by phenylephrine during hypotension. We found that nitrous oxide was associated with greater need for i.v. nitroglycerin (patients: P = 0.031, episodes P = 0.005) and more myocardial ischaemia (patients P = 0.012, episodes P = 0.001) despite systemic and coronary haemodynamics comparable to the control group. We conclude that nitrous oxide, known to have both sympathomimetic and cardiodepressive actions, produced cardiodepression in the face of sympathetic stimulation. Our study design did not allow to conclude if myocardial ischaemia was the consequence of increased wall stress or a reason for the observed LV dysfunction. The higher incidence of introperative myocardial ischaemia and need for NG did not cause increased cardiac morbidity.
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Affiliation(s)
- P Hohner
- Department of Anesthesiology, University of Umeå, Sweden
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64
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Hatangadi RB, Bashein G, Godwin JD, Martin RW. The geometrical relationship between the human esophagus and left ventricle: implications for three-dimensional ultrasonic scanning. ULTRASOUND IN MEDICINE & BIOLOGY 1994; 20:11-20. [PMID: 8197623 DOI: 10.1016/0301-5629(94)90012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
To establish design parameters for a transesophageal ultrasonic probe to image the left ventricle (LV) in three dimensions, the geometrical relationship between the esophagus and the heart was studied in computed tomographic sections of ten humans. Points describing the esophageal centerpoint and the left-ventricular endocardium were digitized. Algorithms were developed to determine from any esophageal viewpoint the ranges of motion required to cover the LV with four modes of scanning; transverse oblique, longitudinal oblique, rotary and linear. Longitudinal oblique scanning was the only single-degree-of-freedom method that allowed complete imaging of the LV in all patients. However, for both conventional and three-dimensional LV imaging, the most promising probe design appears to be a rotary scanning probe with an added degree of freedom to tilt the axis of rotation +/- 29 degrees away from an axis perpendicular to the local esophageal axis.
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Affiliation(s)
- R B Hatangadi
- Center for Bioengineering, University of Washington, Seattle 98195
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65
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De Hert SG, Moens MM, Vermeyen KM, Hageman MP. Use of the right-sided precordial lead V4R in the detection of intraoperative myocardial ischemia. J Cardiothorac Vasc Anesth 1993; 7:659-67. [PMID: 8305655 DOI: 10.1016/1053-0770(93)90049-q] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study evaluated the benefit of additional electrocardiographic monitoring of the right precordial lead V4R for detection of ST segment changes during elective coronary artery bypass surgery in 210 patients. ST segment analysis was performed for leads I, II, CB5, and V4R. ST segment changes were noted in 60 patients. Of these, 32 had combined left-sided and right-sided coronary artery disease (group A), and 28 had only left-sided coronary artery disease on coronary angiography (group B). Lead sensitivity was estimated assuming that all ST segment changes were true positive responses. Sensitivity using a single lead was greatest for lead CB5 in the two groups (76% in group A and 78% in group B). Sensitivity for lead I was low in both groups (34% in group A and 26% in group B). Sensitivity for lead II was 63% in group A and 52% in group B, and sensitivity for lead V4R was 71% in group A but only 37% in group B. Combination of leads V4R and CB5 increased sensitivity to 98% in group A. In group B, this lead combination had a sensitivity of 93%, but lead combinations I-CB5-V4R and II-CB5-V4R were more sensitive (97% and 100%, respectively). The monitoring of lead V4R allowed detection of 20% of ST segment changes in group A that would have passed undetected if only leads I, II, and CB5 were monitored. These results demonstrate the value of additional electrocardiographic monitoring of the right precordial lead V4R during coronary artery bypass grafting in patients with right-sided coronary artery disease.
