Associations of Preoperative Self-rated Symptoms of Anxiety and Depression on Length of Hospital Stay and Long-term Quality of Life in Patients Undergoing Cardiac Surgery.

BACKGROUND: Anxiety and depression are often associated with cardiovascular diseases. Nevertheless, few study authors have investigated psychological effects on immediate and long-term cardiac surgery-related outcomes, such as surgical complications, length of hospital stay (LOS), and long-term health-related quality of life (HRQoL). OBJECTIVES: The aims of this study were to (a) investigate the role of preoperative symptoms of anxiety and depression in predicting LOS in a sample of surgical patients and (b) evaluate the impact of preoperative symptoms of anxiety and depression on the patients' HRQoL 3 months after surgery. METHODS: One hundred fifty-one patients waiting for surgery were included. To evaluate symptoms of anxiety and depression, the Hospital Anxiety and Depression Scale was used. Multiple regression analyses were conducted to evaluate the impact of both clinical and psychological factors on LOS, whereas quantile regression was performed to assess their effect on the patients' HRQoL 3 months after surgery. RESULTS: The multiple regression shows that EuroSCORE, length of endotracheal intubation, and anxiety symptoms predict LOS. The multiple quantile regression analyses also show that both symptoms of anxiety and depression predict a negative HRQoL up to 3 months after surgery. CONCLUSION: Preoperative symptoms of anxiety predict the patients' LOS, and both symptoms of anxiety and depression predict a scarce HRQoL 3 months after cardiac surgery. These results suggest the need for implementing presurgical in-hospital screening procedures for both symptoms of anxiety and depression. Finally, focused psychological interventions should be implemented for reducing inpatients' hospital LOS and improving their future quality of life.

A Morphological and Quantitative Analysis of Lung CT Scan in Patients With Acute Respiratory Distress Syndrome and in Cardiogenic Pulmonary Edema.

BACKGROUND: The acute respiratory distress syndrome (ARDS) and cardiogenic pulmonary edema (CPE) are both characterized by an increase in lung edema that can be measured by computed tomography (CT). The aim of this study was to compare possible differences between patients with ARDS and CPE in the morphologic pattern, the aeration, and the amount and distribution of edema within the lung. METHODS: Lung CT was performed at a mean positive end-expiratory pressure level of 5 cm H2O in both groups. The morphological evaluation was performed by two radiologists, while the quantitative evaluation was performed by a dedicated software. RESULTS: A total of 60 patients with ARDS (20 mild, 20 moderate, 20 severe) and 20 patients with CPE were enrolled. The ground-glass attenuation regions were similarly present among the groups, 8 (40%), 8 (40%), 14 (70%), and 10 (50%), while the airspace consolidations were significantly more present in ARDS. The lung gas volume was significantly lower in severe ARDS compared to CPE (830 [462] vs 1120 [832] mL). Moving from the nondependent to the dependent lung regions, the not inflated lung tissue significantly increased, while the well inflated tissue decreased (ρ = 0.96-1.00, P < .0001). Significant differences were found between ARDS and CPE mostly in dependent regions. In severe ARDS, the estimated edema was significantly higher, compared to CPE (757 [740] vs 532 [637] g). CONCLUSIONS: Both ARDS and CPE are characterized by a similar presence of ground-glass attenuation and different airspace consolidation regions. Acute respiratory distress syndrome has a higher amount of not inflated tissue and lower amount of well inflated tissue. However, the overall regional distribution is similar within the lung.

Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions.

