Anesthetic considerations for functional endoscopic sinus surgery in a patient with Kartagener syndrome

Kartagener's syndrome (KS) is a rare genetic disease characterised by the triad of sinusitis, bronchiectasis, and situs inversus. This syndrome is associated with an increased risk of respiratory complications. Therefore, both the anaesthetic technique and the agents used must be carefully chosen according to the type of intervention and the patient's baseline condition. We present the case of a 48-year-old woman with KS, scheduled for functional endoscopic sinus surgery (FESS) and septoplasty under general anaesthesia. The main anaesthetic considerations in patients with KS are related to anatomical variations, pulmonary and cardiac functions, and respiratory infections. In this case, measures that reduce perioperative complications in KS are reviewed together with the special anaesthetic management in FESS, derived primarily from the need to maintain a bloodless surgical field and the use of induced hypotension techniques.

[A New-born Case of Total Conus Defect and Single Coronary Artery with Situs Inversus Totalis Suspected Kartagener Syndrome]

We report a new-born case of total conus defect type ventricular septal defect (VSD) and single coronary artery with situs inversus totalis, suspected Kartagener syndrome clinically. After the birth, as the patient had suffered from respiratory distress due to high pulmonary blood flow through the large defect, surgery was planned at age of 14-days after birth. Under median sternotomy and cardiac arrest, patch closure of VSD was performed as ordinary fashion. In spite of the situs inversus totalis and single coronary artery arose from right coronary sinus, operator could have completed all of surgical procedure at the right side of patient as usual. No remarkable respiratory complication was seen postoperatively and she was discharged from hospital 18th day in a good condition.

Cardiopulmonary Exercise Testing in Fontan Patients With and Without Isomerism (Heterotaxy) as Compared to Patients With Primary Ciliary Dyskinesia and Subjects With Structurally Normal Hearts

Isomerism, also known as heterotaxy, is a clinical entity that impacts multiple organ systems both anatomically and functionally. The airways and lungs are involved in a great number of these patients, leading to increased sinopulmonary symptoms, increased need for oxygenation, and increased postoperative ventilatory support. Additionally, these patients often have congenital heart disease requiring Fontan palliation. What has not been previously described, and is the focus of this study, is the results of cardiopulmonary exercise testing in those who have undergone Fontan palliation with and without isomerism. We have now compared these finding with those from patients with primary ciliary dyskinesia, as many patients with isomerism have ciliary dyskinesia. We identified patients having the Fontan circulation with and without isomerism who had undergone cardiopulmonary exercise testing, comparing the findings from healthy individuals undergoing exercise, and a comparable number of individuals with primary ciliary dyskinesia but no congenital heart disease. We were able to include a total of 68 patients in our study, with 17 in each of the four groups. Cardiopulmonary exercise testing yielded the best results in healthy patients. All patients with the Fontan circulation demonstrated mixed pulmonary disease, although those with isomerism had greater FVC and FEV1. Exercise times did not differ, although peak consumption of oxygen was greater in those with isomerism. Those with ciliary dyskinesia had only obstructive pulmonary disease and had the lowest FEF25-75 between all groups. Those with isomerism had a lesser degree of obstructive pulmonary disease when compared to those with primary ciliary dyskinesia. Patients with the Fontan circulation with and without isomerism have relatively subtle differences in their cardiopulmonary exercise testing, with both groups demonstrating restrictive lung disease. In regard to obstructive lung disease, those with isomerism tend to be more similar to the patients with primary ciliary dyskinesia than those with the Fontan circulation but without isomerism. The results are likely limited by selection bias and highlight the need for multicentric efforts to characterize cardiopulmonary exercise testing in those patients with pulmonary isomerism.

Clinical features of primary ciliary dyskinesia in Cyprus with emphasis on lobectomized patients

BACKGROUND

Despite the manifestations of primary ciliary dyskinesia (PCD) in early life, the diagnosis is often much delayed. Since 1998 in Cyprus, we have established the only national diagnostic and clinical referral center for PCD.

OBJECTIVE

To review the phenotypic features at presentation of PCD patients in Cyprus in relation to age at diagnosis, with emphasis on previously lobectomised patients.

METHODS

The medical records of the diagnosed PCD patients were retrospectively reviewed to obtain clinical data on presentation.