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Affiliation(s)
- S G De Hert
- Department of Anesthesia, University Hospital Antwerp, Belgium
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66
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Pingitore A, Kozàkovà M, Picano E, Paterni M, Landini L, Distante A. Acute myocardial gray level intensity changes detected by transesophageal echocardiography during intraoperative ischemia. Am J Cardiol 1993; 72:465-9. [PMID: 8352193 DOI: 10.1016/0002-9149(93)91144-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- A Pingitore
- CNR, Institute of Clinical Physiology, Pisa, Italy
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67
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Sutton DC, Cahalan MK. Intraoperative Assessment of Left Ventricular Function with Transesophageal Echocardiography. Cardiol Clin 1993. [DOI: 10.1016/s0733-8651(18)30156-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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68
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Kato M, Nakashima Y, Levine J, Goldiner PL, Oka Y. Does transesophageal echocardiography improve postoperative outcome in patients undergoing coronary artery bypass surgery? J Cardiothorac Vasc Anesth 1993; 7:285-9. [PMID: 8518373 DOI: 10.1016/1053-0770(93)90006-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The incidence and characteristics of ischemic episodes as detected by transesophageal echocardiography (TEE) and their relationship to postoperative myocardial infarction (MI) and adverse clinical outcome were studied in patients undergoing coronary artery bypass grafting (CABG). Seventeen of 50 patients had 21 TEE-defined ischemic episodes: 4 patients (8%) had 4 ischemic episodes in the pre-cardiopulmonary bypass (CPB) period, and 15 patients (30%) had 17 ischemic episodes in the post-CPB period, whereas 19 patients had 20 ECG ischemic episodes: 3 patients (6%) had 3 ischemic episodes in the pre-CPB period and 17 (34%) had 17 ischemic episodes in the post-CPB period. In 14 patients, ischemic episodes were detected by both TEE and ECG. Clinicians were made aware of the TEE data and appropriate treatments were undertaken during ischemic episodes: of the 15 patients with TEE-defined post-CPB ischemia, 4 had an additional saphenous vein graft placed, 8 had an intra-aortic balloon pump (IABP) inserted, 3 were given sublingual nifedipine, and 13 received nitroglycerin. These treatments resulted in improvement in regional wall motion abnormalities (RWMA) by the end of surgery in 11 of the 15 patients (73%), including the 4 with postoperative MI and 2 who died with cardiogenic shock. The authors conclude that: (1) significantly more patients had TEE-defined ischemic episodes in the post-CPB period (30%) than in the pre-CPB period (8%); (2) a poor graft and/or inadequate myocardial protection were strongly suggestive of post-CPB ischemia, which was significantly related to adverse outcome; and (3) TEE was a useful tool enabling detection of problem areas at an early stage and timely and appropriate treatment to support and sustain patients.
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Affiliation(s)
- M Kato
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Anesthesiology, Bronx, NY 10461
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Bashein G, Sheehan FH, Nessly ML, Detmer PR, Martin RW. Three-dimensional transesophageal echocardiography for depiction of regional left-ventricular performance: initial results and future directions. INTERNATIONAL JOURNAL OF CARDIAC IMAGING 1993; 9:121-31. [PMID: 8331304 DOI: 10.1007/bf01151436] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To assess the potential of a prototype transesophageal echocardiography probe for evaluating left-ventricular wall motion in three dimensions, we acquired images under anesthesia in 15 patients who had akinesia or dyskinesia and 8 patients who had normal function demonstrated on preoperative ventriculography. Short-axis, oblique transgastric scans were obtained in 16 of the patients and four-chamber, long-axis oblique scans were obtained in 12 patients, with five patients (22%) yielding good-quality scans of both types. Off-line, we outlined the endocardial borders manually and used the outlines to make computer-generated three-dimensional models of the endocardial surfaces, color-tiled according to regional ejection fraction. Compared with contrast ventriculograms, the regional ejection fraction histograms derived from these models showed 86% concordance for detecting dyssynergy. However, the concordance between the ventriculograms and the color-tiled models in localizing the dyssynergy was only 67% overall. Uncertainty in rotational alignment between the reconstructions and the ventriculograms appeared to contribute to misreading the location of dyssynergy. In addition, the apical region appeared to have been missed in 8 (50%) of the short-axis scans, whereas it was visualized in all long-axis scans. We conclude that three-dimensional analysis of the location, extent, and degree of left-ventricular dyssynergy is feasible from transesophageal echocardiograms and could have wide application in the study of regional ventricular function. However, improvements are necessary to enable the transducer to scan the cardiac apex more reliably from the short-axis viewpoint and to have a means for spatially orienting the images with respect to an external frame of reference.
