RESUMO
PURPOSE: West Nile virus (WNV) transmission through organ transplantation occurs rarely and screening of organ donors for WNV infection remains controversial. This report describes the case of WNV encephalitis in a kidney recipient and the case of asymptomatic WNV infection in the organ donor, both observed at Treviso Hospital, northeastern Italy. After briefly reviewing the literature, we discuss the implications for WNV screening. METHODS: We reviewed medical, laboratory and epidemiological records at our hospital, and the literature concerning cases of organ-transmitted WNV infections and WNV screening of organ donors in Italy and worldwide. RESULTS: The kidney recipient was the first confirmed case of WNV infection notified in northeastern Italy in 2011, and the first case of WNV infection in a cluster of four transplant recipients who acquired the infection from a common organ donor. The organ donor, whose WNV infection was only retrospectively diagnosed by IgM detection, represents the index case of a WNV outbreak in the Treviso Province. Screening of her blood prior to organ recovery did not show detectable levels of WNV nucleic acid with the use of quantitative real-time polymerase chain reaction. CONCLUSIONS: This report emphasizes that transplant-acquired WNV neuroinvasive disease can be particularly severe. We suggest that pre-procurement screening of organ donors by testing blood with both WNV IgM capture ELISA and a sensitive nucleic acid testing should be adopted during the transmission season in the present Italian epidemiological setting.
Assuntos
Doadores de Tecidos , Transplante , Transplantes/efeitos adversos , Febre do Nilo Ocidental/transmissão , Vírus do Nilo Ocidental/isolamento & purificação , Adulto , Anticorpos Antivirais/sangue , Coma/virologia , Feminino , Humanos , Itália , Masculino , RNA Viral/sangue , Transplantes/virologia , Febre do Nilo Ocidental/diagnóstico , Febre do Nilo Ocidental/virologiaAssuntos
Vértebras Cervicais/cirurgia , Potencial Evocado Motor/fisiologia , Monitorização Intraoperatória/métodos , Boca/cirurgia , Movimento/fisiologia , Adulto , Idoso , Anestesia/métodos , Descompressão Cirúrgica/métodos , Potenciais Evocados/fisiologia , Feminino , Humanos , Masculino , Exame Neurológico , Parestesia/etiologia , Parestesia/cirurgia , Neoplasias da Medula Espinal/cirurgia , Estenose Espinal/cirurgiaRESUMO
Aim of this paper is to describe an approach to the patient with congenital heart disease (CHD) who is undergoing noncardiac surgery. Emphasis is placed on the pathophysiology of the lesion in order to facilitate the development of an anesthetic planning. There are three general categories of CHD: obstructive lesions, increased pulmonary blood flow lesions and decreased pulmonary blood flow lesions. Alterations in systemic and/or pulmonary vascular resistances lead to alterations in the quantity of pulmonary blood flow and the ventricles' ability to pump against an obstruction. Selection of anesthetic medications which preserve ventricular function and vascular resistances in a fashion which best maintain pulmonary blood flow and oxygenation and forward cardiac output are the anesthesiologist's goals. No single simple unified approach can be taken when providing anesthesia for the patient with CHD for noncardiac surgery; however, by evaluating each patient's hemodynamic needs in relation to hemodynamic variables which the anesthesiologist may control, a rational and individualized approach can be developed.
Assuntos
Cardiopatias/congênito , Cardiopatias/fisiopatologia , Procedimentos Cirúrgicos Operatórios , Anestesia , Hemodinâmica , Humanos , Monitorização FisiológicaRESUMO
BACKGROUND: The performance of the cardiovascular system depends on the interaction of the left ventricle and arterial system. An appropriate coupling of these two components is important to quantify the efficiency of myocardium, determined by Ea/Ees. The end-systolic elastance of the left ventricle (Ees) is an index of contractility which is independent of loading conditions, while the arterial end-systolic elastance (Ea) represents the properties of the arterial system. The aim of our study is to investigate the effects of a bolus of remifentanil (R) on myocardial efficiency. METHODS: In a period of 3 months we examined prospectively the effects of R in a group of 12 patients, ASA IV, 49-75 years old, submitted intraoperatively to cardiac anesthesia for revascularization of myocardium. After induction of anesthesia and before the beginning of surgery, a bolus of R (1 mg/kg/min) was administered and with the use of trans-esophageal echocardiography we determined both the left ventricle end-systolic volume and end-diastolic volume to assess, with different end-systolic arterial pressures, the ventricle elastance (Ees) and arterial elastance (Ea) before and after administration of R. RESULTS: The present findings indicate that R decreases the ventricular elastance from 6.07 mmHg/ml/m2 to 4.8, with a less decrease of arterial elastance from 3.69 mmHg/ml/m2 to 3.07. CONCLUSIONS: The results suggest that R preserves a good left ventricular-arterial coupling and mechanical efficiency, despite a little increase of coupling, probably because ventricular and arterial properties are so matched as to minimize the systolic work of the left ventricle.