RESULTS

Thirty patients, aged 13.9 years (range 0.1, 58.4 years), were diagnosed with PCD. Twelve of them presented after the age of 18. The most common manifestations were chronic cough (100%), chronic rhinorrhea (96.7%), sputum production (92.9%), laterality defects (63.3%), a history of pneumonia (53.3%) and neonatal respiratory distress (50%). A history of lobectomy in the past was recorded in 16.7% (5 patients). Patients who presented in adulthood had significantly higher frequency of lobectomy (41.7% vs 0%, p-value = 0.006) and had more frequently low FEV1 (58.3% vs 0%, p-value = 0.015) than those who presented before. Serial measurements of FEV1 and FVC indicated significantly lower intercepts in lobectomised compared to the adult non-lobectomised patients both in terms of FEV1 (-4.90 vs -1.80, p-value = 0.022) and FVC (-5.43 vs -1.91, p-value = 0.029) z-score levels. Change in FEV1 and FVC across time was not statistically significant in either group.

CONCLUSIONS

PCD often remains undiagnosed up to adulthood accompanied by appearance of advanced lung disease. Performance of lobectomies seems to be a poor prognostic factor for PCD in adulthood.

Simultaneous sinus and lung infections in patients with primary ciliary dyskinesia

CONCLUSION

The sinuses should be considered as a bacterial reservoir and a target for surgery and antibiotic treatment in patients with primary ciliary dyskinesia (PCD). The observed decrease in serum precipitating antibodies (precipitins) against Pseudomonas aeruginosa may indicate a beneficial effect of combined endoscopic sinus surgery (ESS) and concomitant medical treatment.

OBJECTIVES

The purpose of this research, which is the first study addressing bacteriology in the sinuses of patients with PCD, was to examine the association between sinus and lung infections.

METHODS

We reviewed findings of bacterial pathogens from the sinuses obtained during ESS and the lung infection status in eight PCD patients over a 6 year period. Precipitins against P. aeruginosa were used as a marker of severity of chronic infection and effect of treatment.

RESULTS

Preoperatively, seven of the eight patients (88%) exhibited intermittent or chronic pulmonary infection with P. aeruginosa. Sinus cultures were obtained during ESS in seven patients. The sinuses were colonized with P. aeruginosa in four of seven patients (57%). Bacterial sinusitis was found in five of seven patients (71%) and the same bacterium was found in the sinuses and lungs in all cases. Decreasing precipitins against P. aeruginosa were observed postoperatively in three of four evaluable patients.

A case of surgically resected lung cancer in a patient with Kartagener's syndrome

Kartagener's syndrome is a rare inherited disorder with a triology of symptoms (bronchiectasis, sinusitis and situs inversus) and is also associated with abnormalities of the cilia of the respiratory epithelium. Lung cancer arising in Kartagener's syndrome is very rare and to date only 5 cases have been reported in the English and Japanese literature. We report on a case of a 65-year-old Japanese male Kartagener's syndrome patient with squamous cell carcinoma of the lung. A left pneumonectomy was performed and no recurrence was found within 2 years.

[Difficult airway management for general anesthesia in two patients with Kartagener syndrome]

Two patients with Kartagener syndrome were managed under general anesthesia by nasal intubation for sagital split ramus osteotomy. Many episodes of expectoration were encountered in the former patient's perioperative period and the expectoration discharge was inadequate by postoperative nausea, leading to trouble in airway management. In the second patient, tube collapse was caused after intubation by serious nasal cavity strangulation, and re-intubation was necessary. Expectoration is seen resulting from decreased ciliary function with bronchiectasis during anesthetic management of patients with Kartagener syndrome. It is important to prevent lung complications by nausea prevention and pain killing in the postoperative period, in addition to proper suctioning in the perioperative period. Furthermore, there is nasal cavity narrowing by chronic sinusitis. When performing nasal intubation, the difficult airway management is required.

Dextrocardia and corrected transposition of the great arteries (I,D,D) in a case of Kartagener's syndrome: a unique association

Kartagener's syndrome (KS) usually includes mirror-image dextrocardia. The incidence of congenital heart disease in KS is comparable with that in the general population. This paper reports on a case of Kartagener's syndrome associated with dextrocardia, corrected transposition of the great arteries (I,D,D), ventricular septal defect, and valvar pulmonary stenosis in an 8-year-old girl.