AIMS: The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the accuracy of pre-operative three-dimensional (3D) transthoracic echocardiography (TTE) in the evaluation of MV pathology in cases with simple or complex lesions. METHODS AND RESULTS: Two hundred consecutive patients with severe mitral regurgitation due to degenerative MV prolapse underwent a complete 3DTTE the day before surgery. Three-dimensional TTE data were compared with MV surgical inspection. Three-dimensional echocardiography was feasible in a relatively short time (5 ± 3 min) with good (67%) and optimal (21%) imaging quality in the majority of cases. Three-dimensional TTE allowed an accurate identification (95% accuracy) of all MV lesions. Seventy-three (36.5%) patients had simple lesions at 3DTTE and 71 of them (97.2%) underwent a simple surgical procedure; 127 (63.5%) had complex lesions at 3DTTE and, in these cases, surgeons performed either simple procedures (48%) or complex procedures (47.2%) or valve replacement in 4.7% (after a first attempt for repair). CONCLUSION: Three-dimensional TTE is feasible, not time-consuming, and accurate in identifying cases with simple vs. complex MV lesions.

Assessment of oxidative stress in coronary artery bypass surgery: comparison between the global index OXY-SCORE and individual biomarkers.

The performances of the OXY-SCORE, a summary index of oxidative stress, and of its individual components (plasma malondialdehyde (MDA), oxidized and reduced glutathione, individual antioxidant capacity, alpha- and gamma-tocopherol and urinary isoprostanes) were assessed in 47 patients undergoing coronary surgery, randomly assigned to cardiopulmonary bypass (CPB) or off-pump procedure (OPCAB) associated with less oxidative stress. The ability of the OXY-SCORE to classify correctly the patients was high (area under the ROC curve 0.90). Only free MDA showed a similar performance, but it was insensitive to the minor variations of the oxidative balance in the OPCAB group.

Percutaneous cardiopulmonary support for catheter ablation of unstable ventricular arrhythmias in high-risk patients.

BACKGROUND AND PURPOSE: In patients with severe cardiomyopathy, recurrent episodes of nontolerated ventricular tachycardia (VT) or electrical storm (ES) frequently cause acute heart failure and cardiac death; the suppression of the arrhythmia is therefore lifesaving, but feasibility of catheter ablation (CA) is precluded by the adverse hemodynamic conditions together with the characteristics of the arrhythmia that interdicts efficacious mapping. The use of the percutaneous cardiopulmonary support (CPS) for circulatory assistance may allow patient's stabilization and enhance efficacy and safety of CA in this emergency setting. PATIENTS AND METHODS: 19 patients (19 males; mean age 61 +/- 6 years; chronic ischemic cardiomyopathy, eleven patients; primary dilated cardiomyopathy, six patients; arrhythmogenic right ventricular dysplasia/ cardiomyopathy, two patients) with recurrent nontolerated VT episodes undergoing CPS-assisted CA were retrospectively evaluated. Twelve patients had acute hemodynamic failure refractory to inotropic agents and ventilatory assistance, seven patients had undergone a failing nonconventional CA procedure. 14 patients presented with ES, and in twelve the procedure was undertaken under emergency conditions within 24 h from admission. Patients were ventilated under general anesthesia and assisted by a multidisciplinary team. The CPS system consisted in a Medtronic Bio-Medicus centrifugal pump and in a Maxima Plus oxygenator, a 15-F arterial cannula, and a 17-F venous cannula. RESULTS: Flows between 2 and 3 l/min were activated after induction of 56/62 forms of nontolerated VT, achieving hemodynamic stabilization in all patients. CA was mainly guided by conventional activation mapping and was effective in abolishing 45/56 supported VTs; in 10/19 patients all clinical VTs were suppressed by CA. Mean procedural time was 4 h and 20 min. Complete stabilization was achieved in 13 patients (68%) without VT recurrence during a 7-day in-hospital monitoring. A significant clinical improvement was observed in two patients (11%); one patient (5%) with persistent VT episodes acutely died after heart transplant. At a mean follow-up of 42 months (range 15-60 months), 5/18 patients (28%) were free from VT recurrence, 7/18 (39%) had a clear clinical improvement with reduced implantable cardioverter defibrillator interventions. 5/14 patients (36%) had ES recurrence; among them, three died because of acute heart failure. No serious CPS-related complications were observed. CONCLUSION: The CPS warrants acceptable hemodynamic stabilization and efficacious mapping in high-risk patients undergoing CA for unstable VT in the emergency setting. Safety and efficacy of this technique translate into significant clinical improvement in the majority of patients. Even if only relatively invasive, CPS should be reserved to patients with ES or intractable arrhythmia causing acute heart failure; moreover, the need for an experienced team of multidisciplinary operators implies that its use is restricted to selected high-competency institutions.

