Postoperative hemodynamics after high spinal block with or without intrathecal morphine in cardiac surgical patients: a randomized-controlled trial.

PURPOSE: There is some evidence for the use of intrathecal morphine as a means to provide prolonged analgesia in selective cardiac surgical patients; however, the hemodynamic effects of intrathecal morphine are not well defined. This study was designed to study the effect of intrathecal morphine on hemodynamic parameters in cardiac surgery patients. METHODS: In a prospective, double-blind study, 100 adult cardiac surgical patients were randomized to receive either intrathecal 40 mg of 0.5% hyperbaric bupivacaine alone (intrathecal bupivacaine [ITB] group, n = 50) or intrathecal 250 µg of morphine added to 40 mg of 0.5% bupivacaine (intrathecal bupivacaine and morphine [ITBM] group, n = 50). Hemodynamic data, pain scores, rescue analgesic use, spirometry, and vasopressor use were recorded every four hours after surgery for 48 hr. The primary outcome was the incidence of vasoplegia in each group, which was defined as a cardiac index > 2.2 L·min-1·m-2 with the requirement of vasopressors to maintain the mean arterial pressure > 60 mmHg with the hemodynamic episode lasting > four hours. RESULTS: Eighty-seven patients were analyzed (ITB group, n = 42, and ITBM group, n =45). The incidence of vasoplegia was higher in the ITBM group than in the ITB group [14 (31%) vs 5 (12%), respectively; relative risk, 2.6; 95% confidence interval [CI], 1.0 to 6.6; P = 0.04]. The mean (standard deviation [SD]) duration of vasoplegia was significantly longer in the ITBM group than in the ITB group [8.9 (3.0) hr vs 4.3 (0.4) hr, respectively; difference in means, 4.6; 95% CI, 3.7 to 5.5; P < 0.001]. CONCLUSION: Intrathecal morphine added to bupivacaine for high spinal anesthesia increases the incidence and duration of vasoplegia in cardiac surgery patients. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02825056); registered 19 June 2016.

RéSUMé: OBJECTIF : Certaines données probantes appuient l'utilisation de morphine intrathécale pour une analgésie prolongée chez certains patients de chirurgie cardiaque; cependant, les effets hémodynamiques de la morphine intrathécale ne sont pas bien définis. Cette étude a été conçue pour évaluer l'effet de la morphine intrathécale sur les paramètres hémodynamiques de patients de chirurgie cardiaque. MéTHODE : Dans une étude prospective et à double insu, 100 patients adultes de chirurgie cardiaque ont été randomisés à recevoir 40 mg de bupivacaïne hyperbare 0,5 % intrathécale (groupe bupivacaïne intrathécale [BIT], n = 50) ou 250 µg de morphine intrathécale ajoutés à 40 mg de bupivacaïne 0,5 % (groupe bupivacaïne et morphine intrathécales [BMIT], n = 50). Les données hémodynamiques, les scores de douleur, l'utilisation d'analgésiques, la spirométrie et l'utilisation de vasopresseurs ont été enregistrés toutes les quatre heures après la chirurgie pendant 48 heures. Le critère d'évaluation principal était l'incidence de vasoplégie dans chaque groupe, définie comme un index cardiaque > 2,2 L·min-1·m2 nécessitant des vasopresseurs pour maintenir la tension artérielle moyenne > 60 mmHg avec une durée de plus de quatre heures. RéSULTATS : Quatre-vingt-sept patients ont été analysés (groupe BIT, n = 42, et groupe BMIT, n = 45). L'incidence de vasoplégie était plus élevée dans le groupe BMIT que dans le groupe BIT [14 (31%) vs 5 (12 %), respectivement; risque relatif, 2,6; intervalle de confiance [IC] 95 %, 1,0 à 6,6; P = 0,04]. La durée moyenne (écart type [ÉT]) de la vasoplégie était significativement plus longue dans le groupe BMIT que dans le groupe BIT [8,9 (3,0) h vs 4,3 (0,4) h, respectivement; différence de moyennes, 4,6; IC 95 %, 3,7 à 5,5; P < 0,001]. CONCLUSION : L'ajout de morphine intrathécale à la bupivacaïne pour une anesthésie rachidienne haute augmente l'incidence et la durée de la vasoplégie chez les patients de chirurgie cardiaque. ENREGISTREMENT DE L'éTUDE : www.clinicaltrials.gov ; (NCT02825056); enregistrée le 19 juin 2016.

Systolic anterior motion of mitral valve following resection of subaortic membrane and intracardiac repair of tetralogy of fallot.

Systolic anterior motion (SAM) of the mitral valve is commonly observed in patients with hypertrophic obstructive cardiomyopathy and in few patients after mitral valve repair or aortic valve replacement. It may cause significant hemodynamic instability due to left ventricular outflow tract (LVOT) obstruction and resulting mitral regurgitation. Subaortic septal bulge is considered as a one of the risk factor for the development of SAM as it narrows the LVOT. We report a case of tetralogy of fallot with subaortic septal bulge who developed SAM of the anterior mitral leaflet, intraoperatively, after resection of a subaortic membrane.

Role of perioperative echocardiography in repair of incomplete shone complex: A case series.

Multilevel obstruction of left-sided heart structures was originally characterized by Shone et al. The formulation of an appropriate operative strategy remains challenging and needs to be individualized for this complex subset of patients. Intraoperative transesophageal echocardiography (TEE) not only helps in delineating spatial anatomy but also reveals associated anomalies that help in decision-making regarding operative strategies for these patients. Here, we discuss five such cases of Shone's anomaly presenting at varied age group with different associated anomaly in which intraoperative TEE played a pivotal role in the management.

ST Segment-Elevation Myocardial Ischemia After Arterial Switch Operation due to Pericardial Drain Placement: A Case Report.

Myocardial ischemia postarterial switch operation has been reported extensively in the literature and has been almost exclusively ascribed to issues related to coronary artery translocation. Here, we report a case of a 5-week-old child with D-transposition of the great arteries who underwent an arterial switch operation and developed myocardial ischemia after pericardial drain placement, as evidenced by significant ST segment elevation and abnormal regional cardiac wall motion. The ST segment and cardiac wall motion improved once the drain was withdrawn from the pericardium and placed in the retrosternal space. Few reports in the literature describe this complication, particularly in pediatric patients.