Use of sevoflurane during cardiopulmonary bypass decreases incidence of awareness

BACKGROUND AND OBJECTIVE

The role of sevoflurane has not been studied in relation to awareness during anaesthesia. We observed the effect of sevoflurane on the incidence of awareness during cardiopulmonary bypass for open-heart surgery.

METHODS

Fifty-nine patients of age >17 yr undergoing open-heart surgery with cardiopulmonary bypass were randomly assigned to two groups. In both groups, induction was with etomidate, dehydrobenzperidol and fentanyl; anaesthesia was maintained with sevoflurane, fentanyl and N20; vecuronium was used for muscular paralysis. Group 1 (30 patients) received dehydrobenzperidol and fentanyl during cardiopulmonary bypass; Group 2 (29 patients) received sevoflurane and fentanyl. Patients were given different auditory inputs during different phases of surgery. All patients were interviewed with standard questions 8 and 24 h postoperatively for evidence of explicit awareness.

RESULTS

Five patients in the dehydrobenzperidol group gave a history of awareness (16.67%) as opposed to none in the sevoflurane group. The difference in the incidences of awareness was significant (P < 0.05), but no differences were found between the interviews conducted at 8 and 24 h. Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery.

Aprotinin reduces the IL-8 after coronary artery bypass grafting

The effect of aprotinin, a protease inhibitor, on myocardial interleukin-8 (IL-8) production after ischemia-reperfusion injury was investigated. Twenty patients who had elective coronary artery bypass grafting were included in this study. Patients were randomly divided into two groups (n = 10 in each). Group A patients received high dose aprotinin (20,000 IU/kg as pretreatment followed by 7500 IU/kg for 6 h) and Group B patients received normal saline as a control. Serum IL-8 levels after the termination of cardiopulmonary bypass (CPB) showed a significant improvement in aprotinin treated group compared to control group (70 +/- 42.6 vs 360.71 +/- 87.9 ng/ml) (P < 0.005). Levels were also significantly higher at post-operative 24th hour in patients who did not received aprotinin (340.16 +/- 92.10 vs 96.13 +/- 34.33 ng/ml). However at post-operative 48th hour levels were again higher in control (untreated) group, but the difference was not statistically significant (78.8 +/- 34.4 vs 42.8 +/- 9.29 ng/ml). Aprotinin prevented the IL-8 release from myocytes in ischemia-reperfusion injury. The mechanism is highly dependent on anti-protease activity of aprotinin.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Chlamydia pneumonia seropositivity correlates with serum fibrinogen and lipoprotein a levels: any role in atherosclerosis?

The aim of the study is to determine the impact of Chlamydial seropositivity on atherosclerosis in a group of patient requiring coronary and/or carotid revascularization. A population of 30 diabetic patients (group 3) and 26 nondiabetic patients (group 2) with angiographically documented coronary and/or carotid artery disease were enrolled for the study. Volunteers from the relatives of hospital staff with no known disease (n=29; group 1) were included as the control group. Serum samples from the participants were assayed for cardiovascular risk factors including total serum cholesterol, triglyceride and lipoprotein levels, fibrinogen, Hb A1c levels and IgG titers for Chlamydia pneumonia (C. pneumonia). Chlamydial seropositivity was analysed further to determine a possible impact on atherogenesis. Serum LDL cholesterol levels revealed statistically significant difference between groups 1 and 2 (p=0.001). There was no difference between groups 2 and 3 regarding LDL cholesterol levels. There was no significant difference among the groups with respect to C. pneumonia seropositivity and the other atherosclerotic risk factors. Chlamydial seropositivity was found to be more frequent in males than in females (p=0.008). In the C. pneumonia seropositive group, serum fibrinogen and lipoprotein a levels were found to be significantly higher than the seronegative group (p=0.0001 and p=0.001, respectively). Other atherogenic risk factors were similar in the seropositive and negative groups. The causal role of Chlamydial infections in atherosclerotic plaque formation might be due to their influence on the serum fibrinogen and lipoprotein a levels.