Assuntos
Anestésicos Intravenosos/farmacologia , Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Piperidinas/farmacologia , Função Ventricular Esquerda/efeitos dos fármacos , Idoso , Anestésicos Intravenosos/administração & dosagem , Aorta/efeitos dos fármacos , Fármacos Cardiovasculares/farmacologia , Fármacos Cardiovasculares/uso terapêutico , Terapia Combinada , Doença das Coronárias/tratamento farmacológico , Doença das Coronárias/fisiopatologia , Ecocardiografia Transesofagiana , Impedância Elétrica , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca/efeitos dos fármacos , Hemorreologia/efeitos dos fármacos , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/efeitos dos fármacos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/fisiopatologia , Consumo de Oxigênio/efeitos dos fármacos , Piperidinas/administração & dosagem , Propofol , Estudos Prospectivos , Remifentanil , Volume Sistólico/efeitos dos fármacos , Tiopental , Resistência Vascular/efeitos dos fármacos , Brometo de VecurônioRESUMO
The intraoperative use of two-dimensional transesophageal echocardiography has proved effective in the evaluation of left ventricular function after heart operations, in the assessment of adequacy of valve replacement or repair techniques, and in the detection of intracardiac air bubbles before discontinuation of cardiopulmonary bypass. We report here a patient in whom the presence of a tumor mass in the left leaflet of the aortic valve, which was missed at preoperative transthoracic echocardiogram and would have most likely been the cause of systemic embolization, was diagnosed by two-dimensional transesophageal echocardiographic monitoring. We hope that this experience may support the use of two-dimensional transesophageal echocardiography during cardiac surgery.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Transesofagiana , Implante de Prótese de Valva Cardíaca , Idoso , Humanos , Masculino , Monitorização IntraoperatóriaRESUMO
We report on a case of an 11-year-old asymptomatic child with aortico-left ventricular tunnel arising from the left aortic sinus. Preoperative transesophageal echocardiography showed a dilated aortic root with mild aortic valve incompetence and demonstrated the course of the tunnel, which originated from the left coronary sinus entering the outlet portion of the left ventricular outflow tract. Patch closure of the aortic end of the tunnel eliminated left ventricular volume overload with immediate marked reduction of cardiomegaly. At 10-month follow-up the child is asymptomatic and receiving no oral medications. Control two-dimensional Doppler echocardiography shows trivial central aortic valve incompetence.
Assuntos
Aorta/anormalidades , Cardiopatias Congênitas/cirurgia , Seio Aórtico/anormalidades , Aorta/diagnóstico por imagem , Aorta/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Volume Cardíaco/fisiologia , Cardiomegalia/terapia , Criança , Vasos Coronários/diagnóstico por imagem , Dilatação Patológica/diagnóstico por imagem , Ecocardiografia , Ecocardiografia Doppler , Ecocardiografia Transesofagiana , Seguimentos , Cardiopatias Congênitas/diagnóstico por imagem , Ventrículos do Coração/anormalidades , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Humanos , Masculino , Pericárdio/transplante , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/cirurgia , Transplante Autólogo , Disfunção Ventricular Esquerda/terapiaRESUMO
OBJECTIVE: This study was designed to investigate the haemodynamic response and pharmacokinetics of a low-dose propofol continuous infusion in providing sedation in patients who required mechanical ventilation after coronary artery bypass grafting surgery. PATIENTS: 22 male patients, aged between 45 and 65 years, were evaluated in an open, uncontrolled study. INTERVENTIONS: At the end of the surgical procedure, a low-dose (1 mg/kg/h) propofol infusion was started and adjusted to optimise sedation according to the Ramsay scale. The mean propofol infusion rate was 1.42 +/- 0.4 mg/kg/h. MAIN OUTCOME MEASURES: Electrocardiogram, systemic and pulmonary arterial pressure, and central venous pressure were monitored continuously. Left ventricular shortening fraction was calculated by transoesophageal echocardiography. Propofol plasma levels were calculated in 10 patients to evaluate the pharmacokinetics. RESULTS: Throughout the duration of the study all patients were haemodynamically stable. Sedation was maintained for 363 +/- 244 minutes and was adequate in all patients. The clinical recovery time (postsedation responsiveness) was 15.7 +/- 6.2 minutes, after infusion suspension. There was no correlation between propofol plasma levels or propofol infusion rate and the depth of sedation (respectively, r = 0.39 and r = 0.23), while there was a good correlation (r = 0.62) between propofol infusion rate and plasma levels. Open two-compartment model pharmacokinetics were demonstrated. CONCLUSION: Low-dose propofol infusion (1 to 2 mg/kg/h) proved to be well tolerated and effective in maintaining sedation after cardiac surgery. Sedation was quickly obtained without a propofol loading dose; steady-state plasma concentrations of 0.6 to 0.8 mg/L were rapidly achieved. Propofol pharmacokinetics ensure rapid clearance with rapid clinical recovery.