Nephrocheck after cardiac surgery: Does it play a role in daily practice? A sequel of "Nephrocheck results should be corrected for dilution".

Acute kidney injury is a well-recognized complication after cardiac surgery and significantly affects morbidity and mortality. Although the mechanisms of acute kidney injury are not fully understood, Nephrocheck (Astute Medical, San Diego, CA, USA) is a meter for early detection of acute kidney injury based on bedside urinalysis of two cell-cycle arrest biomarkers. However, considerable overlap in the AKIRiskTM score of different RIFLE groups makes interpretation of the score uncertain. A possible reason for the overlap in the AKIRisk score between different RIFLE groups could be that the score is not corrected for dilution. We performed a pilot study to explore the applicability of the test in our daily practice. A total of 68 patients electively scheduled for cardiac surgery with at least two of the following inclusion criteria: age > 70 years, glomerular filtration rate <60 mL/min, left ventricular ejection fraction <41%, redo procedure and combined procedures have been enrolled in the study, and 25 of them developed acute kidney injury. We described the correlation between urine creatinine and Nephrocheck, all the samples with low Nephrocheck (<0.2) also have low urine creatinine, less than 50 mg/dL, detecting a potential diluted sample. In conclusion, in our daily practice AKIRisk score, together with an assessment of whether urine is diluted or concentrated can better discriminate between various degrees of acute kidney injury.

N-acetylcysteine for prevention of acute renal failure in patients with chronic renal insufficiency undergoing cardiac surgery: a prospective, randomized, clinical trial.

OBJECTIVE: To assess the preventive effect of the antioxidant N-acetylcysteine on postoperative acute renal failure in patients with renal insufficiency undergoing cardiac surgery. DESIGN: Randomized, placebo-controlled, prospective study. SETTING: University cardiology center. PATIENTS: Two hundred fifty-four consecutive patients with chronic renal insufficiency (estimated creatinine clearance < or = 60 mL/min) undergoing elective cardiac surgery. INTERVENTIONS: Patients were randomized to receive N-acetylcysteine (n = 129) or placebo (n = 125). Patients of the N-acetylcysteine group received four boluses of intravenous N-acetylcysteine (1200 mg every 12 hrs, starting immediately before cardiac surgery). MEASUREMENTS AND MAIN RESULTS: The incidence of postoperative acute renal failure (> 25% increase in serum creatinine from baseline) and the in-hospital clinical course were evaluated. Acute renal failure occurred in 46% of patients and was associated with increased in-hospital mortality (7% vs. 0.7%; p = .024). It occurred in 52% of control patients and 40% of N-acetylcysteine-treated patients (p = .06). In-hospital mortality and need for renal replacement therapy were not affected by N-acetylcysteine, but a lower percentage of N-acetylcysteine-treated patients required mechanical ventilation prolonged for > 48 hrs (3% vs. 18%; p < .001) and had an intensive care unit stay > 4 days (13% vs. 33%; p < .001). CONCLUSIONS: Intravenous administration of N-acetylcysteine does not clearly prevent postoperative acute renal failure in patients with renal insufficiency undergoing cardiac surgery.

Anesthetic propofol enhances plasma gamma-tocopherol levels in patients undergoing cardiac surgery.