An alternative repair technique for aortic periprosthetic leakage

In case of aortic periprosthetic leakage, there are several methods of repair. When valve replacement or refixation is not suitable an alternative repair technique, 'curtaining' with a Dacron patch to prevent leakage is presented.

Vascular hamartoma of the mediastinum: a case report

Vascular hamartoma of the mediastinum is a rare benign vascular tumor. A 13-year-old girl presented with back pain, persistent coughing, palpitation, and angina pectoris. Preoperative investigations demonstrated an enlarging mass involving the superior mediastinum extending posteriorly (T6-T8). An encapsulated, 6x5x3 cm dark purplish mass adherent to the aortic wall was found. The main mediastinal mass was totally excised but limited resection was carried out in the paravertebral region. Microscopic examination revealed a vascular hamartoma.

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.

The effect of acute normovolemic hemodilution on homologous blood requirements and total estimated red blood cell volume lost

BACKGROUND

Acute normovolemic hemodilution combined with retransfusion is one of the various techniques proposed to avoid homologous blood transfusion in cardiac surgery. The purpose of the present paper is to study the effect of the volume of autologous blood collected pre-cardiopulmonary bypass (CPB) on homologous blood requirements and total estimated red blood cell (RBC) volume lost in coronary artery bypass grafting (CABG) surgery.

METHODS

Following induction of anesthesia, sequestration of one (5-8 ml/kg; Group I, n = 14) or two units (12-15 ml/kg; Group II, n = 14) of fresh autologous blood was performed under electrocardiographic and hemodynamic control. Group III (n = 14) was designated as the control group. Autologous blood was reinfused at the conclusion of CPB.

RESULTS

The use of homologous blood in the study groups was significantly less than in the control group. High-volume phlebotomy did not make a significant difference in the requirement of the homologous blood, while causing a mild increase in the total estimated RBC volume lost. No significant differences could be demonstrated in preoperative, post-CPB and discharge hematocrit levels and postoperative blood drainage between the groups.

CONCLUSION

Acute intraoperative hemodilution with high- and low-volume phlebotomy reduced the homologous blood requirements similarly regardless of the amount of phlebotomy.

Surgical management of congenital lobar emphysema

Here in nine patients with congenital lobar emphysema who had been treated surgically in the previous 10 years are reported. The ages of the patients at diagnosis ranged from 26 days to 11 months. The six patients whose symptoms started in the neonatal period had more severe dyspnea, cyanosis and respiratory distress. Tube thoracostomy was performed in two of three patients who had been misdiagnosed initially. The affected side was the left upper lobe in five patients, the right upper lobe in three, and the right middle and upper lobes in one patient. Lobectomy was performed in all cases. Dysplasia of the bronchial cartilage was found in six patients and bronchial atresia of the left upper lobe was found in another infant as the etiologic cause of the condition. Although the possibility of conservative management in congenital lobar emphysema has been reported recently, we believe that surgery is the treatment of choice in patients who have persistent or progressive, severe respiratory distress in spite of medical treatment.

Noonan syndrome with double-chambered right ventricle

The association of Noonan syndrome and a double-chambered right ventricle has not been reported previously in the medical literature. We report two patients with Noonan syndrome associated with pulmonary valve stenosis and double-chambered right ventricle due to anomalous hypertrophied muscle bundles. Pulmonary valve stenosis was operated on. However, hypertrophied muscle bundles were not resected, as they caused no obstruction to blood passage. Postoperative follow-up examinations revealed no symptoms. In conclusion, in those with Noonan syndrome there may be anomalous muscle bundles in the right ventricular cavity. It may not be necessary to resect them if they do not obstruct the right ventricular outflow tract.

Echocardiography in patients with constrictive pericarditis before and after pericardiectomy: Are there predictors of surgical outcome?

