Prophylactic preoperative levosimendan administration in heart failure patients undergoing elective non-cardiac surgery: a preliminary report.

INTRODUCTION: Preoperative optimization of cardiac failure (CF) patients undergoing non-cardiac surgery is of utmost importance. Levosimendan is a promising adjunct in our therapeutic repertoire for the treatment of CF; however, it has not been evaluated in CF patients undergoing non-cardiac surgery. Our objective was to evaluate the safety and efficacy of prophylactic preoperative levosimendan administration in these patients. METHODS: CF patients with ejection fraction <35% undergoing elective non-cardiac (abdominal) surgery during a 6-month-period were included in this prospective study. All patients, admitted to the Surgical Intensive Care Unit (SICU) one day preoperatively for levosimendan administration, received a bolus infusion (2.4 Ig/kg) for 10 min followed by a 24-hour continuous infusion (0.1 Ig/kg/min) at the end of which they were operated. Patients were under continuous hemodynamic monitoring in the SICU during levosimendan infusion and for 24 h post-infusion. Hemodynamic parameters, including heart rate, arterial pressure and pulmonary artery catheter data, were recorded before treatment, 10 min after drug initiation, and at 3-hour intervals to 24 h post-infusion. Echocardiography was performed before infusion and on the 7th post-infusion day. RESULTS: Nine patients were enrolled. Cardiac index (0-48 h, 95% CI: -2.790-0.432, p<0.001) and stroke volume index (0-48 h, 95% CI: -32.53-0.91, p=0.01) increased significantly at 24 h after drug initiation and remained increased for 24 h post-infusion. Systemic vascular resistance index decreased at 10 min and remained reduced during the whole observation period (0-48 h, 95% CI: 875.64-2378.14, p<0.001). Ejection fraction was significantly increased on the 7th post-infusion day (32.65 +/- 7.32 vs. 20.89 +/- 6.24, p<0.05). No adverse reactions, complications or deaths occurred during 30 days' follow up. CONCLUSION: Prophylactic preoperative levosimendan treatment may be safe and efficient for the perioperative optimization of heart failure patients undergoing non-cardiac surgery.

The role of second trimester ultrasound in the diagnosis of placental hypoechoic lesions leading to poor pregnancy outcome.

OBJECTIVE: The purpose of the study was to quantify placental hypoechoic areas without blood flow by means of second trimester high-resolution ultrasound with power color Doppler and to evaluate its relationship to pregnancy outcome. METHODS: Patients referred for second trimester ultrasound from January 2001 to December 2003 were eligible for the study. Patients with placental parenchymal hypoechoic areas without blood flow constituted the study group (N = 65). The control group was comprised of 65 patients who had normal placental parenchyma. The groups were similar with regards to maternal age, gestational age, parity, race, and smoking. The mean of the two largest lesion diameters was used for severity classification. RESULTS: Fifty-two patients (80%) had aggregate lesions of 5 cm. Mean +/- standard deviation (SD) gestational age at delivery was 39.1 +/- 1.8 weeks for the control group, 37.9 +/- 2.8 weeks for those with lesions of 5 cm (p < 0.0001). Mean birth weight +/- SD was 3348 +/- 492 g for the controls, 3134 +/- 657 g for those with lesions of 5 cm (p = 0.0005). The incidence of intrauterine growth restriction was 9.6% in the group with lesions of 5 cm, compared to 3.1% in the control group (p = 0.0003; odds ratio (OR) = 5.7, p = 0.015). The incidence of preeclampsia in the control group was 0.0%, in the group with lesions of 5 cm was 15.4% (p < 0.0214; OR = 14.3, p = 0.014). CONCLUSIONS: Increased size of hypoechoic placental lesions is associated with increased risk for adverse perinatal outcome. Such lesions might be the result of intervillous space thrombosis, and ultrasound may be a useful tool in the identification of patients with pro-thrombotic abnormalities. The capability to identify patients with placental thrombosis will help us to identify those patients who will benefit most from anti-thrombotic treatment

Differences in amniotic fluid patterns and fetal biometric parameters in third trimester pregnancies with and without diabetes.

OBJECTIVE: The amniotic fluid index (AFI) has been increasingly used in the assessment of fetal well-being. We conducted the study to evaluate and compare the amniotic fluid index in third trimester normal and diabetic human pregnancy and to assess the correlation between the AFI and the fetal biometric parameters. METHODS: Real-time ultrasound was performed to evaluate the AFI (four-quadrant technique), and to measure the biparietal diameter, head circumference, abdominal circumference, and femur length in 225 normal and 120 diabetic pregnant women from 27 to 42 weeks of gestation. Each patient was studied only once. RESULTS: AFI in normal pregnancies was less than that in diabetic pregnancies throughout the gestational ages studied (27-42 weeks). In normal pregnancy, the mean AFI was 14.0 cm at 27 weeks and decreased to 11.4 cm at 42 weeks (r = 0.25, p = 0.0005), whereas in diabetic pregnancies, the values remained stable throughout the gestational ages studied. There exist significant differences in AFI, estimated fetal weight, estimated fetal weight %, abdominal circumference, abdominal circumference %, and head circumference to abdominal circumference ratio between the two groups. In both normal and diabetic pregnancies, there is a positive correlation between the AFI and the percentile of abdominal circumference (p < 0.0001), and between the AFI and the percentile of estimated fetal weight (p < 0.0001). CONCLUSION: This study provides gestational age-specific values of the AFI in normal and diabetic pregnancies. Diabetic pregnancy has greater AFI values than normal pregnancy between 27 and 42 weeks. The AFI correlates to the percentile of the estimated fetal weight and the abdominal circumference in both groups, suggesting that there may be a relationship between increased AFI and large for gestational age fetus independent of diabetes.