RESUMO
OBJECTIVE: To determine the effects of intraoperative plasmapheresis on total transfusion requirements, mediastinal drainage, and coagulation. DESIGN: The trial was prospective, randomized, and controlled. SETTING: Inpatient cardiac surgery at a university medical center. PARTICIPANTS: Two hundred ninety-three consecutive patients undergoing cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: Intraoperative plasmapheresis (IP) was performed in 147 patients before heparinization; platelet-rich plasma was reinfused immediately after heparin reversal. MEASUREMENTS AND MAIN RESULTS: Mediastinal chest tube drainage during the first 12 postoperative hours was significantly less in the IP group (p = 0.022), but no difference was noted in total postoperative blood loss between the two groups. The amount of packed red cells and fresh frozen plasma transfused to the IP group in the intensive care unit was significantly lower (p = 0.02, p = 0.002, respectively); 51.4% of patients required no transfusion compared with the control group (34.5%) (p = 0.006). No differences were noted for data collected in the intensive care unit in terms of the mean duration of chest tube drainage, ventilator time, or any hematologic variables at baseline or at any subsequent time in the study. CONCLUSIONS: After cardiac surgery, intraoperative plasma-pheresis reduces early postoperative bleeding and decreases the need for homologous transfusions.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Plasmaferese , Perda Sanguínea Cirúrgica , Transfusão de Sangue , Ponte Cardiopulmonar , Feminino , Hematócrito , Hemoglobinas/análise , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Contagem de PlaquetasRESUMO
BACKGROUND: This report describes our experience with primary correction of tetralogy of Fallot in infants. METHODS: Fifty-one consecutive infants younger than 6 months underwent primary correction of tetralogy of Fallot between January 1978 and October 1994. Mean age at repair was 4.2 months. Four were neonates. Correction was accomplished through a right ventriculotomy in the first consecutive 22 patients (43%; group A); since 1991, a combined transatrial-transpulmonary approach was used in 29 consecutive patients (57%; group B). A transannular patch was necessary in 33 infants (65%) 16 of group A (73%) and 17 of group B (59%). RESULTS: There was one early death from possible left anterior descending coronary artery distortion in group A and no deaths in group B. Two patients required early reoperation for systemic-to-pulmonary artery collateral ligation (postoperative day 6) and permanent pacemaker implantation (postoperative day 30). There were no late deaths. All 50 survivors are currently asymptomatic and in New York Heart Association class I. Three patients required late reoperations 36 months, 30 months, and 13 months after repair for (1) subaortic stenosis and dysfunctioning dysplastic mitral valve, (2) residual pulmonary artery branch stenosis, and (3) residual right ventricular outflow obstruction. Four patients underwent balloon dilation and stent insertion (1 patient) for peripheral pulmonary artery stenosis 1.5 year to 12 years (mean, 5 years) after initial repair. Actuarial freedom from need for reintervention at 4 years was 78.4% in group A and 85.7% in group B. Two-dimensional and Doppler echocardiographic follow-up studies showed a residual mild to moderate pulmonary artery branch stenosis in 4 patients in group A, and a recurrent subaortic stenosis in 1 patient in group A. Right ventricular peak systolic pressure was less than 40 mm hg in all but 3 asymptomatic patients who had a residual pulmonary artery branch stenosis. Right ventricular end-systolic and end-diastolic volumes showed larger volumes and reduced ejection fraction in group A compared with group B. CONCLUSIONS: This limited experience with repair of tetralogy of Fallot in patients less than 6 months of age demonstrates that the transatrial-transventricular approach is possible in neonates and young infants with a very low mortality and morbidity and also a low incidence of residual lesions. Follow-up echocardiographic data suggest that right ventricular function is better preserved in those patients who underwent the transatrial-transpulmonary repair.