BACKGROUND: Propofol (2,6-diisopropylphenol) is an anesthetic drug with antioxidant and antiinflammatory properties, documented both in vitro and in experimental models of ischemia-reperfusion injury and septic shock. These properties have been related to the similarity of its chemical structure to that of endogenous tocopherols, which are phenol-containing radical scavengers. This study evaluated the effects of propofol on alpha- and gamma-tocopherol (alpha- and gamma-T) levels and on selected markers of oxidant-antioxidant and inflammatory status in patients undergoing cardiac surgery. METHODS: Patients were randomly assigned for anesthesia with either propofol (propofol group, n = 22) or sevoflurane (control group, n = 21). Plasma levels of alpha- and gamma-T, individual antioxidant capacity, malondialdehyde, and interleukin 10 were measured before, during, and after anesthesia. In addition, levels of the proinflammatory prostaglandin E2 as a marker of cyclooxygenase-2 activity and those of interleukin 10 were measured in whole blood cultured with bacterial lipopolysaccharide. RESULTS: Gamma-T levels increased significantly during surgery in propofol group (P < 0.0001 vs. control group). By contrast, alpha-T similarly decreased in both groups. Malondialdehyde and interleukin 10 increased markedly and individual antioxidant capacity decreased, without differences between groups. Prostaglandin E2 levels measured 24 h after anesthesia induction were significantly lower in the propofol than in the control group. In vitro studies highlighted the different capacity of gamma- and alpha-T to impair prostaglandin E2 synthesis by human monocytes challenged with bacterial lipopolysaccharide. CONCLUSIONS: The antiinflammatory properties of propofol that may be linked to its effect on gamma-T levels could be relevant in controlling the inflammatory response that accompanies tissue injury during reperfusion.

Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery.

OBJECTIVE: The aim of this study was to determine if there is a direct relationship between the duration of cardiopulmonary bypass (CPB time [CPBT]) and postoperative morbidity and mortality in patients undergoing cardiac surgery. DESIGN: Retrospective study. SETTING: Cardiac surgery unit, university hospital. PARTICIPANTS: Five thousand six patients, New York Heart Association classes 1 through 4, who underwent cardiac surgery between January 2002 and March 2008. INTERVENTIONS: All patients were subjected to CPB. MEASUREMENTS AND MAIN RESULTS: The mean CPBT was 115 minutes (median 106). One hundred thirty-one patients (2.6%) died during the same hospitalization. The postoperative median blood loss was 600 mL. Reoperations for bleeding occurred in 193 patients (3.9%), and 1,001 patients received 3 or more units of red blood cells. There were 108 patients (2.2%) with neurologic sequelae, 391 patients (7.8%) with renal complications, 37 patients (0.7%) with abdominal complications, and 184 patients (3.7%) with respiratory complications. Seventy-two patients (1.4%) had an infective complication, and 80 patients (1.6%) had a postoperative multiorgan failure. The multivariate analysis confirmed the role of CPBT, considered in 30-minute increments, as an independent risk factor for postoperative death (odds ratio [OR] = 1.57, p < 0.0001), pulmonary (OR = 1.17, p < 0.0001), renal (OR 1.31, p < 0.0001), and neurologic complications (OR = 1.28, p < 0.0001), multiorgan failure (OR = 1.21, p < 0.0001), reoperation for bleeding (OR = 1.1, p = 0.0165), and multiple blood transfusions (OR = 1.58, p < 0.0001). CONCLUSIONS: Prolonged CPB duration independently predicts postoperative morbidity and mortality after cardiac surgery.

Comparison of on pump and off pump coronary surgery: risk factors for neurological outcome.

