Surgical management of left-sided carcinoid heart disease.

BACKGROUND: Carcinoid involvement of left-sided heart valves has been reported in patients with a patent foramen ovale, carcinoid tumor of the lung, and active carcinoid syndrome with high levels of serotonin. The present study details the clinical features and surgical management of patients with carcinoid heart disease affecting both left- and right-sided valves. METHODS AND RESULTS: Eleven patients (7 men, 4 women) with symptomatic carcinoid heart disease underwent surgery for left- and right-sided valve disease between 1989 and 1999. Mean age was 57+/-9 years, and median preoperative NYHA class was 3. All patients had metastatic carcinoid tumors and were on somatostatin analog. Of 11 patients, 5 (45%) had a patent foramen ovale; 1 of these also had a primary lung carcinoid tumor. Surgery included tricuspid valve replacement in all patients, pulmonary valve replacement in 3 and valvectomy in 7, mitral valve replacement in 6 and repair in 1, aortic valve replacement in 4 and repair in 2, CABG in 2, and patent foramen ovale closure in 5. One myocardial metastatic carcinoid tumor was removed. There were 2 perioperative deaths. At a mean follow-up of 41 months, 4 additional patients were dead. All but 1 surgical survivor initially improved >/=1 functional class. No patient required reoperation. CONCLUSIONS: Carcinoid heart disease may affect left- and right-sided valves and occurred without intracardiac shunting in 55% of this surgical series. Despite metastatic disease that limits longevity, operative survivors had improvement in functional capacity. Cardiac surgery should be considered for select patients with carcinoid heart disease affecting left- and right-sided valves.

Noncardiac surgery in Eisenmenger syndrome.

OBJECTIVES: The purpose of this study was to evaluate the morbidity and mortality associated with noncardiac surgery (NCS) in patients (pts) with Eisenmenger syndrome. BACKGROUND: Noncardiac surgery in pts with Eisenmenger syndrome is associated with increased cardiovascular complications. METHODS: Fifty-eight pts with Eisenmenger syndrome (17M, 41F aged 18 to 69 years (mean 41 years) who had been followed for up to 41.5 years (mean 9.3 years) were retrospectively evaluated for any NCS done at > or = 17 years of age. RESULTS: Twenty-four pts had a total of 28 NCSs at an age of 17 to 55 years (mean 29 years) including 9 tubal ligations, 3 neurosurgeries, 3 cholecystectomies, 3 hysterectomies, 3 vasectomies, and 1 each spinal fusion, appendectomy, eye enucleation, hernia repair, hand surgery, tonsillectomy and therapeutic abortion. There were two deaths (7%), one following spinal fusion and the other following appendectomy at another institution. Fourteen of these NCSs were performed at our institution, including 11 under general anesthesia. The duration of anesthesia varied from 75 to 525 min (mean 165 min). All pts remained in sinus rhythm. The lowest systolic blood pressure (BP) ranged from 78 to 125 mm Hg. Of those 11 pts, 9 were extubated immediately after surgery and 2 needed dopamine. Ten patients were discharged without any complications, including 3 within 1 day of surgery. One death occurred 10 days following spinal fusion. This pt had the longest anesthesia (525 min) and an intraoperative systolic BP as low as 78 mm Hg. She also needed the largest fluid administration (6,475 cc) in addition to postoperative mechanical ventilation and dopamine. CONCLUSIONS: Adult pts with Eisenmenger syndrome are at increased risk with NCS, but with current/modern techniques, the risk of death is less than previously thought. In the vast majority of cases, NCS can be undertaken without substantial morbidity, and early extubation is achievable. However, even with relatively minor surgery, significant complications, including death, can occur. Referral to major centers with expertise in the care of pts with Eisenmenger syndrome is advisable.

Natriuretic peptide levels in atrial fibrillation: a prospective hormonal and Doppler-echocardiographic study.