Assuntos
Tetralogia de Fallot/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Ecocardiografia , Feminino , Hemodinâmica , Humanos , Lactente , Recém-Nascido , Masculino , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/fisiopatologia , Resultado do Tratamento , Função Ventricular DireitaRESUMO
To avoid intraoperative awareness and postoperative respiratory depression from high-dose opioid anesthesia, propofol (P), or isoflurane (I) has been combined with moderate-dose opioid with varying results. However, the effects of both P and I on myocardial contractility and left ventricular afterload have not been completely quantified. The end-systolic pressure-diameter relationship (ESPDR) of the left ventricle (LV) is a reliable method to quantitatively assess LV contractility because it is relatively independent of changes in preload and incorporates afterload changes. The purpose of this study was to quantify the cardiodynamic effects of propofol-fentanyl (PF) anesthesia in comparison with isoflurane-fentanyl (IF) anesthesia in patients undergoing coronary artery bypass grafting (CABG). Thirty patients with normal or moderately impaired LV function (ejection fraction > or = 40% with LV end-diastolic pressure < or = 18 mmHg, no preoperative akinesia or dyskinesia) undergoing elective CABG were studied. After premedication with flunitrazepam, 2 mg orally, all patients were induced with thiopental, 1 mg/kg, fentanyl, 20 micrograms/kg, and vecuronium, 0.1 mg/kg, and were ventilated with oxygen/air (F(1)O2 0.6). Anesthesia was maintained throughout the procedure with a zero-order intravenous (IV) continuous infusion of P, 3 mg/kg/h (PF group), or with isoflurane inhalation of 0.6% (IF group), supplemented by intermittent boluses (5 micrograms/kg) of fentanyl (up to a total maintenance dose of 30 micrograms/kg). After intubation, a cross-section of the LV was visualized by two-dimensional transesophageal echocardiography and an m-mode echocardiogram was obtained at the maximum anterior-posterior diameter. The radial artery pressure tracing and the ECG were simultaneously recorded with the M mode.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Anestesia por Inalação , Anestesia Intravenosa , Ponte de Artéria Coronária , Fentanila/farmacologia , Hemodinâmica/efeitos dos fármacos , Isoflurano/farmacologia , Contração Miocárdica/efeitos dos fármacos , Propofol/farmacologia , Adulto , Idoso , Combinação de Medicamentos , Ecocardiografia Transesofagiana , Procedimentos Cirúrgicos Eletivos , Eletrocardiografia , Feminino , Fentanila/administração & dosagem , Ventrículos do Coração/diagnóstico por imagem , Humanos , Isoflurano/administração & dosagem , Masculino , Pessoa de Meia-Idade , Propofol/administração & dosagem , Volume Sistólico/efeitos dos fármacos , Função Ventricular Esquerda/efeitos dos fármacos , Pressão Ventricular/efeitos dos fármacosRESUMO
Pulmonary atresia with intact ventricular septum is a disorder that involves the whole right ventricle. An associated Ebstein deformity of the tricuspid valve is found in 10% of the cases, further complicating the anatomy and the function of the right ventricle. From January 1966 to December 1990, pulmonary atresia, intact ventricular septum, and Ebstein deformity of the tricuspid valve were observed in 11 cases in our institution; four of them were necropsy findings and the remaining seven were patients treated surgically. Of the latter, two were boys and five were girls (age range 1 day to 18 days). Two patients were managed by pulmonary valvotomy, three by systemic-pulmonary artery shunt, and two had a combination of the two. Operative mortality was 57%. Eight hearts were available for morphologic study. All had viscero-atrial situs solitus, D-loop ventricular structure, and normally related great arteries. A correlation between the degree of tricuspid valve dysplasia and right ventricular cavity size was observed in all. Furthermore, in five cases the anterior leaflet of the tricuspid valve obstructed the right ventricle at the ostium infundibuli level. In two of our surgical patients, a protruding anterior tricuspid valve leaflet was identified and excised and both patients survived. Ebstein anomaly of the tricuspid valve further complicates surgical management and outcome of pulmonary atresia and intact ventricular septum. Potential obstruction at the ostium infundibuli level should always be considered during repair. Various degrees of right ventricular inlet dysplasia, always present in this complex, may contraindicate an anatomic correction. In these cases a modified Fontan-type procedure should be considered as a valid surgical option.
