Predictors, Outcomes and Impact of Mechanical Circulatory Support of Patients With Mechanical Complications After Acute Myocardial Infarction

BACKGROUND

Despite early and currently effective epicardial coronary recanalization, the mortality rate after mechanical complication (MC) remains high, especially in cardiogenic shock. There is an increase in the use of mechanical circulatory support in patients with cardiogenic shock and MC, however, evidence is still scarce and most studies exclude patients with mechanical complications.

METHODS

Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the predictors and outcomes of patients with MC, subtypes and the use of MCS.

RESULTS

We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC and of them 1320 (56.3 %) received MCS. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture (FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582-12.855, p < 0.001) in patients with MC compared to patients without MC (49.7 % vs. 4.6 %, p < 0.001) and all subtypes of MC showed a significant increase in mortality. The use of MCS was associated with decreased mortality in PMR (46.2 % to 34.8 %, p = 0.009) and pseudoaneurysm (64.7 % to 42.1 %, p < 0.001), however, with higher mortality in VSR.

CONCLUSIONS

The incidence of MC after an AMI is very low, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and with fewer comorbidities. The subtype with the highest frequency and highest mortality was VSR. The use of mechanical circulatory support was associated with better survival in PMR and pseudoaneurysm, but not overall survival.

Clinical Use of CathPCI Registry Risk Score and Its Validation to Predict Long-Term Mortality

Risk models to estimate percutaneous coronary intervention (PCI) mortality have limited value in complex high-risk patients. However, it was improved by a recently developed bedside model to predict in-hospital mortality using data from the American College of Cardiology CathPCI Registry that included 706,263 patients. The median risk-standardized in-hospital mortality rate was 1.9%. In an attempt to validate this model in patients admitted because of acute coronary ischemia to predict in-hospital, 30-day, and 1-year mortality, we applied the proposed risk score to the study population of the Acute Coronary Syndrome Israeli Survey (ACSIS). This study was conducted for 2 months in 2018 and included all patients admitted to 25 coronary care units and cardiology departments in Israel. The ACSIS included 1,155 patients admitted because of acute myocardial infarction and who underwent PCI. In-hospital, 30-day, and 1-year mortality were 2.3%, 3.1%, and 6.2%, respectively. The CathPCI risk score yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval [CI] 0.94 to 0.99) for in-hospital mortality; 0.96 (95% CI 0.94 to 0.98) for the 30-day mortality, and 0.88 (95% CI 0.83 to 0.93) for the 1-year mortality. The current model also included frail patients, and those with aortic stenosis, refractory shock, and after cardiac arrest. In conclusion, the CathPCI Registry risk score was validated using data from the ACSIS. Because the ACSIS population comprised patients with acute ischemia including those with high-risk features this model demonstrates a wider scope of application compared with previous ones. In addition, the model seems to be suitable to predict also the 30-day and 1-year mortality.

Risk of ionizing radiation in pregnancy: just a myth or a real concern?

There are natural concerns regarding the risks posed to the foetus by ionizing radiation exposure during pregnancy. Therefore, many female physicians select to avoid working in an environment associated with ionizing radiation exposure like the catheterization laboratory and even exclude training as electrophysiology, interventional cardiologists, or radiologists. For those already working in this field, pregnancy involves usually a 1-year interruption (pregnancy and maternity leave) to their careers, leading at times to delays in the decision to become pregnant. This review describes the low added risk of malformation/cancer in the offspring, highlight gaps in our understanding, discuss several common wrong beliefs, and recommend how to further decrease radiation dose, especially during pregnancy.

Prognosis of PCI in AMI setting in the elderly population: Outcomes from the multicenter prospective e-ULTIMASTER registry

BACKGROUND

Elderly patients with ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI) are usually excluded from major trials.

HYOPTHESIS

This study sought to assess 1-year clinical outcomes following PCI with a drug-eluting stent in patients older than 80 years old with STEMI.

METHODS

The large all-comer, multicontinental e-ULTIMASTER registry included 7507 patients with STEMI who underwent PCI using the Ultimaster stent. The primary clinical endpoint was 1-year target lesion failure, a composite of cardiac death (CD), target vessel-related myocardial infarction (TV-MI), or clinically driven target lesion revascularization (CD-TLR).

RESULTS

There were 457 (6.1%) patients in the elderly group (≥80 years old) that were compared to 7050 (93.9%) patients <80 years. The elderly patients included more female patients and had significantly more comorbidities and had more complex coronary anatomy. The primary endpoint occurred in 7.2% of the elderly, compared to 3.1% of the younger group (p < .001). All-cause mortality was significantly higher among the elderly group compared to the younger group (10.1% vs. 2.3%, p < .0001), as well as CD (6.1% vs. 1.6%, p < .0001), but not TV-MI (1.1% vs. 0.7%, p = .34) or CD-TLR (1.1% vs. 1.4%, p = .63).

CONCLUSION

Elderly patients with STEMI presentation had a higher incidence of the composite endpoint than younger patients. All-cause and CD were higher for elderly patients compared to patients younger than 80 years old. However, there was no difference in the incidence of TV-MI or target lesion revascularizations. These findings suggest that PCI for STEMI in elderly patients is relatively safe.

Trend in CV mortality among patients with mental disorder in the US between 1999–2020

Background

Patients with mental disorders are at increased risk of cardiovascular mortality. While the overall cardiovascular mortality rate in the western world is in decline, there is no up-to-date data on the cardiovascular mortality rates among patients with mental disorders. We aimed to assess the cardiovascular mortality trends over the last two decades among patients with mental co-morbidities in the US.

Methods

Using Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death data set, we determined national trends in age-standardized mortality rates attributed to cardiovascular diseases in patients with and without mental disorders, from 1999 to 2020, stratified by mental disorders subtype, age, gender, race, and place of residence.

Results

Among more than 18.7 million cardiovascular deaths in the United States, 13.5% were patients with a concomitant mental disorder. During the study period, among patients with mental disorders, the age-adjusted mortality rate increased by 113.9% (vs 44.8% decline in patients with no mental disorder). In patients with mental disorders, the age-adjusted mortality rate increased more significantly among patients whose mental disorder in secondary to substance abuse (+532.6%) than among with organic mental disorders, such as dementia or delirium (+6.2%), while among patients with mood disorders the age-adjusted CV mortality rate dropped by 23.5%. Men patients, minorities, and residents of more rural areas experienced a more prominent increase in the age-adjusted cardiovascular mortality compared to women, white, and residents of metro areas.

Conclusions

While there was an overall reduction in cardiovascular mortality in the US in the past two decades, we demonstrated an overall increase in cardiovascular mortality among patients with mental disorders. The increase was more significant among patients with substance abuse-related mental disorders, in men, minorities, and residents of rural areas.

Funding Acknowledgement

Type of funding sources: None.