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Affiliation(s)
- G Bashein
- Department of Anesthesiology, University of Washington School of Medicine, Seattle 98195
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Abstract
Transesophageal echocardiography complements transthoracic examination in 5-10% of patients referred to the echocardiographic laboratory. Clinical indications for performing this procedure are continually evolving. The semi-invasive nature of this procedure necessitates that it be judiciously used and that trained personnel undertake the procedure. Complications of the procedure need to be kept in mind. Future directions in the development of this technology involve newer, multiplanar, multifrequency transducers, digital archiving and retrieval, wide-field imaging, and 3-dimensional reconstruction. For the present, transthoracic echocardiography must remain the primary echocardiographic window imaging the heart, with defined clinical applications for transesophageal echocardiography.
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Affiliation(s)
- B K Khandheria
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Krupski WC, Layug EL, Reilly LM, Rapp JH, Mangano DT. Comparison of cardiac morbidity between aortic and infrainguinal operations. J Vasc Surg 1992. [DOI: 10.1016/0741-5214(92)90257-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Granieri R, Macpherson DS. Perioperative care of the vascular surgery patient: the perspective of the internist. J Gen Intern Med 1992; 7:102-13. [PMID: 1548534 DOI: 10.1007/bf02599112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- R Granieri
- Department of Medicine, University of Pittsburgh, Pennsylvania
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Mangano DT, London MJ, Tubau JF, Browner WS, Hollenberg M, Krupski W, Layug EL, Massie B. Dipyridamole thallium-201 scintigraphy as a preoperative screening test. A reexamination of its predictive potential. Study of Perioperative Ischemia Research Group. Circulation 1991; 84:493-502. [PMID: 1860194 DOI: 10.1161/01.cir.84.2.493] [Citation(s) in RCA: 184] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND We examined the value of dipyridamole thallium-201 (201Tl) scintigraphy as a preoperative screening test for perioperative myocardial ischemia and infarction. METHODS AND RESULTS We prospectively studied 60 patients undergoing elective vascular surgery. We performed 201Tl scintigraphy preoperatively and blinded all treating physicians to the results. Historical, clinical, laboratory, and physiological data were gathered throughout hospitalization. Myocardial ischemia was assessed during the intraoperative period using continuous 12-lead electrocardiography (ECG) and transesophageal echocardiography (TEE) and during the postoperative period using continuous two-lead ambulatory ECG. Adverse cardiac outcomes (cardiac death, myocardial infarction, unstable angina, severe ischemia, or congestive heart failure) were assessed daily throughout hospitalization. Twenty-two patients (37%) had defects that improved or reversed on delayed scintigrams (redistribution defects), 18 (30%) had persistent defects, and 20 (33%) had no defects on 201Tl scintigraphy. There was no association between redistribution defects and adverse cardiac outcomes: 54% (seven of 13) of adverse outcomes occurred in patients without redistribution defects, and the risk of an adverse outcome was not significantly increased in patients with redistribution defects (relative risk 1.5, 95% confidence interval 0.6-3.9, p = 0.43). Consistent with these findings, there was also no association between redistribution defects and perioperative ischemia: 54% (19 of all 35) of perioperative ECG and TEE ischemic episodes and 58% (14 of 24) of severe ischemic episodes occurred in patients without redistribution defects. The sensitivity of 201Tl scintigraphy for perioperative ischemia and adverse outcomes ranged from 40% to 54%, specificity from 65% to 71%, positive predictive value from 27% to 47% and negative predictive value from 61% to 82%. CONCLUSIONS These results differ from those of previous studies and suggest that the routine use of 201Tl scintigraphy for preoperative screening of patients undergoing vascular surgery may not be warranted.
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Affiliation(s)
- D T Mangano
- Department of Anesthesia, University of California, San Francisco
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