Fifteen patients with constrictive pericarditis were prospectively evaluated with echocardiography and Doppler recordings during respiratory monitoring. Eleven who agreed to surgery also underwent right heart catheterization and a repeat echocardiography with Doppler 10 days after pericardiectomy. Preoperatively, there was a significant inspiratory decrease in the mitral E wave (P < 0.05) and increase in the tricuspid E wave velocities (P < 0.05), which both normalized after pericardiectomy. The mitral deceleration times increased from 110 +/- 40 to 149 +/- 46 msec (P < 0.05) postoperatively. The preoperative hepatic vein velocities showed an accentuated systolic flow pattern. The systolic to diastolic ratio of the hepatic vein velocities was higher in patients who improved with surgery (1.42 +/- 0.31 vs 0.65 +/- 0.13) (P < 0.05). Postoperatively the diastolic flow became more pronounced. There was a 100% expiratory diastolic flow reversal in eight patients preoperatively, which normalized after pericardiectomy. Clinically these patients improved significantly postoperatively. Left atrial size, ejection fraction, and mitral and tricuspid filling velocities during respiratory monitoring could not predict surgical outcome. Pericardiectomy improved Doppler filling dynamics in all patients although this was not parallel to clinical improvement.

Multicentric angiofollicular lymph-node hyperplasia associated with myasthenia gravis

Castleman's disease is often referred to as giant lymph-node hyperplasia. Although this localized disorder most commonly involves the mediastinum, recently many patients have been described with multicentric lymph-node hyperplasia associated with various clinical abnormalities. Here a new case of multicentric angiofollicular lymph-node hyperplasia associated with myasthenia gravis and gammopathy is presented. At first, the patient responded to surgery well, but after some months her condition deteriorated: plasmapheresis was then performed, one year after the operation, with great clinical improvement.

Surgical treatment of giant hydatid cyst of the left ventricle and diagnostic value of magnetic resonance imaging

Cardiac echinococcosis has not been reported frequently. Because of the risk of potentially lethal complications, early diagnosis and definitive treatment are very important. The case of a 41-year-old physician, in whom diagnosis of giant left ventricular hydatid cyst was established with cross-sectional echocardiography and magnetic resonance imaging, is presented. The cyst was removed surgically and mitral valve replacement performed because of destruction of the valve.

The influence of pulmonary insufficiency on ventricular function following total correction of Fallot's tetralogy: evaluation using radionuclide ventriculography and clinical findings

Long-standing pulmonary insufficiency after repair of tetralogy of Fallot may adversely affect ventricular function. We evaluated 20 patients postoperatively by radionuclide ventriculography and clinical findings after total correction of tetralogy of Fallot. Patients were divided into two groups as follows: Group I patients (10) had no pulmonary insufficiency; Group II patients (10) had moderate or severe pulmonary insufficiency. Preoperatively, there was no difference between groups in terms of age, functional capacity according to the New York Heart Association criteria, hemoglobin and hematocrit level, cardiothoracic ratio, McGoon ratio, left and right ventricular ejection fraction, cardiac output or cardiac index. Postoperatively, right ventricular ejection fraction was 40.10 +/- 2.28 in Group I and 29.5 +/- 2.86 in Group II, p < 0.01. Left ventricular ejection fraction was 59.3 +/- 2.90 in Group I and 50.9 +/- 4.19 in Group II, p < 0.01. Radionuclide ventriculography is a useful means of identifying right ventricular dysfunction following repair of tetralogy of Fallot. The dysfunction appears significantly worse in patients with pulmonary insufficiency.