Impact of Multisite artery disease on Clinical Outcomes After Percutaneous Coronary Intervention: An Analysis from the e-Ultimaster Registry

BACKGROUND

multisite artery disease is considered a 'malignant' type of atherosclerotic disease associated with an increased cardiovascular risk, but the impact of multisite artery disease on clinical outcomes after percutaneous coronary intervention (PCI) is unknown.

METHODS

Patients enrolled in the large, prospective e-Ultimaster study were grouped into 1) those without known prior vascular disease; 2) those with known single-territory vascular disease 3) those with known 2-3 territories (i.e, coronary, cerebrovascular, or peripheral) vascular disease (multisite artery disease). The primary outcome was coronary target lesion failure (TLF) defined as the composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target lesion revascularization at 1-year. Inverse propensity score weighted (IPSW) analysis was performed to address differences in baseline patient and lesion characteristics.

RESULTS

Of the 37,198 patients included in the study, 62.3% had no prior known vascular disease, 32.6% had single-territory vascular disease, and 5.1% multisite artery disease. Patients with known vascular disease were older and were more likely to be men and to have more co-morbidities. After IPSW, the TLF rate incrementally increased with the number of diseased vascular beds (3.16%, 4.44% and 6.42% for no, single- and multisite artery disease, p<0.01 for all comparisons). This was also true for all cause death (2.22%, 3.28% and 5.29%, p<0.01 for all comparisons) and cardiac mortality (1.26%, 1.91% and 3.62%, p≤0.01 for all comparisons).

CONCLUSIONS

Patients with previously known vascular disease experienced an increased risk for adverse cardiovascular events and mortality post percutaneous coronary intervention. This risk is highest among patients with multisite artery disease.Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02188355.

Impact of the Admission Pathway on the Gender-Related Mortality of Patients With ST-Elevation Myocardial Infarction

The mortality of women with ST-elevation myocardial infarction (STEMI) exceeds that of men, supposedly the result of older age and co-morbidities. Patients with STEMI can be transported directly to the catherization lab by the emergency medical service (EMS) or to the emergency department (ED) by the EMS, a regular ambulance, or independently. This raises the question whether gender disparity in the transport of patients with STEMI may affect time to therapy and consequently explain the disparate outcome in men and women with STEMI. We analyzed a large nationwide registry of prospectively-recorded patients with acute coronary syndromes in order to determine if there is a survival gap between men and women with STEMI, and to assess the gender-related effect of admission pathway on time intervals and 5-year mortality. Study population included 2,740 patients with STEMI who underwent primary percutaneous coronary interventions, comprising 464 women (17%, median-70 years) and 2,276 men (83%, median-58 years). The unadjusted 5-year mortality of women was higher compared with men (26.4% vs 15.6%, p = 0.001) but adjustment abrogated this survival difference. Regardless of adjustment, the 5-year mortality of patients with STEMI admitted directly to the catherization lab or to the ED by EMS was similar for men and women but significantly lower in the directly admitted patients (p <0.028). In contrast, admission to the ED by non-EMS was associated with markedly worse survival among women. These results indicate that women suspected of STEMI benefit from transportation by the EMS and should use this pathway exclusively to reach the hospital.

Can transcatheter aortic valve implantation [TAVI] be performed at institutions without on-site cardiac surgery department?

Transcatheter aortic valve implantation [TAVI] represents a paradigm shift in therapeutic options for patients with severe aortic stenosis [AS]. In less than 20 years, TAVI has rapidly disseminated to include a significant proportion of AS patients. The number of AS patients needing TAVI is expected to further increase. Since there is a limited number of centers performing TAVI, wait times are expected to increase. This might have a critical impact of AS patient life as mortality rate of AS patients awaiting TAVI, is substantial, ranging from 2 to 10%. With time, as more patients were treated, improved experience, better imaging and devices, this technology became safer with more reliable results. Today most TAVI complications are related to vascular access [4-6%] and there is less need for emergency thoracic bail out [0.2-0.5%]. In this review, we summarize the prognosis while waiting, the outcomes of patients undergoing TAVI at institutions without on-site cardiac surgery departments and the data describing rates and outcomes of TAVI patients requiring treatment of intra-procedural life-threatening complications. Similar to coronary interventions in the past, TAVI should be considered also in centers without on-site cardiac surgery departments under certain conditions such as, experienced operators, heart team discussion, well established imaging modalities, skilled and qualified support personal, and adequate pre- and post-care facility.

Differentiation between myopericarditis and acute myocardial infarction on presentation in the emergency department using the admission C-reactive protein to troponin ratio

Background

The treatment of myopericarditis is different than that of acute myocardial infarction (AMI). However, since their clinical presentation is frequently similar it may be difficult to distinguish between these entities despite a disparate underlying pathogenesis. Myopericarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We hypothesized that evaluation of the CRP/troponin ratio on presentation to the emergency department could improve the differentiation between these two related clinical entities whose therapy is different. Such differentiation should facilitate triage to appropriate and expeditious therapy.

Methods

We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large single center registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed on discharge as myopericarditis. CRP and troponin were sampled on admission in all patients and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of myopericarditis against all AMI, STEMI, and NSTEMI patients.

Results

Median admission CRP/troponin ratios were 84, 65, and 436 mg×ml/liter×ng in STEMI, NSTEMI and myopericarditis groups, respectively (p<0.001) demonstrating good differentiating capability. The Receiver-operator-curve of admission CRP/troponin ratio for diagnosis of myopericarditis against all AMI, STEMI, and NSTEMI patients yielded an area-under-the curve of 0.74, 0.73, and 0.765, respectively. CRP/troponin ratio>500 resulted in specificity exceeding 85%, and for a ratio>1000, specificity>92%.

Conclusion

The CRP/troponin ratio can serve as an effective tool to differentiate between myopericarditis and AMI. In the appropriate clinical context, the CRP/troponin ratio may preclude further evaluation.

The impact of lockdown enforcement during the SARSCoV-2 pandemic on the timing of presentation and early outcomes of patients with ST-elevation myocardial infarction

Introduction

Early reports described decreased admissions for acute cardiovascular events during the SarsCoV-2 pandemic. We aimed to explore whether the lockdown enforced during the SARSCoV-2 pandemic in Israel impacted the characteristics of presentation, reperfusion times, and early outcomes of ST-elevation myocardial infarction (STEMI) patients.

Methods

A multicenter prospective cohort comprising all STEMI patients treated by primary percutaneous coronary intervention admitted to four high-volume cardiac centers in Israel during lockdown (20/3/2020–30/4/2020). STEMI patients treated during the same period in 2019 served as controls.

Results

The study comprised 243 patients, 107 during the lockdown period of 2020 and 136 during the same period in 2019, with no difference in demographics and clinical characteristics. Patients admitted in 2020 had higher admission and peak troponin levels, had a 2.4 fold greater likelihood of Door-to-balloon times> 90 min (95%CI: 1.2–4.9, p = 0.01) and 3.3 fold greater likelihood of pain-to-balloon times> 12 hours (OR 3.3, 95%CI: 1.3–8.1, p<0.01). They experienced higher rates hemodynamic instability (25.2% vs 14.7%, p = 0.04), longer hospital stay (median, IQR [4, 3–6 Vs 5, 4–6, p = 0.03]), and fewer early (<72 hours) discharge (12.4% Vs 32.4%, p<0.001).

