The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

OBJECTIVES

Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO.

METHODS

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes.

RESULTS

We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86).

CONCLUSIONS

Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation

BACKGROUND

Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated.

METHODS

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year.

RESULTS

In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality.

CONCLUSIONS

A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study

Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.

The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane Oxygenation

BACKGROUND

Obesity is an important health problem in cardiac surgery and among patients requiring postcardiotomy venoarterial extracorporeal membrane oxygenation (V-A ECMO). Still, whether these patients are at risk for unfavorable outcomes after postcardiotomy V-A ECMO remains unclear. The current study evaluated the association between body mass index (BMI) and in-hospital outcomes in this setting.

METHODS

The Post-cardiotomy Extracorporeal Life Support (PELS-1) study is an international, multicenter study. Patients requiring postcardiotomy V-A ECMO in 36 centers from 16 countries between 2000 and 2020 were included. Patients were divided in 6 BMI categories (underweight, normal weight, overweight, class I, class II, and class III obesity) according to international recommendations. Primary outcome was in-hospital mortality, and secondary outcomes included major adverse events. Mixed logistic regression models were applied to evaluate associations between BMI and mortality.

RESULTS

The study cohort included 2046 patients (median age, 65 years; 838 women [41.0%]). In-hospital mortality was 60.3%, without statistically significant differences among BMI classes for in-hospital mortality (P = .225) or major adverse events (P = .126). The crude association between BMI and in-hospital mortality was not statistically significant after adjustment for comorbidities and intraoperative variables (class I: odds ratio [OR], 1.21; 95% CI, 0.88-1.65; class II: OR, 1.45; 95% CI, 0.86-2.45; class III: OR, 1.43; 95% CI, 0.62-3.33), which was confirmed in multiple sensitivity analyses.

CONCLUSIONS

BMI is not associated to in-hospital outcomes after adjustment for confounders in patients undergoing postcardiotomy V-A ECMO. Therefore, BMI itself should not be incorporated in the risk stratification for postcardiotomy V-A ECMO.

Heterogeneity in Clinical Practices for Post-Cardiotomy Extracorporeal Life Support: a Pilot Survey from the PELS-1 Multicenter Study

BACKGROUND

High-quality evidence for post-cardiotomy extracorporeal life support (PC-ECLS) management is lacking. This study investigated the real-world PC-ECLS clinical practices.

METHODS

This cross-sectional, multi-institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC-ECLS monitoring and transfusions practices. Twenty-nine questions were distributed among 34 hospitals participating in the Post-cardiotomy Extra-Corporeal Life Support Study.

RESULTS

Of the 32 centers [16 low-volume (50%); 16 high-volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty-six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patient's bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged 7-10 g/dL. Most centers used cardiac venting on a case-by-case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols including daily echocardiography (87.5%), Swan-Ganz catheterization (40.6%), cerebral near-infrared spectroscopy (53.1%) and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d-dimer (59.4%), lactate dehydrogenase (56.3%) and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis.

CONCLUSIONS

This study shows remarkable heterogeneity in clinical practices for PC-ECLS management. More standardized protocols and better implementation of available evidence are recommended.

Cost-Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand

Background

Transcatheter aortic valve implantation (TAVI) has been shown to be effective in treating patients with severe symptomatic AS who are high-risk population for conventional surgical aortic valve replacement (SAVR). This study aimed to evaluate the cost–utility of TAVI compared with SAVR for severe aortic stenosis with high surgical risk in Thailand.

Methods

Lifetime costs and quality-adjusted life years (QALYs) from societal and healthcare perspectives were estimated using a two-part constructed model. The study population consisted of 80-year-old severe AS patients with high surgical risk. Mortality and complication rates were obtained from landmark trials. All cost–related and utility data were based on Thai population. Costs and QALYs were discounted at a rate of 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were computed. Sensitivity analyses were performed both deterministically and probabilistically.