OBJECTIVES: The objective was to determine the independent association between atrial fibrillation (A-Fib) and activation of natriuretic peptides. BACKGROUND: The association of A-Fib with activation of N-terminal atrial and brain natriuretic peptides (N-ANPs and BNPs, respectively) is uncertain but of great importance for the diagnostic utilization of natriuretic peptides. This uncertainty is related to the lack of appropriate controls, with left ventricular (LV) and atrial overload similar to A-Fib. METHODS: We prospectively measured N-terminal atrial and BNPs and endothelin-1 levels in 100 patients and 14 age- and gender-matched control subjects. The 32 patients with A-Fib were compared with 68 patients in sinus rhythm and similar LV and atrial overload (due to mitral regurgitation or LV dysfunction) measured simultaneously with hormonal levels with comprehensive Doppler echocardiography. RESULTS: Patients with A-Fib compared with those in sinus rhythm had similar symptoms, comorbid conditions, cardioactive medications, pulmonary pressure, left atrial volume, and LV ejection fraction and filling characteristics but demonstrated higher N-ANP levels (2,613 +/- 1,681 vs. 1,654 +/- 1,323 pg/ml, p = 0.007) even after adjustment for the underlying cardiac disease (p < 0.0001). Conversely, BNP levels were similar in both groups (165 +/- 163 vs. 160 +/- 269 pg/ml, p = 0.9). In multivariate analysis, a higher N-ANP level was associated with A-Fib (p = 0.0003), symptom class (p < 0.0001) and endothelin-1 level (p = 0.032) independently of left atrial volume and LV ejection fraction. Conversely, BNP showed no independent association with and was most strongly associated with LV ejection fraction (p < 0.0001). CONCLUSIONS: Atrial fibrillation is an independent determinant of higher N-ANP levels and blurs its association with LV dysfunction. Conversely, the BNP is not independently associated with A-Fib and is strongly determined by LV dysfunction, for which it is an independent marker.

Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion.

OBJECTIVE: This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mitral valve repair for mitral regurgitation. BACKGROUND: Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure. METHODS: Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months. Before and after repair, the functional morphology of the mitral apparatus was defined by two-dimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity. RESULTS: There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 +/- 0.8 to 0.7 +/- 0.7; p less than 0.00001). Excellent results from initial repair with grade less than or equal to 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade greater than or equal to 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade greater than or equal to 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease. Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade less than or equal to 1 residual mitral regurgitation without further operative intervention. Transthoracic echocardiography before hospital discharge demonstrated grade less than or equal to 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (greater than 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%). CONCLUSIONS: Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair.

Mediastinal mass and tracheal obstruction during general anesthesia.

A 24-year-old man had a large anterior mediastinal mass and a nonproductive cough of 6 weeks' duration. With the patient under general anesthesia, a diagnostic mediastinoscopy was performed with endotracheal intubation. During the procedure, acute respiratory failure developed as a result of tracheal obstruction. Fiberoptic bronchoscopic examination of the patient in the supine position revealed almost total extrinsic compression of the trachea and no evidence of intraluminal disease. Reexamination of the trachea with the patient in sitting and semiprone positions showed resolution of the extrinsic compression and respiratory distress. Flow-volume curves obtained before treatment of the mediastinal mass (histologically diagnosed as Hodgkin's lymphoma) disclosed major airway compression with the patient in the supine position; the abnormality disappeared after chemotherapy. The mechanisms responsible for tracheal compression by mediastinal masses during general anesthesia may include the following: (1) the effect of anesthesia on pulmonary mechanics, (2) the supine body position, (3) the elimination of glottic regulation of airflow by endotracheal intubation, (4) changes related to the surgical manipulation of the tumor itself, (5) the size and location of the mediastinal mass, (6) the young age of the patient, and (7) preexisting airways disease. Anticipation and prevention of potential respiratory complications and preparedness to treat them appropriately are important aspects of the management of these patients.

Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management.