Conclusions

The lockdown imposed during the SARSCoV-2 pandemic was associated with a significant lag in the time to reperfusion of STEMI patients. Measures to improves this metric should be implemented during future lockdowns.

Modern Stents: Where Are We Going?

Coronary artery stenting is the treatment of choice for patients requiring coronary angioplasty. We describe the major advancements with this technology. There have been significant developments in the design of stents and adjunctive medical therapies. Newer-generation drug-eluting stents (DES) have almost negligible restenosis rates and, when combined with proper anti-platelet treatment and optimal deployment, a low risk of stent thrombosis. The introduction of newer-generation DES with thinner stent struts, novel durable or biodegradable polymer coatings, and new antiproliferative agents has further improved the safety profile of early-generation DES. In parallel the effectiveness has been kept, with a significant reduction in the risk of target lesion revascularization compared with the early-generation DES. However, to date, the development of completely bioresorbable vascular scaffolds has failed to achieve further clinical benefits and has been associated with increased thrombosis. Newer-generation DES-including both durable polymer as well as biodegradable polymer-have become the standard of care in all patient and lesion subsets, with excellent long-term results.

Massive Gastrointestinal Bleeding from a Jejunal Dieulafoy Lesion: An Extraordinary Presentation

We present an atypical and rare case of a previously healthy 27-year-old male who presented with acute onset of abdominal pain, bloody diarrhea, and syncope. At the Emergency Department, vital signs were stable with no signs of shock. Physical examination revealed diffuse tenderness of the abdomen and cherry red blood was noted upon rectal examination. Blood tests showed marked leukocytosis without anemia. Sigmoidoscopy was performed which revealed hematochezia with no obvious site of bleeding. The patient was admitted to the hospital with a working diagnosis of dysentery and received supportive care. During the following days, blood tests revealed an ongoing decline of hemoglobin levels which necessitated a new workup of gastrointestinal bleeding. Investigation modalities including upper and lower endoscopies as well as angiography failed to demonstrate a bleeding site. Scintigraphy, which was performed next, demonstrated an increased radiotracer activity in the right abdomen consistent with small bowel bleeding. Following these results, the patient underwent urgent laparotomy and surgical resection was performed. The histopathological findings were consistent with a Dieulafoy lesion. This case illustrates the importance of the complementary role of various modalities in locating the bleeding site along the gastrointestinal tract.

Proximal Left Anterior Descending Artery Treatment Using a Bioresorbable Polymer Coating Sirolimus-Eluting Stent: Real-World Outcomes From the Multicenter Prospective e-Ultimaster Registry

Background Guidelines recommend heart team discussion and coronary artery bypass graft consideration in patients with proximal left anterior descending (LAD) artery stenosis. Evidence suggests that outcomes of proximal LAD angioplasty might not differ from treatment of nonproximal LAD locations. We aim to determine clinical outcomes of patients undergoing percutaneous coronary intervention in the proximal LAD segment in comparison with nonproximal LAD angioplasty, using a thin-strut drug-eluting stent. Methods and Results In this analysis of the e-Ultimaster registry, patients undergoing angioplasty in the proximal LAD territory were compared with those treated in nonproximal LAD locations. Multivariate analysis and propensity score were used to adjust for differences among the groups. The primary outcome was target lesion failure: a composite of cardiac death, target-lesion-related myocardial infarction, and/or clinically driven target lesion revascularization at 1-year follow-up. Of the 17 805 patients (mean age, 64.2±11; 76% male), 5452 (30.6%) underwent proximal LAD and 12 353 (69.4%) nonproximal LAD percutaneous coronary intervention. Patients in the proximal LAD group had more multivessel disease (48.7% versus 43.5%; P<0.001) and 2-fold more bifurcations lesions (18.8% versus 9.2%; P<0.0001). After propensity-weighted adjustment, target lesion failure did not differ between the groups (3.3% versus 2.9%; P=0.17 for proximal LAD versus nonproximal LAD angioplasty, respectively). In multivariate analysis, proximal LAD treatment was not an independent predictor of target lesion failure (odds ratio, 1.07; 95% CI, 0.88-1.31; P=0.48). Conclusions At 1-year follow-up, patients had similar clinical outcomes independent of stenting location, questioning whether proximal LAD treatment should be regarded differently from stenting in any other coronary artery territory.

[Daily management of acute pericarditis: clinical and paraclinical outcomes, etiological diagnosis]

INTRODUCTION

Acute pericarditis is a frequent hospitalization cause. A prospective, bicentric study aimed at different goals: population description, aetiologies screening, and evaluation of the interest of a coordinated and combined management between cardiologists and internists.

PATIENTS AND METHODS

Between May 2005 and September 2007, all patients admitted for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening were performed. Patients were asked to consult both cardiologist and internist, one month later.

RESULTS

Hundred and three patients were enrolled (mean age 43 years). Clinical outcome was classical in 60% of cases. ECG was typical in 59%. Troponin elevation was noted in 30% of patients. CRP was normal at diagnosis in 27% of patients, and increased significantly at first day (P=0.002). Possible cause was identified in 44 patients. In 26 patients (24.3%), precise diagnosis was performed: six cancers, one hemopathy, three connectivities, one EBV and one parvovirus B19 seroconversions, two untreated HIV patients, four inflammatory diseases, three endocrinology troubles, one oesophagitis, one dental sepsis, one amyloidosis, one acute pancreatitis, one declined dialysis indication. Eighteen de novo diagnoses (16.5%) were performed, out of them at least 12 benefited from specific management.

CONCLUSION

Population of patients admitted for acute pericarditis are very heterogeneous. Our co-management between internists and cardiologists aims to diagnose earlier and easier curable diseases. Long-term follow-up remains of great interest, in order to diagnose later other disorders, which remained hidden, and to follow evolution of the population.

[Comparative susceptibility evolution in Escherichia coli from urinary tract infections in outpatients and inpatients at Perpignan hospital in 2002 and 2004]

The medical emergency ward makes a link between outpatients and hospitalized ones, so we can study community bacterial ecology. The antibiotic susceptibility in Escherichia coli strains isolated from urinary tract infections (UTI) of patients consulting at emergency ward of our hospital in 2002 and 2004 was determined and compared with the susceptibility of the same strains isolated from UTI of hospitalized patients on the same period. The antibiotic susceptibility was performed with Microscan (Dade Behring). All bacteria were tested against the following antimicrobial agents: amoxicilline (Amx), l'amoxicilline+clavulanic acid (AMC), nalidixic acid (NA), ciprofloxacine (Cip), cotrimoxazole (SXT), nitrofurantoin (Ft). Susceptibility in E. coli strains isolated from outpatients vary from 58 to 54% for Amx, from 88 to 83% for NA, from 96 to 89% for Cip, from 82 to 79% for SXT, from 94 to 96% for Ft and remains at 60% for AMC from 2002 to 2004. Susceptibility in E. coli strains isolated from hospitalized patients vary from 52 to 47% for Amx, 55 to 53% for AMC, from 79 to 70% for NA, from 87 to 79% for Cip, from 74 to 69% for SXT, from 93 to 92% for Ft. Susceptibility in E. coli strains isolated in the community from UTI outpatients is decreasing and it becomes worrying particularly concerning the fluoroquinolones, therefore empiric treatment of pyelonephritis by fluoroquinolones must be assessed again.