Results

The findings from a societal perspective revealed that TAVI treatment was associated with higher cost (THB 1,551,895 [USD 47,371.64] vs THB 548,438 [USD 16,741.09] and higher QALYs than SAVR treatment (3.15 vs 2.31 QALYs). The estimated ICER was THB 1,196,191/QALY (USD 36,513.78 QALY). For the healthcare system perspective, TAVI treatment resulted in a higher total cost than SAVR treatment (THB 1,451,317 [USD 44,301.49] vs THB 432,398 [USD 13,198.95]) with comparable gains in LY and QALYs from a societal perspective. The ICER was calculated to be THB 1,214,624/QALY (USD 37,076.42/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4884/QALY). The model was the most sensitive to changes in TAVI valve cost and TAVI or SAVR treatment utilities.

Conclusion

TAVI is not a cost-effective strategy in patients with severe AS who are at high surgical risk when compared to SAVR at the WTP of THB 160,000/QALY (USD 4884/QALY) from the perspectives of society and the healthcare system.

Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement

Background

Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs).

Methods

Consecutive patients who underwent TAVR during December 2009–March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University—Thailand’s largest national tertiary referral center—were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively.

Results

A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56–35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86–40.62; p =  < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896).

Conclusion

This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm.

Trial registration: TCTR, TCTR20210818002. Registered 17 August 2021—Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

P861 Immediate aortic dissection after transcatheter aortic valve replacement (TAVR)

Transcatheter aortic valve replacement (TAVR) is a treatment of choice for treating symptomatic severe aortic stenosis patient whose condition is considered the high and intermediate operative risk for surgical aortic valve replacement. Here, we present a case of 67-year-old man with symptomatic severe aortic stenosis, triple vessels disease, type 2 diabetes mellitus and end-stage renal disease who was treated with TAVR. After the valve was deployed, we found the abnormal leakage at descending aorta by transesophageal echocardiogram (TEE). Under intraoperative close monitoring, the dissection was slowly expanding so we decided to perform thoracic endovascular repair (TEVAR). In conclusion, TEE after TAVR procedure is helpful to detect this rare complication.

Reported cases of AD status post TAVR Author Sex/Age Comorbidity Detection time of AD Site of AD Detection of AD Treatment for AD Result Route access of TAVR This case 2018 M/67 DM, ESRD Immediate after implant Ds TEE TEVAR Recovery Femoral Losmanova et al. 2018 F/81 NA 3 yrs As Autopsy Conservative Died NR Kratimenos et al. 2016 F/81 COPD, renal dysfunction, angiodysplasia 12 days Ds CT TEVAR Recovery Femoral Nagasawa et al. 2016 F/86 Heart failure During the procedure Ds TEE Conservative Recovery Femoral Yashima et al. 2015(14) F/88 NA 3 days As CT Conservative Recovery Femoral Van Mieghem et al. 2013 F/86 Coronary artery disease, post total knee prosthesis 1-2 hours As Angiogram TEVAR Recovery Femoral Loeser et al. 2013 F/89 NA 2-5 hours As Autopsy NA Cardiogenic shock and died Femoral Bibombe et al. 2013 M/83 Previous CBG, HT, DLP During the procedure As and Ds TEE, CTA, angiogram Open surgery Recovery Femoral Al-Attar et al. 2013 F/84 HT, thrombophlebitis 8 months 2 weeks As CT Open surgery Arrest and died Femoral D"Onofrio et al. 2012 F/79 RA, pulmonary edema, cerebral hemorrhage Immediate after implant As TEE Open surgery Died 32 day later due to septic shock Aortic Ong et al. 2011 M/90 HT, CA prostate, CKD, gastric and duodenal ulcer Immediate after implant As TEE Conservative Recovery Femoral Gerber et al. 2010 F/83 DM, LE 22 days As Autopsy NA Cardiac arrest and died Femoral Abbreviations M Male; F Female; DM Diabetes mellitus; ESRD End-stage renal disease; NA Not available; COPD Chronic obstructive pulmonary disease; CBG Coronary bypass graft; HT hypertension; DLP Dyslipidemia; RA Rheumatoid arthritis; CA cancer; CKD Chronic kidney disease; LE Lupus erythematosus; AD Aortic dissection; As Ascending; Ds Descending; TEVAR Thoracic endovascular aortic repair.