Surgical treatment in tetralogy of Fallot diagnosed by echocardiography

The purpose of this paper is to present the authors' 3-yr experience of echocardiographic examination of patients with the clinical diagnosis of tetralogy of Fallot, and their evaluation for surgical treatment without prior cardiac catheterization. Among the patients with the clinical diagnosis of tetralogy of Fallot 227 had a definite diagnosis made by M-mode, two-dimensional, Doppler and contrast echocardiography. For the diagnosis of tetralogy of Fallot, ventricular septal defect, pulmonary stenosis, and overriding of the aorta were considered to be fundamental. Ventricular septal defect could be seen easily in the subaortic region by two-dimensional echocardiography. However, in some patients whose ventricular septal defect was not seen clearly, peripheral vein contrast echocardiography was performed. The diameters of pulmonary artery, and main branches at a few millimeters distal to their origin were measured. These parameters were correlated with the aortic diameter for evaluation as to whether they were able to accept the total cardiac output. In patients whose left ventricular end-diastolic dimension was small, shunt operation was preferred. In 115 patients the pediatric cardiologist performing the echocardiography thought that cardiac catheterization was necessary. In these cases the reliability of echocardiography in detecting important cardiac abnormalities was evaluated. Detection of ventricular septal defect, presence of pulmonary valve, detection of stenosis on the pulmonary bifurcation and/or main branches revealed a high sensitivity. Two-hundred-and-one patients diagnosed by echocardiography underwent total correction. In all cases except one the preoperative diagnosis was confirmed by surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Mycotic aneurysm of the descending aorta diagnosed by echocardiography

We present a 3-yr-old girl with coarctation of aorta and patent ductus arteriosus in whom mycotic aneurysm and bacterial endarteritis developed postoperatively and was diagnosed by two-dimensional and Doppler echocardiography. Five weeks after the operation of ligation of ductus and resection of coarctated segment, the patient was readmitted with complaints of vomiting, fever and coughing. Bacterial endarteritis, empyema and septic arthritis were diagnosed. Suprasternal echocardiographic examination demonstrated an aneurysmatic appearance 60 x 65 mm in size at the location of coarctation. The patient died, most probably due to aortic rupture, before surgical treatment could be undertaken. Autopsy study confirmed our diagnosis.

Mitral valve surgery in the presence of pulmonary hypertension

Mitral valve surgery was performed in 59 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure 77.1 +/- 18.6 mmHg; range 50-115 mmHg) between 1983 and 1990. Thirty-eight patients had been subjected to mitral valve replacement, 16 patients both mitral and aortic valve replacement, and 5 patients had open mitral commissurotomy, with an operative (30 day) mortality of 5.0%. These 3 deaths happened during the early postoperative period. Survivors were followed up for a period ranging from 6 months to 7 years with a mean of 36 months. Four late deaths (7.1%) occurred in patients with valve replacement. Actuarial survival was 93 +/- 3% at 5 years, and 90.7 +/- 4.4% at 7 years. Right ventricular catheterization was performed on 14 patients a mean of 38 months following operation. Systolic pulmonary artery pressure had decreased from a mean of 77.1 +/- 18.6 to 39.7 +/- 14.0 mmHg (p less than 0.001) and 90% of the survivors were in New York Heart Association Class 1 or II compared to 23.7% preoperatively. The clinical and hemodynamic findings in this series suggest that severe pulmonary hypertension is not a contraindication, and pulmonary hypertension decreases significantly after mitral valve surgery.

Right ventricular hydatid cyst causing recurrent pulmonary emboli

A hydatid cyst of the heart is rare. Surgical treatment is the preferable method in the treatment of cardiac echinococcosis. A 27-year-old patient with right ventricular hydatid cyst causing recurrent pulmonary emboli and diagnosed by 2-dimensional echocardiography and treated surgically is presented.

Blood cyst originating from tricuspid septal leaflet

Successful removal of a blood cyst of the tricuspid valve in a 34 years old man is reported. The rarity of this cyst in an adult and diagnostic clues are discussed.

Creation of right ventricle-pulmonary artery continuity without cardiopulmonary bypass

A closed technique was applied successfully in a patient with Fallot's tetralogy in whom total correction had been previously performed, for creation of continuity between the right ventricle and left pulmonary artery without the use of cardiopulmonary bypass. A surgical approach was achieved by an anterolateral thoracotomy incision in the left third intercostal space. A Dacron non-valved tubular graft, 10 mm. in diameter, was anastomosed to the proximal end of the left pulmonary artery. The proximal end of the graft was anastomosed to the pericardial outflow tract patch with a running technique using a monofilament suture. The peripheral arterial oxygen saturation increased postoperatively, and the patient's condition improved dramatically.