Pregnancy and progression to AIDS: results of the French prospective cohorts. SEROGEST and SEROCO Study Groups

OBJECTIVE

To investigate whether pregnancy accelerates HIV-1 disease progression.

METHOD

In two large French SEROCO and SEROGEST prospective cohorts of HIV infected patients, the progression to AIDS in 365 women with a known date of HIV-1 seroconversion was examined by comparing those who delivered after HIV infection (n = 241) with those who did not become pregnant while HIV-infected (n = 124).

RESULTS

The crude relative risk of developing AIDS associated with pregnancy was 0.7 [95% confidence interval (CI), 0.4-1.2]. Adjustment for age at seroconversion, the CD4+ cell percentage at entry, and the method used to date seroconversion did not modify the results (adjusted relative risk, 0.7; 95% CI 0.4-1.2).

CONCLUSIONS

No deleterious effect of pregnancy on progression from seroconversion to AIDS was found. This result has important implications for the counselling of HIV-infected women of child-bearing age.

Haemodynamic assessment of hypovolaemia under general anaesthesia in pigs submitted to graded haemorrhage and retransfusion

We have compared the value of different variables used in the assessment of blood loss during progressive hypovolaemia and resuscitation under general anaesthesia in anaesthetized pigs. We measured mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), the negative component of the systolic arterial pressure variation (delta Down) and left ventricular end-diastolic area (LVEDa) using echocardiography. Blood was progressively withdrawn (up to 35 ml kg-1 in seven steps) and then reinfused after the same pattern. Regression coefficient (r) and normalized slope (nS) of the regression relationship between each variable and amount of blood loss were determined. The difference between the withdrawal and reinfusion curves was assessed by the area between the curves. We also estimated the minimal loss of blood volume which induced significant changes in each variable compared with that under control conditions during withdrawal of blood (minWBV) and maximal loss in blood volume which induced no significant changes in a variable compared with control conditions during retransfusion (maxRBV). During haemorrhage, MAP decreased (from mean 74 (SD 9) to 31 (5) mm Hg; P < 0.001), delta Down increased (from 1.2 (1.4) to 11.4 (4.2) mm Hg; P < 0.001), PCWP decreased (from 6.2 (2.1) to 0.3 (1.0) mm Hg; P < 0.001) and LVEDa decreased (from 13.8 (2.0) to 5.1 (2.0) cm2; P < 0.01). The highest r values were obtained with MAP and LVEDa, and the highest nS value with delta Down. The least difference between withdrawal and reinfusion was with LVEDa, the lowest values of minWBV were with PCWP and LVEDa, and the highest value of maxRBV was obtained with PCWP. During progressive haemorrhage under general anaesthesia, LVEDa was an accurate variable for assessment of blood volume loss, delta Down contributed no further information compared with MAP, and PCWP was the most reliable variable for assessing return to baseline blood volume.

Use of transesophageal echocardiography for diagnosis of traumatic aortic injury

This prospective study was conducted to describe the signs on transesophageal echocardiography (TEE) associated with traumatic aortic injury (TAI). Twenty-eight patients with TAI underwent TEE, and they were compared with a control group of 30 thoracic trauma patients without aortic injury. The TEE signs were classified as direct or indirect signs, and the quality of imaging was assessed. Patients' TEE images were compared with their anatomic lesions. The direct signs were thick stripes (n=19), false aneurysm (n=7), aortic dissection (n=6), free-edge intimal flap (n=15), aortic wall hematoma (n=2), fusiform aneurysm (n=13), and complete aortic obstruction (n=2). The indirect signs included minor increases in aortic diameter (n=7), impairment of the aortic Doppler color flow (n= 18), and an increase of aorta-probe distance, indicating hemomediastinum (n=23). TEE allowed diagnosis of recently described limited intimal lesions frequently missed by other conventional methods, and permitted rapid diagnosis of complete rupture in which fast degeneration means that more time-consuming methods are not practicable. Significant blurring of the aortic outline was noted in 20% of cases and intraluminal artifacts were observed in 36% of cases, but neither sign impaired accurate diagnosis of TAI. The echocardiographic signs of aortic injury are complex and may be confined to a short section of the aorta. Therefore, examination by a physician highly trained in echocardiography is necessary in such cases.

Lack of behavioural risk factors for squamous intraepithelial lesions (SIL) in HIV-infected women

HIV-infected women have a high prevalence of abnormal Papanicolaou smears and cervical intraepithelial neoplasia. A multiparametric analysis of epidemiological and behavioural risk factors has been performed in a cohort of 204 HIV-infected women in an outpatient clinic with the aim to investigate risk factors associated with squamous intraepithelial lesions (SIL) in HIV-seropositive women. The prevalence of SIL in the study population was 35.7%. Univariate and multivariate analysis of demographic, behavioural and immunological variables only identified cigarette smoking > 20/day and CD4+ cell counts < or = 200 x 10(6)/L as risk factors significantly associated with SIL in the study population. We found no epidemiological/behavioural risk factors specifically associated with SIL in HIV-infected women as compared with the general population. The results suggest that the high prevalence of SIL in HIV disease is related to acquired immune deficiency in HIV-seropositive women.

[Ectopic pregnancy recurrence: role of gynecologic, obstetric, contraceptive and smoking history]

The purpose of this study, based on data from the register of ectopic pregnancy in Auvergne (centre of France), is to identify risk factors of recurrence of ectopic pregnancy (EP). The social characteristics, gynaecological, surgical and reproductive history and conditions of the conception of 96 women with a previous EP were compared to those for 566 women without previous EP. Risk factors associated with the management of the first EP could not be analysed with the data available. Several factors increased the risk of recurrence: previous proved or suspected salpingitis (OR = 3.6), maternal smoking (OR = 1.7 to 2.0 according to the consumption level), maternal age greater than 30 (OR = 2.0), and previous recurrent spontaneous abortions (SA) among childless women (OR = 3.4 to 11.9 according to the number of SA). The last of these factors may reflect another unknown risk factors common to recurrent SA and recurrent EP (for example hormonal or karyotype factors). Previous use of intra uterine device is associated with a decrease in the risk of recurrence of EP (OR = 0.27), but this contraceptive method should be considered as an indicator of good fertility rather than as a protective factor for EP recurrence.