OBJECTIVE: Cerebrovascular accidents (CVA) are devastating complications after coronary artery bypass grafting (CABG). The reported incidence of neurological complications after conventional CABG (CCABG) is 3-6%. Off-pump coronary bypass grafting (OPCAB) has been associated in recent studies to a decreased morbidity and risk of perioperative stroke. Nevertheless, uncertainty still surrounds the relative benefits of OPCAB. We investigated whether, in our experience, OPCAB was associated with lower neurological morbidity than conventional CABG approach. METHODS: Eight thousand and two patients underwent isolated CABG at our institution between January 1998 and January 2005. OPCAB operation was performed on 1415 patients. Data were prospectively collected. A multiple logistic regression analysis was used to evaluate the influence of the two different surgical techniques on the neurological outcomes. RESULTS: Patients in the OPCAB group were significantly older (66.2 vs 63.5%, p<0.0001), had a higher incidence of renal injury (5.4 vs 2.4%, p<0.0001), and were more redo interventions (6.95 vs 1.53%, p<0.0001). The CCABG patients were more urgent at operation (5.46 vs 3.26, p=0.0007), were less hypertensive (57.6 vs 63% of the patients, p=0.0003) more diabetics (22 vs 20.6%, NS), and had an ejection fraction less than 0.40 (10.4 vs 9.6%, NS). CVA incidence was similar in both groups (Type I outcome: OPCAB=0.70% vs CCABG=0.68%, p=0.91; Type II outcome OPCAB=0.70% vs CCABG=0.83%, p=0.63). CONCLUSIONS: In our experience patients undergoing CCABG were not exposed to a greater risk of neurological adverse events when compared to OPCAB patients.

Lvad pump speed increase is associated with increased peak exercise cardiac output and vo2, postponed anaerobic threshold and improved ventilatory efficiency.

BACKGROUNDS: Peak exercise cardiac output (CO) increase is associated with an increase of peak oxygen uptake (VO2), provided that arteriovenous O2 difference [Δ(Ca-Cv)O2] does not decrease. At anaerobic threshold, VO2, is related to CO. We tested the hypothesis that, in heart failure (HF) patients with left ventricular assistance device (LVAD), an acute increase of CO obtained through changes in LVAD pump speed is associated with peak exercise and anaerobic threshold VO2 increase. METHODS: Fifteen of 20 patients bearing LVAD (Jarvik 2000) enrolled in the study successfully performed peak exercise evaluation. All patients had severe HF as shown by clinical evaluation, laboratory tests, echocardiography, spirometry with alveolar-capillary diffusion, and maximal cardiopulmonary exercise testing (CPET). CPETs with non-invasive CO measurements at rest and peak exercise were done on 2days at LVAD pump speed set randomly at 2 and 4. RESULTS: Increasing LVAD pump speed from 2 to 4 increased CO from 3.4±0.9 to 3.8±1.0L/min (ΔCO 0.4±0.6L/min, p=0.04) and from 5.3±1.3 to 5.9±1.4L/min (ΔCO 0.6±0.7L/min, p<0.01) at rest and peak exercise, respectively. Similarly, VO2 increased from 788±169 to 841±152mL/min (ΔVO2 52±76mL/min, p=0.01) and from 568±116 to 619±124mL/min (ΔVO2 69±96mL/min, p=0.02) at peak exercise and at anaerobic threshold, respectively. Δ(Ca-Cv)O2 did not change significantly, while ventilatory efficiency improved (VE/VCO2 slope from 39.9±5.4 to 34.9±8.3, ΔVE/VCO2 -5.0±6.4, p<0.01). CONCLUSIONS: In HF, an increase in CO with a higher LVAD pump speed is associated with increased peak VO2, postponed anaerobic threshold, and improved ventilatory efficiency.

Oxygen metabolism during and after cardiac surgery: role of CPB.

BACKGROUND: Cardiopulmonary bypass (CPB) has been reported to increase oxygen metabolism and to influence the relation between oxygen consumption (VO(2)) and delivery (DO(2)) in the early hours after cardiac surgery. To investigate the role of CPB, we studied oxygen metabolism in coronary artery bypass procedures performed on-pump (CABG) and off-pump (OPCAB). METHODS: Twenty-five patients were randomized to undergo CABG (n = 14) or OPCAB (n = 11). All patients received the same anesthetic management. Oxygen metabolism variables were assessed before induction of anesthesia and up to 18-hours after surgery. RESULTS: At baseline, before induction of anesthesia, there were no differences between CABG and OPCAB in oxygen consumption (VO(2)), delivery (DO(2)), or extraction (ExO(2)). After surgery VO(2) and ExO(2) increased in both groups, while DO(2) decreased. No significant differences between CABG and OPCAB were detected in postoperative VO(2), DO(2), and ExO(2) levels. The relation between VO(2) and DO(2) was very similar in CABG and OPCAB patients throughout the study, and no significant differences were detected in slopes and intercepts of the regression lines between CABG and OPCAB at all time points. There was, however, a significant effect of time on the relation between VO(2) and DO(2): this relation was stronger in the postoperative period, and the slope of this relation increased over time as well. CONCLUSIONS: A hypermetabolic state and progressive and significant increases in the strength of the relationship between VO(2) and DO(2) and in the slope of this relationship occur after both CABG and OPCAB. Cardiopulmonary bypass is not responsible for these changes in oxygen metabolism.