Assuntos
Anormalidades Múltiplas/cirurgia , Anomalia de Ebstein/cirurgia , Comunicação Interventricular/cirurgia , Valva Pulmonar/anormalidades , Anormalidades Múltiplas/diagnóstico por imagem , Anormalidades Múltiplas/patologia , Cateterismo Cardíaco , Cineangiografia , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/patologia , Feminino , Comunicação Interventricular/diagnóstico por imagem , Comunicação Interventricular/patologia , Humanos , Recém-Nascido , Masculino , Complicações Pós-Operatórias/mortalidade , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/patologia , Valva Pulmonar/cirurgia , Taxa de SobrevidaRESUMO
There is international experience of Extracorporeal Membrane Oxygenation (ECMO) in children suffering acute Respiratory failure (eg. meconium aspiration syndrome); on the contrary there is a lack of consistent experience in pediatric ECMO application in cardiac surgery as bridge to cardiac transplantation and as heart mechanical support after postcardiotomy failure. In fact there are good standardization criteria for selection, inclusion and exclusion in ECMO application for neonatal respiratory failure; differently pediatric ECMO timing (that is when to start and to stop this ventricular support) is not clear and standardized. We present one case of pediatric ECMO application in a neonate, who underwent cardiac operation for pulmonary valve aplasia and who was impossible to wean from cardiopulmonary bypass.
Assuntos
Oxigenação por Membrana Extracorpórea , Cuidados Pós-Operatórios , Valva Pulmonar/anormalidades , Valva Pulmonar/cirurgia , Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Humanos , Recém-Nascido , MasculinoRESUMO
Many patients report problems of impotence after heart transplantation, which definitely impairs their quality of life. Ten men, with a mean age of 41 years, were evaluated for persistent erection problems after heart transplantation by measurement of nocturnal penile tumescence using a Rigiscan. Three men had a positive response, and their disturbances were therefore considered to have a psychological basis; seven men had a negative or only weakly positive response, and their impotence was attributed to organic causes. To all patients, intracavernous injections of an initial dose of 10 to 20 micrograms of prostaglandin E1 were administered as first-choice treatment. Nine patients obtained a firm, lasting erection 2 to 5 minutes after injection, with no relevant side effects. The patients were then instructed to self-administer the drug before intercourse, and some were able to return to spontaneous sexual activity at various intervals. Intracavernous injection of prostaglandin E1 seems to be an effective treatment of erectile impotence in heart transplant recipients; it is well tolerated with no side effects and considerably improves the patient's quality of life.
Assuntos
Alprostadil/uso terapêutico , Disfunção Erétil/tratamento farmacológico , Transplante de Coração/efeitos adversos , Adulto , Alprostadil/administração & dosagem , Disfunção Erétil/etiologia , Humanos , Injeções , Masculino , Pessoa de Meia-IdadeRESUMO
We present the clinical case of a patient affected by mitral and aortic valvular disease submitted to double valvular replacement. This patient was also affected by congenital deficiency of factor X. We describe the normal problems encountered in cardiac surgery and the specific implications of this clinical case.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Deficiência do Fator X/complicações , Insuficiência da Valva Mitral/cirurgia , Estenose da Valva Mitral/cirurgia , Idoso , Feminino , HumanosRESUMO
Two cases of massive mitral regurgitation due to mitral valve disruption following percutaneous balloon valvuloplasty are reported. This severe complication occurred in two elderly women with recurrent mitral stenosis after previous surgical commissurotomy. Due to their unstable hemodynamic and clinical condition, both patients underwent emergency valve replacement. At surgery, the commissures appeared fused and heavily calcified; the chordae tendineae thickened, shortened, and fused; and the leaflets presented a large tear with sheared edges. Because the technical aspects of both procedures were unremarkable, the anatomic features of the mitral valve seemed to affect the occurrence of severe mitral regurgitation. Percutaneous balloon valvuloplasty should be therefore applied carefully to patients with prior surgical valvotomy, in whom the structural alterations of the mitral apparatus may predispose to severe valvular damage.