[Attendance at a health center by clandestine prostitutes in Djibouti]

The extent of clandestine prostitution in Djibouti is difficult to evaluate. Due to the secrecy of the prostitutes and often their low level of education, the follow-up of these patients is also difficult. A sexually transmitted disease clinic specialized in the treatment of prostitutes and their customers has been established in Djibouti since 1963. We tried to evaluate the available data on the clandestine prostitutes attendance at the center. The population was young with a mean age of 23 years. Fifty percent had children and 60% were divorced or separated. Ninety-one percent were Ethiopian and 73% lived in the same district of the city of Djibouti. Almost half of them were HIV positive. The duration of residence in Djibouti before the first visit to the clinic varied widely with a median of 12 months. However, the total duration of prostitution before the first visit was shorter with a median of 3 months. The complaint at the first visit was most often minor. Among the prostitutes who first came to the center in 1993, half of them came only once. The overall duration of follow-up was 8 months, for an average of 3.7 visits per patient. Alternatively, 20 patients had more than 10 consultations and this represented one third of the consultations given to previous patients. This last group is the only one which tended to respect the monthly visits proposed to each patient at the first consultation. The other patients seemed to come only when they felt ill. The routine statistical activities which separately counted the new and previous patients gave an optimistic but faulty impression: these showed an increase in the total number of patients and also an increase in the percentage of previous patients visiting (from 42 to 69% between 1988 and 1994). It is difficult to evaluate the follow-up of such a mobile population. The few patients known for their fidelity contrasted with the fact that half of the patients had visited the center only once. This low frequency of visitation could be due to either the management of the center or to the lack of proximity of the contacts within the districts.

Comparison between radionuclide ejection fraction and fractional area changes derived from transesophageal echocardiography using automated border detection

BACKGROUND

Left ventricular fractional area changes (FAC) can be derived from transesophageal echocardiography using an automated border detection system. However, FAC has not yet been compared to left ventricular ejection fraction (EF) evaluated by a reference technique. The aim of this study was to correlate transesophageal echocardiography automated FAC to EF derived from radionuclide angiography to obtain a quantifying method of global left ventricular systolic function at the bedside.

METHODS

Ten critically ill patients, whose lungs were mechanically ventilated, were included in this prospective study. Patients were scheduled for radionuclide EF evaluation when at least 75% of the endocardium was clearly visualized on transesophageal echocardiography. Patients with esophageal pathology or cardiac dysrhythmia were excluded. Ejection fraction derived from radionuclide angiography was measured using technetium 99m. Echocardiographic data were obtained using an ultrasound system with automated border capabilities. Simultaneous measurements of left ventricular EF and FAC were obtained for each patient, both before and after starting a dobutamine intravenous infusion to modify left ventricular contractility.

RESULTS

Mean values for radionuclide EF and transesophageal echocardiography FAC were, respectively: 55% +/- 19% (range 19-89%) and 46% +/- 18% (range 17-80%). Left ventricular EF and FAC were significantly correlated (r = 0.85, SEE = 9.6%). Variations of EF and FAC, induced by dobutamine, were also correlated (r = 0.70, SEE = 4.9%).

CONCLUSIONS

Fractional area changes determined by transesophageal echocardiography using automated border detection correlate well with radionuclide EF and may be used at the bedside to quantify left ventricular function in selected intensive care unit patients.

Plasma ionized calcium in brain-dead patients

BACKGROUND

The mechanism of brain death-induced myocardial dysfunction remains debatable. Hypocalcemia is known to induce reversible myocardial dysfunction. However, the incidence of hypocalcemia and its effect on myocardial function during brain death is unknown.

METHODS

In 54 consecutive brain-dead patients, we measured plasma total and ionized calcium concentrations, QT and corrected QT intervals, and left ventricular ejection fraction area (LVEFa), using transesophageal echocardiography.

RESULTS

49 (91%) of brain-dead patients had a decrease in total plasma total calcium concentration but only 19 (35%) had a decrease in plasma ionized calcium. Corrected total plasma calcium failed to predict ionized calcium concentration and QT intervals were not significantly different in normo and hypocalcemic patients. The LVEFa was not significantly different between normo and hypocalcemic patients (53 +/- 13 versus 50 +/- 20%), and no correlation was found between LVEFa and ionized calcium (R = 0.02, NS). Hypocalcemic patients required greater doses of dopamine (8.2 +/- 5.2 versus 5.0 +/- 3.4 micrograms.kg-.min-1, p < 0.02) to maintain arterial pressure. Hypocalcemia was associated with a higher volume loading and a lower plasma protide concentration which reflected hemodilution.

CONCLUSION

A decrease in plasma ionized calcium is not frequent, rarely severe, and probably not the main mechanism of myocardial dysfunction in brain-dead patients. Hypocalcemic patients required higher doses of dopamine, suggesting a decrease in systemic resistance. Only direct measurement of ionized calcium can assess plasma calcium ion status in brain-dead patients.

Circulating cardiac troponin T in potential heart transplant donors

BACKGROUND

Brain death may induce myocardial dysfunction, the mechanisms of which are not yet fully understood. Circulating cardiac troponin T is considered a highly sensitive and specific marker of myocardial cell injury.

METHODS AND RESULTS

We prospectively measured circulating cardiac troponin T in 100 brain-dead patients and measured the left ventricular ejection fraction area (LVEFa), using transesophageal echocardiography. Sixty-one patients had normal LVEFa, 25 had moderate decrease in LVEFa (30% to 50%), and 14 had severe decrease in LVEFa (< or = 30%). Circulating cardiac troponin T concentrations were significantly higher (1.68 +/- 1.03 micrograms/L-1, P < .01) in patients with a severe decrease in LVEFa than in the two other groups (0.42 +/- 0.43 and 0.12 +/- 0.16 microgram/L-1, respectively), and there was a significant correlation between LVEFa and cardiac troponin T concentration (p = -0.59, P < .0001). An elevated circulating cardiac troponin T concentration (> or = 0.5 microgram/L-1) was more accurate (sensitivity, 1.00; specificity, 0.84) in predicting a severe decrease in LVEFa than an elevated CKMB value or an increased CKMB/CK ratio.

CONCLUSIONS

An elevated circulating cardiac troponin T was associated with a severe decrease in LVEFa in brain-dead patients, suggesting that severe and potentially irreversible myocardial cell damage occurred. In contrast, CKMB determination was not useful. Since the quality of the donor's heart is considered an important prognosis factor in heart transplantation, the determination of circulating cardiac troponin T concentration could be useful to the heart transplantation team.