OBJECTIVE: To determine the impact of intraoperative transesophageal echocardiography (IOTEE), an important adjunct in many types of cardiac surgical cases, on the surgical decisions made perioperatively in adult patients undergoing cardiac surgery. PATIENTS AND METHODS: All adult patients who had cardiac surgery between 1993 and 1997 and who also had IOTEE were studied. New findings before and after cardiopulmonary bypass and alterations in the planned surgical procedure or management were documented prospectively. RESULTS: A total of 3245 patients (60% men, 40% women; aged 18-93 years with a mean +/- SD age of 62 +/- 15 years) were included in the study. The most common operations performed were mitral valve repair (26%) and aortic valve replacement (22%). Over the 5-year period, 41% of patients had IOTEE. New information was found before bypass in 15% of patients, directly affecting surgery in 14% of the patients. The most common new prebypass information found was patent foramen ovale resulting in closure in the majority of patients. New information was found after bypass in 6% of the patients, resulting in a change in surgery or hemodynamic management in 4% of the total. The most common postbypass finding was valvular dysfunction with repeat bypass in most patients for re-repair or replacement. No major complications occurred. CONCLUSION: In adult patients undergoing cardiac surgery, IOTEE provides important important information both before and after bypass that affects surgical and hemodynamic management.

Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies.

Evaluation of diastolic filling of the heart has been difficult because of its complexity and the numerous interrelated contributing factors. Previous determinations have depended on high-fidelity, invasive measurements of instantaneous pressure, volume, mass, and wall stress, which could not be done on a routine clinical basis. With the advent of Doppler echocardiography, intracardiac blood flow velocities can now be noninvasively assessed. For application of this technique to evaluation of diastolic function in patients with heart disease, it is necessary to understand what the Doppler-derived variables represent. It is also necessary to know how they are affected by changes in loading conditions and changes in myocardial relaxation. In this review, we provide an interpretation of the mitral valve, tricuspid valve, and systemic and pulmonary venous inflow velocities in the normal patient and in various disease states.

Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting.

Bone cement implantation syndrome is characterized by hypotension, hypoxemia, cardiac arrhythmias, cardiac arrest, or any combination of these complications. It may result from venous embolization that occurs in conjunction with intramedullary hypertension in the femur during insertion of the prosthesis in patients undergoing cemented total hip arthroplasty (THA). Intramedullary hypertension does not occur in patients undergoing noncemented THA. In this study, we sought to compare embolization between patients undergoing cemented and noncemented THA and to determine whether this state resulted in cardiorespiratory deterioration. In this prospective investigation of 35 patients undergoing elective THA, we used transesophageal echocardiography and invasive hemodynamic monitoring, and in 12 of them, we monitored distribution of pulmonary ventilation and perfusion intraoperatively. Embolization was significantly greater after insertion of the prosthesis in patients undergoing cemented than in those undergoing noncemented THA. Cemented THA was also associated with decreased cardiac output and increased pulmonary artery pressure and pulmonary vascular resistance. Increases in ventilation-perfusion mismatching, however, could not be demonstrated 30 minutes after insertion of the femoral prosthesis. Intraoperative monitoring for embolism may help physicians assess patients in whom cardiorespiratory function deteriorates during THA.

Mitral regurgitation: a new clinical perspective.

Mitral regurgitation is a common valvular heart disease, particularly in the elderly population. The timing of surgical repair is controversial, but recent literature suggests a new clinical perspective on the management of this disease. Despite receiving medical treatment and having few initial symptoms, patients with mitral regurgitation due to flail leaflets have an excess mortality rate (6.3% per year) and high morbidity. Ten years after mitral regurgitation has been diagnosed, 90% of the patients have either died or undergone an operation. After surgical correction of mitral regurgitation, left ventricular dysfunction is a frequent complication and is the cause of excess heart failure and mortality. This complication is due to preoperative left ventricular dysfunction but is incompletely predictable with use of current methods. Conversely, considerable progress in surgery has resulted in an extremely low operative mortality rate (about 1% in patients younger than 75 years of age) and high feasibility of valve repair, even in patients with anterior leaflet prolapse. These facts have led to the new perspective that early surgical correction (before occurrence of overt symptoms or left ventricular dysfunction) should be considered when patients are diagnosed with severe mitral regurgitation.

Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications.

The introduction of transesophageal echocardiography has provided a new acoustic window to the heart and mediastinum. High-quality images of certain cardiovascular structures [left atrial appendage, thoracic aorta, mitral valvular apparatus, and atrial septum] can be obtained readily (average examination, 15 to 20 minutes). In this article, we discuss the technique of image acquisition, image orientation, and anatomic validation. In addition, we describe our experience with the first 100 awake patients who underwent transesophageal echocardiography at our institution. The procedure was well accepted by the patients and associated with no major complications. The clinical indications for this procedure have included thoracic aortic dissection, prosthetic cardiac valve dysfunction, detection of an intracardiac source of embolism, endocarditis, cardiac and paracardiac masses, and mitral regurgitation. Transesophageal echocardiography also proved to be useful in assessment of critically ill patients in whom standard transthoracic echocardiographic images did not provide complete assessment. In these patients (who had extensive chest trauma, had undergone an operation, or were in an intensive-care unit), rapid assessment of the cardiovascular status at the bedside was possible with transesophageal echocardiography. On the basis of our initial experience, we conclude that transesophageal echocardiography complements standard two-dimensional Doppler and color flow examinations and will considerably improve the care of patients with cardiovascular disorders by providing high-quality unique images.

Influence of the heart on the vertical gradient of transpulmonary pressure in dogs.

Estimations were made of the vertical gradient of transpulmonary pressure (VGTP) from measurements of esophageal pressure in nine head-up dogs at functional residual capacity (FRC) when alive, when dead, and after total bilateral pneumothorax. The VGTP of 0.4 cmH2O/cm height in the alive state was abolished by pneumothorax, and roentgenograms showed that the heart moved in a caudal-dorsal direction. There was a small but significant increase in the VGTP on going from FRC to near total lung capacity (TLC) in alive head-up dogs. In eight dead head-up dogs heart weight was increased by replacing various amounts of heart blood with Hg. The VGTP was significantly increased from 0.28 to 0.51 cmH2O/cm height. The fractional increase in the VGTP was similar to the fractional increase in heart weight. In five dogs extrapolation to zero heart weight gave an average VGTP of 0.14 cmH2O/cm height. We conclude that the lungs help support the heart in the head-up dog and that the VGTP is in part determined by the pressure distribution required for this support.

Concomitant repair of a chronic traumatic aortic aneurysm with tracheal erosion.

Tracheal erosion from a chronic false aneurysm secondary to trauma is unusual. Resection with graft interposition is the treatment of choice. This case report describes the additional use of an intrathoracic muscle flap necessitated by tracheal erosion and contamination.

A prospective, randomized study of cardiopulmonary bypass temperature and blood transfusion.

BACKGROUND: We hypothesized that normothermic cardiopulmonary bypass (CPB) would be associated with decreased blood loss and allogeneic transfusion requirements relative to hypothermic CPB. METHODS: After obtaining institutional review board approval and informed patient consent, we conducted a prospective, randomized study of 79 patients undergoing CPB for a primary cardiac operation at normothermic (37 degrees C) (n = 44) or hypothermic temperature (25 degrees C) (n = 35). Blood loss and transfusion requirements in the operating room and for the first 24 hours in the intensive care unit were determined. A paired t test and rank sum tests were used. A p value of less than 0.05 was considered significant. RESULTS: The normothermic and hypothermic CPB groups did not differ in demographic variables, CPB or cross-clamp duration, heparin sodium or protamine sulfate dose, prothrombin time, or thromboelastogram results. There were no differences between the two CPB groups in blood loss or transfusion requirements. CONCLUSIONS: We found that when there was no difference in duration of CPB, normothermic and hypothermic CPB groups demonstrated similar blood loss and transfusion requirements even though other studies have shown hypothermia induces platelet dysfunction and alters the activity of the coagulation cascade.

Comparison of intraoperative transesophageal echocardiographic examinations with the operative findings: prospective review of 1918 cases.