Kinetics of plasma SPB and RAGE during mechanical ventilation in patients undergoing major vascular surgery.

Receptor-of-Advanced-Glycation-End-products (RAGE) and Surfactant-Protein-type-B (SPB) are reported as lung injury markers. Unlike SPB, RAGE is secreted by several tissues, so that RAGE specificity as lung injury marker is questionable. We measured SPB and RAGE in 19 patients undergoing major vascular abdominal surgery. SPB and RAGE were measured before mechanical ventilation (T0), at 1st (T1), 2nd (T2) and, when present, 3rd (T3) hour of mechanical ventilation, and 1h after extubation (T(POST)). Last data during mechanical ventilation, either T2 or T3, are reported as T(END). SPB and RAGE values were normalized for total protein (SPB(N) and RAGE(N)). SPB(N) and RAGE(N) increments from T0 to T(END) were 56.2 [39.1] ng/mg (mean [75-25 percentile]) and 10.6[7.1] pg/mg, respectively. SPB values increased progressively during mechanical ventilation, whereas RAGE values increased at T(1) but not thereafter. SPB(N) increase (T(END)-T0), but not RAGE(N), was related to ΔPaO(2)/FiO2 changes during mechanical ventilation (r=0.575, p=0.01). Plasma RAGE(N) and SPB(N) kinetics in patients undergoing major vascular surgery are different.

Feasibility of intraoperative three-dimensional transesophageal echocardiography in the evaluation of right ventricular volumes and function in patients undergoing cardiac surgery.

BACKGROUND: The aim of this study was to test the feasibility of the assessment of right ventricular (RV) volumes and function using real-time three-dimensional (3D) transesophageal echocardiographic (TEE) imaging in patients undergoing cardiac surgery. METHODS: One hundred-fifty surgical patients were enrolled: 65 undergoing mitral valve repair, 10 undergoing mitral valve and tricuspid valve repair, four with congenital heart disease, two undergoing Jarvik implantation, 13 undergoing aortic valve surgical replacement, and 56 undergoing transcatheter aortic valve implantation. Real-time 3D TEE acquisition for RV evaluation was performed before and after the surgical procedure and compared with standard two-dimensional multiplane TEE measurements. In a subgroup of 81 patients, 3D transthoracic echocardiographic imaging was also performed. RV volumetric quantification was performed for all data using dedicated software. RESULTS: Three-dimensional RV analysis was feasible in 98.7% in the preoperative TEE data set and in 92.7% in the postoperative TEE data set. Agreement between 3D transthoracic and transesophageal echocardiography for end-diastolic volume (r = 0.98; 95% confidence interval [CI], -0.2 ± 13.6 mL), end-systolic volume (r = 0.97; 95% CI, -2.1 ± 10.2 mL), ejection fraction (r = 0.77; 95% CI, 1.8 ± 8.2%), and stroke volume (r = 0.91; 95% CI, 2.0 ± 12.9 mL) was significant. RV parameters were highly reproducible in patients with both normal and dilated RV volumes. CONCLUSIONS: Intraoperative 3D TEE assessment of RV volumes and function is feasible in patients with normal and dilated right ventricles, with good correlation between 3D transthoracic echocardiographic and TEE RV parameters. These measurements could improve the quantitative evaluation of RV function during cardiac surgery.