Systemic gas embolism complicating pulmonary contusion. Diagnosis and management using transesophageal echocardiography

Systemic air embolism has been frequently reported after penetrating thoracic trauma. In blunt thoracic trauma, systemic air embolism has been rarely diagnosed, and then only after an invasive procedure such as thoracotomy. Transesophageal echocardiography has been recently introduced for the early assessment of trauma patients and is considered a sensitive noninvasive procedure to diagnose air embolism. We report three cases of systemic air embolism in patients with pulmonary contusion secondary to a blunt thoracic trauma requiring controlled ventilation. Transesophageal echocardiography was performed for evaluation of hemodynamic instability, and it showed air bubbles in the left atrium and left ventricle during the insufflation phase, which disappeared during apnea. A decrease in airway pressure (release of PEEP, low tidal volume, high frequency jet ventilation) significantly reduced the systemic air embolism. We concluded that systemic air embolism can occur after blunt thoracic trauma, and transesophageal echocardiography enables a rapid and accurate diagnosis that may be useful for therapeutic management.

Cardiovascular consequences of severe hypophosphataemia in brain-dead patients

Hypophosphataemia is known to induce reversible myocardial dysfunction, but the incidence of hypophosphataemia and its effect on myocardial function during brain death are unknown. In 90 consecutive brain-dead patients, we measured plasma concentrations of phosphate and left ventricular ejection fraction area (LVEFa), using transoesophageal echocardiography. In 15 severely hypophosphataemic (< 0.40 mmol litre-1), consecutive, brain-dead patients, haemodynamic status, LVEFa, and oxygen delivery and consumption were assessed before and after phosphorus loading (0.30 mmol kg-1). In 10 other brain-dead patients, urine elimination of phosphates was measured. Only 30 (33%) brain-dead patients had normal plasma phosphate concentrations, 22 (24%) had mild hypophosphataemia (0.40-0.80 mmol litre-1) and 38 (42%) had severe hypophosphataemia (< 0.40 mmol litre-1). There were no significant differences in LVEFa between these three groups (mean 53 (SD 16), 55 (12) and 51 (17)%, respectively) and no significant correlation between LVEFa and plasma phosphate concentration (r = 0.04). In 15 severely hypophosphataemic patients, phosphorus loading increased plasma phosphate concentration from 0.30 (0.10) to 1.06 (0.41) mmol litre-1, but did not modify haemodynamic status, LVEFa or oxygen delivery and consumption. In 10 other patients, urine phosphorus elimination was 16.8 (23.3) mmol/24 h while plasma phosphate concentration was at its highest level (0.80 (0.37) mmol litre-1), and only one of these patient had a slightly elevated phosphaturia. In conclusion, hypophosphataemia frequently occurs after brain death but has no significant cardiovascular consequences, suggesting that it is related to intracellular transfer and not phosphorus depletion.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the effects of rocuronium bromide on haemodynamics and left ventricular function in patients undergoing abdominal aortic surgery

In an open study of 26 patients undergoing abdominal aortic surgery, the effects of rocuronium 0.6 mg kg-1 (eight patients) and 0.9 mg kg-1 (nine patients) were compared with those of pancuronium 0.085 mg kg-1 (eight patients) on haemodynamic parameters and transoesophageal echocardiography. The anaesthetic technique was based on a benzodiazepine and low dose fentanyl (6 micrograms kg-1). Pancuronium was associated with a significant increase in mean arterial pressure, end-diastolic area and heart rate, none of which were seen after rocuronium at either dose level.

A comparison of systolic blood pressure variations and echocardiographic estimates of end-diastolic left ventricular size in patients after aortic surgery

As suggested by experimental studies, systolic pressure variation (SPV), the difference between maximum and minimum values of systolic blood pressure after a single positive pressure breath, may be a fair indicator of left ventricular preload. SPV was quantified in 21 patients who had undergone abdominal aortic surgery and were sedated under mechanical ventilation. The aim of the study was to assess the ability of this parameter to qualitatively estimate left ventricular preload measured using transesophageal echocardiography. All patients had preoperative radionuclide ejection fraction > 45%. Postoperative mechanical ventilatory patterns were the same for all patients: tidal volume = 10 mL/kg; respiratory frequency = 12-14 breaths/min; and zero end-expiratory pressure mode. Left ventricular dimensions at end-diastole correlated well with the magnitude of both SPV (r = 0.80) and its delta down (dDown) component (i.e., the degree by which systolic pressure decreases with each mechanical breath) (r = 0.83). Once the first measurement was completed, volume loading with two increments of 250 mL of human albumin 5% was performed in all but three patients. Each volume loading step caused a significant increase in the end-diastolic area (EDa) index (7.0 +/- 1.6 to 8.5 +/- 1.6 cm2/m2) and cardiac index (CI) (3.1 +/- 0.9 to 4.1 +/- 0.9 L.min-1 x m-2) and a concomitant significant decrease in the SPV (8.6 +/- 4.5 to 6.1 +/- 3.7 mm Hg) and its dDown component (5.9 +/- 4.1 to 2.9 +/- 2 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of transesophageal echocardiography in intensive care: a prospective assessment]

The benefits of transoesophageal echocardiography (TOE) were assessed prospectively in intensive care patients. The doctors carrying out TOE were not the same as those who ordered it. TOE was performed in 32 patients, all of whom but one were intubated and artificially ventilated, to elucidate the cause of circulatory shock, or to search for valvular vegetations or an intracardiac mass. TOE confirmed the diagnosis previously obtained with pulmonary arterial catheterization (10 patients), transthoracic echocardiography (3 patients) or ventriculography (1 patient) in 54% of cases. In 28% of cases, TOE invalidated the suspected diagnosis, and, in the remaining 28% of patients, TOE invalidated provided a previously unsuspected diagnosis. TOE was particularly useful in confirming the presence of valvular vegetations, endocarditis, or intracardiac thrombi, and to assess left ventricular function and preload in patients in shock. Like others, this study confirms the benefits of TOE in the intensive care setting.

Can portable chest x-ray examination accurately diagnose lung consolidation after major abdominal surgery? A comparison with computed tomography scan

PURPOSE

To prospectively quantify the degree of accuracy of portable chest x-ray film examination in the detection of postoperative lung consolidations.

STUDY

Nineteen patients had a chest x-ray film and computed tomography (CT) scan the day before and 48 h following elective abdominal aortic replacement.

RESULTS

The diagnosis of lung consolidations by x-ray film examination showed sensitivity of between 0.33 and 1.00, depending on the lung zone considered (lower at the lung bases). Specificity always was greater than 0.79. Radiologic lung volume decreased 16 percent postoperatively (p < 0.01) on average and noninflated parenchyma increased by a factor of 3 (p < 0.0001). Postoperatively, PaO2 correlated with the amount of condensed lung by CT scan (p < 0.002).

CONCLUSION

In postoperative conditions, x-ray film examination is a method which presents good specificity but poor sensitivity in the diagnosis of lung consolidations.