Sudden hypoxia during anesthesia in a patient with Kartagener's syndrome

We report a case of anesthesia in an adolescent with recurrent left pneumothorax, Kartagener's syndrome, and severe learning disability with behavioral difficulties. After induction of anesthesia, he rapidly developed severe desaturation as measured on pulse oximetry. Placement of an intercostal chest drain did not remedy the situation and he was found to have blocked the left main bronchus with viscous secretions. Subsequent suctioning relieved the obstruction. Despite successful postoperative thoracic epidural analgesia and minitracheostomy for bronchial toilet, he developed bronchopneumonia that resolved with antibiotics. We discuss anesthesia for patients with Kartagener's syndrome and for patients with pneumothorax.

Spinal anesthesia in Kartageners syndrome

Kartageners syndrome, an autosomal recessive disorder is a combination of dextrocardia situs inversus, bronchiectasis and sinusitis. We report a 22-year-old woman with this syndrome scheduled for appendectomy. Spinal anesthesia was preferred for the patient with this rare disorder due to the relative advantages of the regional technique over general anesthesia.

Anaesthetic considerations in Kartagener's syndrome -- a case report

Kartagener's syndrome is a rare disorder characterized by the triad of situs inversus, including dextrocardia, bronchiectasis and paranasal sinusitis. We report the anaesthetic management of a patient with Kartagener's syndrome and postrenal transplant immunosuppression, presenting for repair of uterovaginal prolapse. Combined spinal epidural anaesthesia was administered to this patient. The anaesthetic considerations of this rare disorder and the relative advantages of the regional technique over general anaesthesia in this situation are discussed.

General anaesthesia for lobectomy in an 8-year-old child with Kartagener's syndrome

Kartagener's syndrome (KGS) is an autosomal recessive disorder characterized by the clinical triad of bronchiectasis, sinusitis and dextrocardia (situs inversus). Reports of general anaesthesia in a child with KGS are rare in medical literature. We describe the case of a young boy who underwent lobectomy under general anaesthesia using a single lumen tube. Anaesthetic implications of this syndrome are mentioned. Key points in the management of anaesthesia in KGS are discussed.

Radiofrequency catheter ablation of "typical" atrial flutter in a patient with Kartagener's syndrome

Kartagener's syndrome and radiofrequency catheter ablation for the treatment of atrial flutter have been well described in separate reports. This case report includes both in describing a patient with Kartagener's syndrome who had medically refractory atrial flutter that was successfully treated with radiofrequency catheter ablation.

[Kartagener's syndrome: a case report]

The authors report a rare case of Kartagener's syndrome in 8 years old girl revelated by congenital cardiopathy with chronic bronchitis and severe heart failure. Incomplet endocardial cushion defect with single atrium was found and situs inversus suspected, confirmed by ultrasonography. She undergone cardiac surgery in Europe: atrial septation and mitralvalve repair. Surgery redux was neccessary formitral insufficency and residual shunt. Persistent atelectasia in lower inferior lobe indicated bronchoscopy. Lung biopsy confirmed Kartagener's syndrome. Now, she has no cardiac symptom, but bronchitis and chronic pansinusitis.

[Observation of nasal mucosal cilia ultrastructure of Kartagener's syndrome]

OBJECTIVE

To report the ultrastructure of nasal mucosal cilia of Kartagener's syndrome and the operative results of 2 cases.

METHODS

Both two cases were underwent endoscopic sinus surgery. Transmission and scanning electron microscopic examinations of nasal mucosa for case 1 were performed.

RESULTS

All 2 cases presented situs inversus, chronic paranasal sinusitis and bronchiectasis. The electron microscopic examination showed that the shape of nasal cilia and "9 + 2" structure were normal, but the lack of inner dynein arm of cilia and confused arrangement of central pair of microtubules were confirmed. The recurrent of nasal polyps after 1-year follow-up was observed in case 1.

CONCLUSIONS

The disturbance of mucociliary clearance due to congenital ciliary structure defect might be the cause of chronic sinusitis and polyps, which might be one of reasons for poor prognosis after operation and we should pay more close attention.