Abstract P861 Figure. Intraoperative TEE after TAVR

Validation of EuroSCORE for coronary artery bypass grafting at Siriraj Hospital

OBJECTIVE

To access the performance of the EuroSCORE when applied to CABG patients at Siriraj hospital.

MATERIAL AND METHOD

One thousand five hundred forty nine patients diagnosed with coronary artery disease (CAD) who underwent isolated CABG between January 2007 and December 2009 was prospectively studied.

RESULTS

The patients included 1,102 men and 447 women and had a mean age of 67 years old. The mean additive score in expired and survived groups were 9.65 +/- 5.14 and 3.87 +/- 3.06. In logistic, score were 25.43 +/- 26.31 and 4.88 +/- 7.88 respectively (p < 0.001). The best cut-off value of EuroSCORE for prediction of a death rate was 6 for additive score and 10 for logistic score. Area under the curve was 0.831 for the additive score and 0.823 for the logistic score. The observed overall mortality rate was 2.0% while the predict mortality was 5.27%. The difference between observed and predicted deaths was significant with additive score and logistic score (p < 0.001).

CONCLUSION

Our results suggest that EuroSCORE is not valid for CABG in Thai patient due to over prediction.

Transcatheter aortic valve implantation (TAVI): first case in Thailand

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.

Successful late restoration of traumatic distal bronchial separation

Traumatic distal bronchial interruption is unusual. A 42-year-old male with history of blunt injury to his chest and abdomen 20 years previously presented with recurrent pneumonia of the right lung. Patient's middle and lower lobes were partially atelectatic and the right intermediate bronchus was found completely dehisced at the time of surgical exploration. A direct re-implantation of intermediate bronchus was successfully performed. At late follow-up the anastomosis had healed well without any stricture and patient remains without symptoms.

Postpneumonectomy syndrome in single lung transplantation recipient following previous pneumonectomy

Successful single lung transplantation following previous pneumonectomy has not been reported in the literature. We report a patient with cystic fibrosis who underwent left single lung transplantation following right pneumonectomy 13 years previously. The outcome was adversely affected by postpneumonectomy syndrome.

Minimal access closure of patent foramen ovale: is it also recommended for patients with paradoxical emboli?

BACKGROUND

To investigate the outcome of the port-access approach for patent foramen ovale (PFO) closure and to identify the long-term risk of recurrent thromboembolic events in the paradoxical embolus subgroup after closure.

METHODS

Between 1997 and 2001, 31 patients underwent PFO closure using the port-access approach. Twelve of the 31 patients underwent PFO closure secondary to at least one paradoxical embolic event leading to either transient ischemic attack or cerebral infarction. All patients were followed longitudinally with office visits and telephone interviews.

RESULTS

The mean age was 47 years (range 18 to 85 years). All procedures were completed successfully without conversion to median sternotomy. The mean duration of aortic occlusion and cardiopulmonary bypass for all patients (n = 31) was 32 minutes (range 17 to 55 minutes) and 72 minutes (range 40 to 124 minutes), respectively. Postoperative complications included pneumonia/pulmonary embolus (n = 1), transient atrial fibrillation (n = 3, 9.7%), and exploration for bleeding (n = 3, 9.7%). No deaths were recorded. All patients were assessed using transesophageal echocardiography, and the closure of the PFO was documented. The average length of hospital stay was 3.8 days (range 2 to 10 days) for patients with paradoxical emboli. The mean follow-up period for the paradoxical embolus subgroup was 23 months (range 4 to 45 months). One patient was lost to follow-up. Neither transient ischemic attack nor cerebral infarction recurred during follow-up.

CONCLUSIONS

The port-access approach to PFO closure is a safe and effective procedure, with acceptable initial experience outcome and excellent low-risk rate of recurrent thromboembolic events.

Double annulus enlargement, Rastan-Manouguian's technique: a case report

A 35-year old female patient underwent a double valve replacement. The operative findings revealed a small aortic annulus (about 17 mm in diameter). In order to implant the adequate-size prosthetic valve, the aortic and mitral annulus were enlarged using the technique described by Rastan and Manouguian. The annulus were enlarged with a patch of gel-sealed dacron graft. After the enlargement, the prosthetic valve No. 23A and 31M could be implanted in the aortic and mitral annulus, respectively. This is an effective technique to enlarge the aortic and mitral annulus in a double valve replacement procedure. The annular diameter could be increased approximately 30 per cent.