Effect of preoperative normovolemic hemodilution on left ventricular segmental wall motion during abdominal aortic surgery

Preoperative normovolemic hemodilution (PNH) has been proposed for patients scheduled to undergo aortic surgery. Coronary artery disease is frequent in these patients. The aim of the study was to assess the effect of PNH on hemodynamics and segmental wall motion (SWM) evaluated by transesophageal echocardiography in such patients. Twenty patients with coronary artery disease were allocated randomly to either PNH or no PNH; PNH was performed after anesthetic induction using dextran 60,000. Patients were operated on under general anesthesia and monitored intraoperatively with electrocardiographic lead CM5, radial and pulmonary artery catheters, and transesophageal echocardiography positioned to obtain a short-axis view. Hemodynamic and transesophageal echocardiographic data were collected after anesthetic induction and after PNH, before and 5 min after aortic clamping, after unclamping, and at the end of surgery. Aortic clamping induced a significant increase in systemic vascular resistance and arteriovenous difference in oxygen and a decrease in cardiac index (P < 0.05), but the effect of aortic clamping was inversely related to hemodilution. The SWM score (graded from 1 = normal to 5 = dyskinesia) was significantly increased after aortic clamping, mainly in the anterior segment (P < 0.05). Four patients in the control (no PNH) group and one in the PNH group developed new SWM abnormalities indicative of myocardial ischemia during surgery (P = NS). This study suggests that PNH may improve hemodynamic tolerance to aortic clamping in patients with coronary artery disease. The observed changes in SWM indicate that PNH may not worsen myocardial ischemia in patients scheduled to undergo aortic surgery.

Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography

Patients scheduled for vascular surgery are considered at risk for perioperative cardiac complications. Choice of anesthetic in such patients is guided by a desire not to adversely affect myocardial function. On the basis of data from laboratory studies, thoracic epidural anesthesia (TEA) has been advocated to prevent myocardial ischemia. The aim of this study was to assess whether TEA combined with general anesthesia has any effect on segmental wall motion (SWM) monitored by transesophageal echocardiography in these patients. Patients received alfentanil, midazolam, vecuronium, and 50% N2O in oxygen, and ventilation was controlled after orotracheal intubation; 12.5 mL of 2% lidocaine HCl was injected through an epidural catheter placed at T6-7 or T7-8. Hemodynamic measurements and transesophageal echocardiographic recordings were obtained before and 10, 20, 30, 40, and 60 min after lidocaine injection. Segmental wall motion was graded a posteriori by two independent experts on a predetermined scale (from 1 = normal to 5 = dyskinesia). A decrease greater than or equal to 2 grades was considered an SWM abnormality indicative of ischemia. Thoracic epidural anesthesia induced a decrease in systemic arterial blood pressure, heart rate, and cardiac index. The SWM score decreased slightly from 1.34 +/- 0.68 to 1.27 +/- 0.64 (mean +/- SD) (at 10 and 20 min, respectively) (P less than 0.05). Patients were a posteriori analyzed according to whether they had documented coronary artery disease or not. The SWM score before TEA was significantly higher in patients with documented coronary artery disease (1.51 +/- 0.88 vs 1.17 +/- 0.51, respectively; P less than 0.05) and did not change significantly after TEA.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of clonidine on variation of arterial blood pressure and heart rate during carotid artery surgery

The effect of oral premedication with 300 micrograms of clonidine on systemic arterial pressure, heart rate, and plasma norepinephrine levels was assessed in a double-blinded, placebo-controlled study conducted in 29 patients subjected to carotid artery surgery (CAS). Anesthesia was induced with thiopental, 6 mg/kg, and alfentanil, 0.05 mg/kg, and maintained with alfentanil and 0.6% isoflurane in 50% N20/O2. The study was divided into five periods as follows: (1) anesthesia to start of surgery; (2) surgery to carotid artery clamping; (3) carotid artery clamping to unclamping; (4) carotid artery unclamping to the end of surgery; and (5) the first 4 postoperative hours in the recovery room. In the clonidine group (n = 14), plasma norepinephrine concentrations were significantly lower before induction of anesthesia and during the operative period. Heart rate and systemic arterial pressure were lower (P less than 0.01) in the clonidine group at 3 different time intervals (control, carotid clamping, carotid unclamping). However, during each of the previously defined periods, the variability of heart rate and systemic arterial pressure, assessed by the coefficient of variation, was not different between the two groups. The lability of these hemodynamic parameters, expressed as the percentage of values, which increased or decreased more than 20% of control values during the corresponding period, was also comparable between the two groups. The number of patients who experienced at least one episode of hypertension (systolic arterial pressure greater than 180 mm Hg), hypotension (systolic arterial pressure less than 100 mm Hg), or bradycardia less than 45 beats/min was not different between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of epidural clonidine on analgesia and pharmacokinetics of epidural fentanyl in postoperative patients

Epidural clonidine produces postoperative analgesia in patients and potentiates opioid analgesia in animals. The aim of the current study was to assess the effect of epidural clonidine on the plasma concentrations and analgesic effect of fentanyl after epidural administration. Twenty ASA physical status 2 or 3 patients recovering from abdominal surgery were allocated randomly to receive either epidural fentanyl (100 micrograms in 10 ml isotonic saline; EF group) or epidural fentanyl (same dose) plus epidural clonidine (150 micrograms; EF + C group) in isotonic saline solution. Analgesia was assessed over a period of 12 h after epidural injection. Venous samples were obtained until 360 min after epidural injection for radioimmunoassay determination of plasma fentanyl concentration. Onset of analgesia was similar in the two groups of patients (13 +/- 6 and 13 +/- 3 min, respectively, after injection), but duration was more than doubled in the patients receiving clonidine (543 +/- 183 vs. 250 +/- 64 min). Peak plasma fentanyl concentrations (Fmax) and the time to reach Cmax (Tmax) were comparable in the two groups (0.29 +/- 0.15 ng.ml-1 at 16.2 +/- 14.8 min in the EF group and 0.27 +/- 0.11 ng.ml-1 at 8.3 +/- 5.5 min in the EF + C group), as were plasma concentrations at each definite time of measurement. Drowsiness and hypotension were noticed in the EF + C group. Thus, epidural clonidine appears to prolong epidural fentanyl analgesia without affecting its plasma concentration.

Intraoperative transesophageal echocardiography for pulmonary embolectomy without cardiopulmonary bypass

This case report describes a patient with massive pulmonary embolism and acute circulatory failure in whom transesophageal echocardiography permitted the diagnosis of thrombi in the main pulmonary truncus and in the right branch and guided intraoperatively the surgical embolectomy performed under simple venous inflow occlusion because of a contraindication to heparin administration. Transesophageal echocardiography seems to be a very helpful technique to diagnose promptly massive pulmonary embolism and a very useful tool at the time of operation to guide the embolectomy.