Anaesthesia for Kartagener's syndrome

Kartagener's syndrome is a hereditary syndrome involving a combination of dextrocardia (situs inversus), bronchiectasis and sinusitis, transmitted as an autosomal recessive trait. We describe a patient who had three anaesthetics over a period of a few months. Discussion relates to anaesthetic considerations in the syndrome and to recent findings relating to the molecular mechanisms of left-right development.

[Sequential double lung transplant in Kartagener's syndrome]

Very few cases of lung transplantation have been described for patients with Kartagener's syndrome. We report the first case to be published in Spain. A 15-year-old girl with complete Kartagener's syndrome underwent sequential transplantation of both lungs. Due to the unusual distribution of the organs in this syndrome, the bronchial stumps of donor and recipient had to be distributed differently. With the initial technical difficulties overcome, the patient now leads a normal life two years after transplantation.

Severe hemoptysis requiring lobectomy in an 11-year-old patient with Kartagener's syndrome

The case of a young girl with severe hemoptysis in a Kartagener's syndrome is described. Because bronchoscopy failed to locate the origin of the bleeding, preoperative angiography was performed. The patient was treated by resection of the middle lobe. The bronchus wall was located as the origin of bleeding.

Cardiac surgery for Kartagener syndrome

Two patients (one girl, one boy) with Kartagener syndrome (situs inversus, bronchiectasis, sinusitis), despite pulmonary problems and associated congenital cardiac anomalies, were operated on at the ages of 4 years and 7 years, respectively. They had had previous palliative treatment at the age of 3 months and 1.3 years, respectively. Both postoperative periods after total correction were without significant complications. Long-term follow-up was available for 9 and 19 years, respectively, with no manifestations of heart insufficiency. Both patients are physically active, and neither requires cardiac medication. Patients with Kartagener syndrome and associated congenital cardiac anomalies can successfully undergo multiple cardiac operations with good long-term outcome.

Kartagener's syndrome: clinical presentation and cardiosurgical aspects

BACKGROUND

Long-term observations in patients with Kartagener's syndrome (situs inversus, bronchiectasis, and sinusitis) are rare. The role of additional cardiac malformations and their surgical repair is not well known.

METHODS

Nine patients (5 female and 4 male) with Kartagener's syndrome were identified and followed. Four patients had associated cardiac anomalies; 4 underwent total surgical repair at the ages of 4 (2 patients), 7, and 34 years.

RESULTS

The postoperative period was uneventful, and these 4 patients are doing well 7 months and 2, 9, and 19 years after repair. The other patients are being treated with conservative therapy and are in relatively good condition.

CONCLUSIONS

This disease can be temporarily benign when treated with antibiotics and physiotherapy. Associated cardiac anomalies seem to be quite common, and such patients need careful cardiologic follow-up. Surgical intervention can be safely performed in patients suffering from Kartagener's syndrome associated with a congenital cardiac malformation and produces good long-term results. Bilateral lung transplantation seems to be the therapy of choice in patients with respiratory insufficiency but without concomitant cardiac anomalies.

Heart-lung transplantation in situs inversus

Reconstruction was accomplished in a 2 heart-lung recipients with situs inversus resulting in a left-sided systemic venous atrium. We created a large common atrium that was closed on the left side, leaving an atrial cuff on the inferior right quadrant. To this we anastomosed the donor right atrium, which had been opened laterally between the cavae. This resulted in some clockwise rotation of the ventricles and anterior positioning of the apex. The right pulmonary veins passed superior to the atrial anastomosis and posterior to the donor right atrium. Cardiopulmonary function was excellent in both cases.

[The Kartagener syndrome]

A 25-year-old woman with Kartagener's syndrome was admitted to hospital for laparoscopy because of sterility. Kartagener's syndrome is a rare disorder involving the combination of situs inversus, bronchiectasis and sinusitis. A dynein deficiency leads to ciliary dyskinesia. When general anaesthesia is to be induced in a patient with Kartagener's syndrome the following points must be borne in mind: ascertainment of the preoperative pulmonary status, antibiotic coverage, recognition of dextrocardia, necessity for aseptic techniques because of the possibility of abnormal neutrophil chemotaxis. Anticholinergic and antitussive medications are relatively contraindicated, as are nasal tubes. In the present case an intubation anaesthesia with thiopental, nitrous oxide, enflurane and succinylcholine was carried out; cefoxitin was administered for antibiotic treatment, and the patient made an uneventful recovery.