The purpose of this study was to prospectively compare the intraoperative transesophageal echocardiographic (IOTEE) findings with the operative findings in 1918 consecutive cardiac cases. Forty-eight discordant findings were found between the IOTEE and operative findings. Of the 48 discordant findings, most were related to valve pathology. Structural abnormalities that were missed by IOTEE included those of the aortic valve, 12 cases (25%), mitral valve, 13 cases (27%), and pulmonic and tricuspid valves, 5 cases (10%). Functional discrepancies occurred in 8% of cases. Overall, incidence of discrepant findings between IOTEE and operative findings was low (2.5%). This resulted in an alteration of the planned surgical procedure in a small number of cases (0.3%).

Entrapment of subvalvular mitral tissue causing intermittent failure of a St Jude mitral prosthesis.

Frequently portions of the mitral valve and sub-valvular apparatus are left intact during mitral valve replacement to help preserve left ventricular function. We describe a patient with paroxysmal congestive heart failure caused by intermittent entrapment of the subvalvular apparatus in the prosthesis, preventing complete valve closure.

Mitral flow velocity curves as a function of different loading conditions: evaluation by intraoperative transesophageal Doppler echocardiography.

Transesophageal pulsed wave Doppler echocardiography was performed intraoperatively on 10 patients undergoing coronary artery bypass operation. Mitral flow velocity curves and hemodynamic values were recorded during control conditions and intravenous infusion of (1) nitroglycerin, (2) phenylephrine, and (3) fluids. During nitroglycerin infusion blood pressure and wedge pressure decreased, peak filling velocity decreased, and deceleration time increased compared with control values. During infusion of phenylephrine blood pressure increased, there was a trend toward a decrease in peak filling velocity, and deceleration time increased. During infusion of fluids wedge pressure increased, deceleration time decreased, and peak filling velocity increased. Mitral flow velocity curves are therefore altered by changes in hemodynamic loading conditions.

Role of emergency intraoperative transesophageal echocardiography.

Transesophageal echocardiography (TEE) has a definitive role in the diagnosis and management of critically ill patients with cardiovascular disease and patients undergoing cardiac operations. The diagnostic role of emergency intraoperative TEE and the impact on clinical outcome have not been evaluated. We reviewed the indications, findings, and impact of emergency intraoperative TEE in 66 patients over a 4-year period. The indications for emergency TEE were unexplained hemodynamic instability (36 patients), preoperative evaluation of patients having emergency surgery (19 patients), cardiac evaluation of trauma cases (6 patients), and unexplained intraoperative hypoxemia (5 patients). New findings were disclosed in 53 (80%) patients, with an alteration of the planned surgical procedure in 15 (23%). Despite the therapeutic impact, 24 patients (36%) did not survive to hospital dismissal. We recommend that TEE be considered as the diagnostic tool of choice when surgical patients have unexplained hemodynamic instability, when time does not permit complete preoperative evaluation, when cardiovascular injury is suspected in a trauma patient, and to evaluate unexplained hypoxemia.

Resection of a large temporooccipital parenchymal arteriovenous fistula by using deep hypothermic circulatory bypass. Case report.

The authors believe this to be the first published case in which a deep hypothermic cardiopulmonary bypass was used to facilitate resection of a large parenchymal arteriovenous fistula. The use of this procedure facilitated resection of the lesion by allowing compression and manipulation of large venous varices that were overlying the deeper arterial feeding vessels. The surgical rationale, technique, and intra- and postoperative management are discussed.

An evaluation of an automated anesthesia record keeping system.

Mayo Clinic makes use of an automated anesthesia record keeping system in its cardiovascular operating rooms. Over 20,000 anesthesia records have been recorded with this system since its installation in 1983. How successful is this system? Does it meet the needs of the anesthesiologist? What are their attitudes towards the computer? A questionnaire survey was conducted to solicit the experiences, opinions, and recommendations of the users of this system. The results are described in this paper. The feedback will be used to determine the tasks and their priority for improving the current system, and to define the requirements for future computerization to meet the needs of the anesthesiologist in the operating room.