[Analysis of failures of spinal anesthesia as a function of practice development in a university hospital]

This study is a retrospective analysis of 303 consecutive spinal anaesthesia performed in orthopaedic patients of a University Hospital between January and December 1990. Failure of spinal anaesthesia was defined as the requirement for general anaesthesia to perform surgery. The parameters studied as possible risk factors of failure were patients demographics, local anaesthetic agents and solutions and techniques of spinal anaesthesia (single injection versus continuous spinal anaesthesia). Failures were related to inadequate or incomplete extension of sensory blockade or to difficulties to perform spinal injection. Continuous spinal anaesthesia was performed in 209 patients mostly with 0.5% isobaric bupivacaine, while 94 patients received a single injection of either hyperbaric 0.5% tetracaine with adrenaline or 0.5% bupivacaine or 5% lidocaine. Failures occurred in 6.3% of the cases but were significantly less frequent with continuous spinal anaesthesia (4.8%) than with the conventional technique (9.6%). The incidence of failure was higher with hyperbaric tetracaine (11.1%) confirming its poor reliability. Inadequate extension of the anaesthetic block was the main cause of failure whatever the spinal anaesthetic technique. These results point out the reliability of continuous spinal anaesthesia but problems may occasionally occur due to spinal catheter misplacement.

Effects of oral and subarachnoid clonidine on spinal anesthesia with bupivacaine

This study was designed to determine whether clonidine has analgesic properties, decreases the minimum alveolar concentration of inhalational anesthetics, or affects the quality and the duration of spinal anesthesia with bupivacaine. The comparative effects of oral and subarachnoid clonidine on spinal anesthesia with bupivacaine were studied in 36 patients scheduled for orthopedic surgery. Patients were allocated randomly into four groups to receive either oral diazepam (10 mg in Groups I and II) or oral clonidine (150 micrograms and 300 micrograms in Groups III and IV, respectively), as premedication. Spinal anesthesia was performed with 15 mg hyperbaric bupivacaine 0.5% plus either 1 ml isotonic saline in Groups I, III, and IV, or 150 micrograms clonidine in Group II. Subarachnoid but not oral clonidine significantly prolonged the duration of sensory block (time for regression to L2 was 157 +/- 21 minutes in Group I and 267 +/- 75 minutes in Group II) and the duration of motor block (duration of Grade 3 motor block--Bromage scale--was 103 +/- 20 minutes in Group I and 175 +/- 68 minutes in Group II). Only the subarachnoid administration of clonidine achieves adequate concentrations to significantly increase the duration of spinal anesthesia.

Clonidine-induced analgesia in postoperative patients: epidural versus intramuscular administration

To compare the analgesic efficacy and plasma concentration of intramuscular (IM) versus epidural (EP) clonidine, 20 patients recovering from orthopedic or perineal surgery were randomly divided into two groups of ten. Clonidine (2 micrograms/kg) was administered epidurally in group 1 and intramuscularly in group 2. Analgesia was assessed using a visual analog scale (VAS) over a period of 6 h following clonidine administration. Venous blood samples were obtained at specific intervals for radioimmunoassay determination of plasma clonidine concentrations. The maximum reduction in VAS pain score was 78.5 +/- 20.6% in the EP group and 68.1 +/- 31.5% in the IM group (NS). Onset of analgesia was similar (within 15 min of injection), but duration tended to be longer after epidural than intramuscular administration (208 +/- 87 min vs. 168 +/- 95 min, mean +/- SD, P greater than 0.05). The peak plasma clonidine concentration after EP injection was 0.82 +/- 0.22 ng/ml and 1.02 +/- 0.76 ng/ml after IM injection. Hypotension, bradycardia, and drowsiness occurred with both methods of administration. None of these effects required treatment. Thus, in postoperative patients clonidine produces similar analgesia and side effects after parenteral or EP administration.

[Opening of a foramen ovale during liver transplantation. The value of transesophageal echocardiography]

A case is reported of a foramen ovale becoming patent during orthotopic liver transplantation (OLT). The patient had a hepatoma secondary to post-hepatitis cirrhosis. Monitoring included transesophageal echocardiography (TEE). A veno-venous shunt between the right femoral, portal and left axillary veins was used so as to maintain the venous return during portal and caval clamping. The patient's haemodynamic state remained quite stable throughout this period, and no vasoactive drug was required. Five min after graft reperfusion, pulmonary arterial pressure increased suddenly (mean PAP: 27 mmHg). TEE revealed paradoxical movements of the atrial septum. Colour coded Doppler ultrasound showed blood flowing from the right to the left atrium through a patent foramen ovale. Fifteen min later, mean PAP decreased (18 mmHg) and TEE no longer showed any flow between the two atria. Several studies have reported transient pulmonary hypertension after unclamping when the donor liver is reperfused. This could induce right ventricular failure, with transient inversion of the atrial pressure gradient, which, in turn, could result in a right-to-left shunt through a patent foramen ovale. TEE can monitor regional and overall left ventricular function as well as the atrial septum. This technique might therefore to be useful for cardiac monitoring during OLT.

[Comparison between conventional and continuous spinal anesthesia using bupivacaine]

A study was carried out to find out whether dividing the dose of local anaesthetic would give a better control of the spread and duration of sensory blockade due to spinal anaesthesia. It was carried out in 34 patients (mean age 62 years) scheduled for elective limb vascular surgery. All were classed ASA 2 or 3. Sensory blockade was assessed using a fine needle, and the degree of motor blockade with Bromage's scale. This was carried out every 5 min for the first 30 min, and thereafter, every 15 min until recovery from anaesthesia was complete. In the first group of patients (n = 16), spinal anaesthesia was obtained with a 26 gauge needle, the patient lying on his side; 4 ml of 0.5% bupivacaine were injected (1 ml every 10 seconds) before putting the patient supine. In the second group (n = 18), the catheter for continuous spinal anaesthesia was set up with the patient in the same position as for the first group. Once a length of 1 cm had been introduced in the subarachnoid space, the patient was placed supine and 2 ml of 0.5% bupivacaine were injected. If 15 min later sensory blockade did not reach T10, further 0.5 ml aliquots were given every 10 min so as to obtain a level of sensory blockade between T9 and T11. Maximum extension of sensory blockade was 15.1 +/- 2.3 metamers in group 1, with an extension to T3 in 2 patients. In group 2, 12.9 +/- 3.1 mg bupivacaine anaesthetized 14.2 +/- 1.9 metamers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of severe pulmonary embolism by transesophageal echocardiography]

A 56-year-old woman was admitted to the Emergency Department for profuse diarrhoea, associated with hypokaliemia and dehydration. A subclavian venous catheter was inserted after she had a cardiac arrest. Six days later, the subclavian and innominate veins were thrombosed. Prophylactic low molecular weight heparin was then replaced by sodium heparinate. The patient's platelet count decreased to 65 G.1-1. It was nevertheless decided to remove her villous tumour. After the operation, the patient became shocked, with worsening thrombocytopaenia (15 G.1-1). She was unresponsive to fluid replacement. Transoesophageal echocardiography (TEE) was carried out, as pulmonary arterial catheterization was considered too dangerous. A "white" thromboembolus was discovered in the right pulmonary artery. Embolectomy was successfully performed without extracorporeal circulation. Flow was completely restored in the main pulmonary artery, but only partially in the right branch. Oral anticoagulation was started postoperatively. It is concluded that TEE might be a very helpful technique to promptly diagnose acute pulmonary embolism; moreover, it could be an alternative to pulmonary angiography, especially in patients in a poor state.