Cardiac rhabdomyoma in a newborn two-dimensional echocardiographic diagnosis

Primary cardiac tumors are quite rare in the newborn period. Prior to surgery, cardiac catheterization and angiocardiography have been performed to confirm the two-dimensional echocardiographic findings. In this report a 2-day-old baby with the clinical impression of severe cyanotic congenital heart disease diagnosed by two-dimensional echocardiography as multiple rhabdomyoma and confirmed by surgery is presented. It is emphasized that two-dimensional echocardiography is a very useful technique for the diagnosis of primary cardiac tumors. By means of this method severely symptomatic newborns may be taken directly to surgery without prior cardiac catheterization, thus minimizing complications.

Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases

At the Department of Thoracic and Cardiovascular Surgery of Hacettepe University, a total number of 822 pediatric bronchoscopies were performed from 1984 through 1990 for suspected foreign body aspiration. Of the children 65.3% were boys and 34.7% were girls ranging in age from one month to 14 years. Definitive statement of foreign-body aspiration was obtained from 394 patients. Unilateral hyperaeration, atelectasis, and unilateral parenchymal infiltration were the most common radiological findings. In all endoscopic procedures, a pediatric rigid bronchoscope was used under general anesthesia and controlled ventilation. Foreign bodies were found in 77.7% of the 822 patients. In the rest of the children inflammatory disorders were confirmed. The foreign bodies most commonly found in 639 patients were sun-flower seeds (21.1%), beans (10.4%), water-melon seeds (10%), and hazelnuts (9.8%). In our presented series, the incidence of non-fatal complication was 1.8%, apart from these patients 5 of them (0.6%) died after the bronchoscopic procedures.

The effect of aprotinin (trasylol) on postoperative bleeding in cyanotic congenital heart disease

Despite the widespread clinical success in open-heart surgery, bleeding after cardiopulmonary by-pass (CPB) has been a common problem especially in cyanotic congenital heart disease. Recently, there have been reports demonstrating that treatment with high doses of aprotinin reduces postoperative bleeding. We studied the effect of aprotinin on postoperative bleeding in patients with tetralogy of Fallot who had undergone total correction in the Department of Thoracic and Cardiovascular Surgery of the Hacettepe University Faculty of Medicine, and compared our results with those in the literature. Ten patients out of 20 in the study were given high doses of aprotinin and were compared with the remaining 10 patients who had not received the drug. Standard anesthesia, perfusion and surgical techniques were used in all operations. The total amount of bleeding in the aprotinin-treated group was found to be 1530 ml, while in the other group it was 4185 ml (p < 0.05). The total quantity of blood transfused in the aprotinin-treated patients was 3250 ml while it was 5865 ml in the control group (p < 0.05). No significant effect of aprotinin was found on Hb, Hct, PT, aPTT and thrombocyte counts (p > 0.05). However, the effect of the drug on bleeding and coagulation time was found to be statistically significant (p < 0.05).

Right atrial myxoma in an infant

Cardiac myxomas are extremely rare in infancy. We report a case of right atrial myxoma in a 35-day-old male infant (with cyanosis and convulsions). Echocardiography was carried out and a diagnosis of right atrial myxoma was made. Open heart surgery was performed using cardiopulmonary bypass and a 2.5 X 3.0 cm mass was removed. The patient's postoperative course was uneventful. To our knowledge there is no previously reported case of right atrial myxoma in such a young infant which was operated on successfully.

Surgical treatment of renovascular hypertension in children

Hypertension of renovascular origin in pediatric patients is frequently encountered. Herein, we review our experience, as well as that of others, with this type of patient, and discuss the characteristic features of renovascular hypertension and the favourable response to reconstructive vascular surgery.