Effect of different oral anticoagulant intensities on prothrombin fragment 1 + 2 in Thai patients with mechanical heart valve prostheses

The minimal intensity of oral anticoagulant required for antithrombotic protection in patients with a mechanical heart valve is still debatable, and that of the Westerner may not be directly applied to Thai patients. Our preliminary clinical review suggested that International Normalized Ratio (INR) 2-3 might be enough but it needs further supporting evidence. Therefore, we studied the effect of different anticoagulant intensities, expressed as INR, on the in vivo coagulation activation by measuring prothrombin fragment 1 + 2 (F1 + 2) in 116 patients with mechanical heart valve replacements. The patients had received warfarin for not less than one month with different intensities. The mean +/- S.D. of F1 + 2 level in 30 normal controls was 0.7 +/- 0.17 nmol/L. After excluding two outliers, the maximum linear correlation between INR and F1 + 2 was -0.658 (p < 0.001) when only patients whose intensities were lower than INR3 were taken into account. Adding more data from the patients having higher intensities decreased the correlation coefficient. The patients were subsequently classified by INR values in the range INR 1.1-1.9, 2-3 and 3.1-4.2. The F1 + 2 in each group was 0.6 +/- 0.30, 0.28 +/- 0.13 and 0.24 +/- 0.13 nmol/L respectively. The F1 + 2 in the first group did not differ from normal (p = 0.119) but was higher than the others (p = 0.000). The latter two groups had no difference between them (p = 0.112). Hence, from the laboratory point of view, we did not see additional benefit in the reduction of thrombin activation by the anticoagulant intensities higher than the range INR 2-3. The evidence supported that this therapeutic range might be enough for Thai patients with mechanical heart valves.

Intraoperative transesophageal echocardiography: preliminary experience at Siriraj hospital

In order to evaluate the result of intraoperative TEE monitoring for cardiothoracic surgery, 113 patients were involved in this study. They included 65 males and 48 females, with an average age of 48.8 +/- 16.6 years, ranging from 10 to 74 years. The pre-operative diagnoses consisted of 41.6 per cent coronary artery disease, 34.5 per cent valvular disease, 12.4 per cent congenital heart disease, 8 per cent aortic aneurysm or aortic dissection, and 3.5 per cent of miscellaneous. The TEE appeared to provide accurate information by beating to changes in the left ventricular preload and contractility in all patients. The severity of valvular dysfunction, intracardiac air/mass, Swan Ganz catheter position, sites of congenital heart defect and aortic dissection were either assessed or reconfirmed during the operation. The ease of TEE technique was satisfactory, since unsuccessful attempt was observed in only 1.8 per cent. One patient died from rupture of thoracic aortic dissection which was related to TEE probe insertion. These data suggest the favorable result of intraoperative TEE as a valuable tool for monitoring in cardiothoracic surgery. Although the technique is simple, special precaution must be observed for patients suffering from acute aortic dissection.

Echocardiographic diagnosis of a ruptured aneurysm of the sinus of Valsalva: operation without catheterisation in seven patients

A ruptured aneurysm of the sinus of Valsalva was diagnosed by Doppler, colour, and cross sectional echocardiography in a consecutive series of seven patients. The diagnoses were confirmed at operation without cardiac catheterisation. Examination by pulsed and continuous Doppler echocardiography showed continuous turbulence in six patients with aneurysms rupturing into the right ventricular outflow tract and in the patient with rupture of an aneurysm of the non-coronary sinus into the right atrium. Colour Doppler echocardiography showed turbulent flow across the defects in all seven patients. A ventricular septal defect with aortic regurgitation was detected in one patient and an associated ventricular septal defect in another. Doppler, colour, and cross sectional echocardiography were useful non-invasive techniques for diagnosing a ruptured aneurysm of the sinus of Valsalva without the need for cardiac catheterisation.