Double lung transplantation in situs inversus with Kartagener's syndrome. Paris-Sud University Lung Transplant Group

En bloc double lung transplantation with bilateral bronchial anastomoses was successfully performed in three patients with complete situs inversus and end-stage Kartagener's syndrome. Dextrocardia was not a technical problem for institution of cardiopulmonary bypass, but a large azygos vein draining the systemic venous return was systematically preserved. The major technical difficulty was restoration of airway continuity, because patients with situs inversus have an inverse direction and length of the main stem bronchi. The right and left main bronchi of the recipients were approached in the aortocaval sinus and transected approximately at 1.5 cm from the carina. The donor right main stem bronchus was divided at its origin and the donor left main stem bronchus was divided proximal to the upper lobe takeoff. The different bronchial angulation was not an obstacle, and airway continuity was reestablished twice with an end-to-end anastomosis and once with a telescopic technique. Because of the midline position of the left atrium and pulmonary artery, the anastomoses with the respective recipient's structures were made as in patients with situs solitus. One patient required a right lower lobectomy because the position of the right side of the heart interfered with lobar expansion. One patient died of obliterative bronchiolitis 36 months after the operation. The remaining two are alive and doing well after 48 and 6 months, respectively.

Lung transplantation in Kartagener's syndrome

Kartagener's syndrome is associated with bronchiectasis and situs inversus and may offer an indication for lung transplantation. One case of heart and lung transplantation has been published that stresses the necessity for a modified surgical procedure creating a large single atrium to manage the situs inversus. We performed a double lung transplantation in a 46-year-old patient with this disease. No technical modifications for the different anatomic relationship were necessary; discrepancies of the bronchial lumina were easily overcome.

Heart-lung transplantation in situs inversus. A case report in a patient with Kartagener's syndrome

After a long history of recurrent chronic pulmonary infections in a 25-year-old woman with Kartagener's syndrome, a heart-lung transplantation was performed. A modified surgical procedure was needed to perform transplantation because of the presence of a situs inversus, which is usually associated with bronchiectasis and sinusitis in this congenital syndrome. A large single atrium was created with both the right and left recipient atria used to facilitate anastomosis with the donor's right atrium. The patient was discharged after resolution of early ventilatory complications and is in good condition 8 months after transplantation.

Kartagener's syndrome seen on CT

The authors present a case of Kartagener's syndrome that was seen on CT. To the authors' knowledge, this is the first reported case of such. The appearance and interesting aspects of the case will be described.

[Cartagener syndrome. Pathogenesis and therapy]

Kartagener's syndrome (situs inversus totalis, bronchiectasis and sinusitis) was demonstrated in two patients. Electron microscopic investigations of the bronchial epithelium showed an accidental arrangement of ciliary axes, but not the expected lack of dynein arms. In both cases severe disturbance of maturation of spermiogenesis, not noted in this syndrome so far, was observed. Whereas one patient is largely free of symptoms after two operations, the other died after the second operation as a consequence of bronchopleural fistulation and bilateral pneumonic complications.

Surgical treatment of bronchiectasis in Kartagener's syndrome

A case of Kartagener's syndrome in which bilateral partial pulmonary resection was performed is reported. The literature concerning the surgical treatment of severe bronchiectasis is reviewed.

[Kartagener's syndrome in childhood. Report of 2 cases]

Two cases of children with the syndrome (triad) of Kartagener are described. One of them presented two of the triad's components; the other one, probably complete, as a part of a partial revision of clinical charts, corresponding to children with "situs inversus", from 1970 to December 1973, at the Children's Hospital of Mexico. The literature is reviewed, concerning this unfrequently seen entity, finding a great majority of reports in children, less than 14 years old, a positive family history and serious respiratory disease complications on those affected. It is important to understand the early diagnosis and treatment of these patients, mainly if they have upper respiratory disease, to avoid future onset of bronchiectasis. The genetical aspects, as well as variable clinical affections are mentioned.