Familial atrial myxoma

Familial and biatrial myxomas of the heart have rarely been described. We describe a familial atrial myxoma involving a parent with biatrial and a child with a left atrial myxoma. Atrial myxomas were diagnosed preoperatively by echocardiography and successfully removed at operation. Echocardiography can be used in the diagnosis of cardiac myxoma, detection of its possible recurrence and for screening other members of the family.

De Vega's tricuspid annuloplasty: analysis of 195 patients

In the years 1984-1989, 195 De Vega tricuspid annuloplasties were performed in association with mitral or mitral-aortic valve procedures. Preoperatively, 9 patients (4.6%) were in New York Heart Association functional class II, 124 (63.6%) were in class III, and the remaining 62 (31.8%) were in class IV. Tricuspid insufficiency was recognized by routine digital palpation of the tricuspid valve during the operation in 42 (21.5%) of the patients. Hospital mortality rate was 7.6% (15 patients). Late deaths occurred in 6 (3.0%) cases during a follow-up period of 3 to 72 months (mean 42 months). 8 patients (4.1%) required reoperation. Tricuspid annuloplasty failure was observed in 4 patients (2%). These valves were replaced with biological valves in three patients and with a mechanical valve in one patient. 112 of the survivors (64.3%) were evaluated by echocardiography and/or right ventriculography. Analysis of postoperative data showed that in 84 of the 112 patients (75%) tricuspid regurgitation disappeared completely after annuloplasty, 88% of surviving patients were in functional class I or II. For the series presented actuarial survival rate at 6 years was 79.1% +/- 14.4%. In the light of this study we recommend De Vega's annuloplasty as the method of choice for moderate to severe functional tricuspid insufficiency.

Peripheral vein contrast echocardiography in atrial septal defect

This study was carried out on 233 children suspected clinically of having atrial septal defect with the aim of investigating the diagnostic capability of peripheral venous contrast echocardiography. The transfer of contrast material from the right atrium into the left atrium was evaluated as "positive contrast", while noncontrast blood, passing from the left atrium into the right atrium was termed "negative contrast". Positive contrasts were quantitated in four grades. A significant negative contrast effect was graded 3- or 4-. Three positive, 4+ and/or 3-, 4- contrast effects were considered definite evidence of an atrial septal defect. Among the cases with the above findings 92 underwent surgical closure of atrial septal defect. The procedure was successful in all patients operated; the size of the defect was large. This result demonstrates that the method applied is a safe and reliable one. However, in a group of cases without the above echocardiographic findings the presence of an atrial septal defect was detected by cardiac catheterization and angiocardiography. Therefore, we can conclude that the method applied is not a sensitive, but a specific one, for definite detection of atrial septal defect.

Echocardiographic diagnosis of congenital left ventricular-right atrial communication

The clinical diagnosis of congenital left ventricular-right atrial (LV-RA) communication is difficult. Echocardiography appears to be a useful method in the diagnosis of this congenital cardiac defect. In previous reports authors have described M-mode echocardiographic findings of this anomaly. We present here two-dimensional echo findings in a patient with congenital LV-RA communication. A 12 year old boy presented the following echocardiographic findings. A perimembranous septal defect and an abnormal tricuspid septal leaflet were seen. The defect was located at the membranous atrioventricular septum, resulting in a communication between the RA and the LV. Pulsed Doppler echocardiography demonstrated turbulent flow through the defect during systole, suggesting an LV-RA communication. M-mode echo examination of the septal tricuspid leaflet revealed systolic fluttering of the tricuspid valve. Peripheral vein contrast echocardiography showed passage of the echo contrast material from the RA to the LV (positive contrast effect). At the same time there was a negative contrast effect during ventricular systole, indicating a left to right shunt from the LV to the RA. After surgical repair of the anomaly, systolic flutter of the tricuspid valve and the other findings disappeared echocardiographically, as they did in the other reported cases. We can conclude that two-dimensional echocardiography with M-mode evaluation is a reliable method for the diagnosis of congenital LV-RA communication, and that this method should be applied to all cases where this anomaly is suspected clinically.