Left main coronary artery occlusion after percutaneous aortic valve implantation.

Left main coronary artery occlusion occurred immediately after transfemoral aortic valve implantation in an 87-year-old woman, which resulted in ventricular fibrillation and hemodynamic collapse. This life-threatening complication was promptly diagnosed with transesophageal echocardiography, which showed the disappearance of diastolic left main coronary artery jet flow and was confirmed with aortic root angiography. After prompt defibrillation, hemodynamic support was obtained with intra-aortic balloon pump and inotropic drugs. Functional recovery and survival were achieved with coronary stenting. This report highlights the importance of an integrated team approach of highly skilled specialists for these novel interventions.

Real-time three-dimensional transoesophageal echocardiography: a new intraoperative feasible and useful technology in cardiac surgery.

A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.

High thoracic epidural anesthesia in coronary artery bypass surgery: a propensity-matched study.

OBJECTIVES: To assess if 2 different anesthesia strategies, high-thoracic epidural anesthesia (HTEA) plus inhalation anesthesia and total intravenous anesthesia (TIVA) with sufentanil/propofol had different influence on outcomes of coronary artery bypass graft (CABG) surgery patients. DESIGN: Retrospective comparison of outcomes between HTEA and TIVA patients using propensity score pair-wise matching of patients. SETTING: A university teaching hospital. PARTICIPANTS: A study of 1,473 consecutive patients undergoing elective CABG surgery; of these, 476 (32%) received HTEA combined with inhalation anesthesia, whereas 997 (68%) underwent TIVA alone. INTERVENTIONS: The patients undergoing CABG surgery were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS: Propensity matching yielded 389 pairs of patients. Patients were well matched in preoperative and operative features. Postoperative mortality, myocardial infarction, stroke, acute renal failure rates, and intensive care unit (ICU) stay were not statistically different in HTEA and TIVA groups. On the other hand, patients treated with HTEA had shorter ventilation times (5.8 +/- 3.11 v 6.9 +/- 5.0 hours, HTEA and TIVA, respectively, p < 0.001); in addition, vasoconstrictors were more frequently used in cases of HTEA, whereas vasodilators were mainly used with TIVA both intra- and postoperatively. No neurologic complications related to the use of HTEA were observed. CONCLUSIONS: HTEA and TIVA provided similar early outcomes after CABG surgery, and there were no major differences between these 2 strategies in the average risk CABG patient populations. Although HTEA did not cause neurologic problems and yielded a significant reduction in time to extubation, a consistent benefit over standard techniques could not be shown.

Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse.

OBJECTIVES: The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the feasibility and accuracy of 3-dimensional (3D) transthoracic (TTE) and transesophageal (TEE) echocardiography in the evaluation of MV pathology. BACKGROUND: A pre-operative assessment of MV anatomy is essential to surgical design in patients undergoing MV repair. Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy, 3D TTE and 3D TEE could increase the understanding of MV apparatus and individual scallop identification. METHODS: One-hundred-twelve consecutive patients with severe mitral regurgitation due to MV prolapse underwent a complete 2D and 3D TTE the day before surgery and a complete 2D and 3D TEE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. RESULTS: Three-dimensional techniques were feasible in a relatively short time (3D TTE: 7 +/- 4 min; 3D TEE: 8 +/- 3 min), with good (3D TTE 55%; 3D TEE 35%) and optimal (3D TTE 21%; 3D TEE 45%) imaging quality in the majority of cases. Three-dimensional TEE allowed more accurate identification (95.6% accuracy) of all MV lesions in comparison with other techniques. Three-dimensional TTE and 2D TEE had similar accuracies (90% and 87%, respectively), whereas the accuracy of 2D TTE (77%) was significantly lower. CONCLUSIONS: Three-dimensional TTE and TEE are feasible and useful methods in identifying the location of MV prolapse. They were superior in the description of pathology in comparison with the corresponding 2D techniques and should be regarded as an important adjunct to standard 2D examinations in decisions regarding MV repair.