Modified Tricuspid Annular Plane Systolic Excursion Using Transesophageal Echocardiography for Assessment of Right Ventricular Function.

OBJECTIVES: The authors defined a modified tricuspid annular plane systolic excursion (m-TAPSE) measurement using the transesophageal echocardiography (TEE) midesophogeal 4-chamber view and investigated its clinical validity in comparison with other indices of heart function. DESIGN: Retrospective medical record review. SETTING: A single tertiary care medical center. PARTICIPANTS: One hundred ninety-six patients who underwent successful mitral valve repair. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were divided into 2 groups using a proposed guideline cutoff of 16 mm of m-TAPSE. m-TAPSE was measured by apical systolic/diastolic shortening as shown in the TEE midesophogeal 4-chamber view. Right ventricular fractional area change (RV FAC) was measured by using planimetry in the same view. Correlation analysis was performed for m-TAPSE and RV FAC. One hundred six (54.1%) patients showed m-TAPSE>16 mm and 90 patients (45.9%) showed m-TAPSE<16 mm. There were no significant differences in patient demographics and comorbidities between the 2 groups except for atrial fibrillation (7.5% in m-TAPSE>16 mm v 24.4% in m-TAPSE<16 mm, p<0.001). Compared to the m-TAPSE>16 mm group, the m-TAPSE<16 mm group demonstrated significantly lower RV FAC (38.0±10.4 v 26.4±8.1, p<0.001). The correlation coefficient between m-TAPSE and RV FAC was 0.618, p< 0.001. CONCLUSIONS: m-TAPSE validated a good correlation to right ventricular systolic function as reflected by RV FAC. m-TAPSE should be considered as an easily measurable parameter to evaluate right ventricular systolic function.

[A Trained-in-Japan Anesthesiologist Going Through Anesthesia Training in the United States : What Adjustments Should be Made for Upcoming Renewal in Anesthesia Board Certification in Japan?].

We reviewed the anesthesiology training in the United States from the viewpoint of Japanese Anes- thesiologists. The Accreditation Council for Graduate Medical Education (ACGME) strictly supervises anes- thesiology residency programs in the U.S. Recently, the ACGME has become stricter on training supervi- sion, and American Board of Anesthesiology (ABA) revised its board examination system. The quality of anesthesia training in the U. S., how- ever, is decreasing because of new regulations. Addi- tionally, in the continuing economic recession, hospitals have started to hire more nurse anesthetists (CRNA) with cheaper salary than anesthesiologists. This situa- tion led more anesthesiology residents to seek an extra year of subspecialty fellowship training and research experience. This trend will come to Japan in the near future, for which we should be well prepared. As the first step, the process for Japanese Anesthesiology Board Recertification should be modified. Continuing medical education should be mandatory for each re- newal with recertification examination. Second, the number of residents and the quality of each program should be strictly supervised by a third party. Lastly, we should encourage residents to seek subspecialty training and more research experience to become bet- ter anesthesiologists.

Pulmonary artery rupture in a patient receiving an orthotopic heart transplant after total artificial heart explant.

Our case illustrates a patient who suffered a pulmonary artery rupture despite previous total artificial heart implantation and replacement with orthotopic heart transplant. Pulmonary artery rupture during or following cardiac surgery has been reported to occur due to both pulmonary artery catheter use and surgical technique. Our case is the first to demonstrate the occurrence of this complication in the total artificial heart patient population.

Echocardiographic Left Ventricular Mass Estimation: Two-Dimensional Area-Length Method is Superior to M-Mode Linear Method in Swine Models of Cardiac Diseases.

Echocardiography offers rapid and cost-effective estimations of left ventricular (LV) mass, but its accuracy in patients with cardiac disease remains unclear. LV mass was measured by M-mode-based linear method and two-dimensional echocardiography (2DE)-based area-length method in pig models and correlation with actual LV weight was assessed. Twenty-six normal, 195 ischemic heart disease (IHD), and 33 non-IHD HF pigs were included. A strong positive linear relationship to the actual LV weight was found with 2DE-based area-length method (r = 0.82, p < 0.001), whereas a moderate relationship was found with M-mode method in the overall population (r = 0.68, p < 0.001). Two correlation coefficients were significantly different (p < 0.001), and were driven mainly by incremental overestimation of LV mass in heavier hearts using the M-mode method. IHD and LV dilation were the factors contributing to overestimation using M-mode method. 2DE-based area-length method provides a better estimation of LV weight in swine models of HF, particularly in those with IHD.

Recognition of a cleft mitral valve utilizing real-time three-dimensional transoesophageal echocardiography.

We present a case in which real-time three-dimensional transoesophageal echocardiography was utilized to obtain better understanding of a cleft mitral valve. Additionally, the embryological development of a cleft mitral valve will be reiterated.

Left Ventricular Unloading Using an Impella CP Improves Coronary Flow and Infarct Zone Perfusion in Ischemic Heart Failure.

BACKGROUND: Delivering therapeutic materials, like stem cells or gene vectors, to the myocardium is difficult in the setting of ischemic heart failure because of decreased coronary flow and impaired microvascular perfusion (MP). The aim of this study was to determine if mechanical left ventricular (LV) unloading with the Impella increases coronary flow and MP in a subacute myocardial infarction. METHODS AND RESULTS: Anterior transmural myocardial infarction (infarct size, 26.0±3.4%) was induced in Yorkshire pigs. At 2 weeks after myocardial infarction, 6 animals underwent mechanical LV unloading by Impella, whereas 4 animals underwent pharmacological LV unloading using sodium nitroprusside for 2 hours. LV unloading with Impella significantly reduced end-diastolic volume (-16±11mL, P=0.02) and end-diastolic pressure (EDP; -32±23 mm Hg, P=0.03), resulting in a significant decrease in LV end-diastolic wall stress (EDWS) (infarct: 71.6±14.7 to 43.3±10.8 kdynes/cm2 [P=0.02]; remote: 66.6±20.9 to 40.6±13.3 kdynes/cm2 [P=0.02]). Coronary flow increased immediately and remained elevated after 2 hours in Impella-treated pigs. Compared with the baseline, MP measured by fluorescent microspheres significantly increased within the infarct zone (109±81%, P=0.003), but not in the remote zone. Although sodium nitroprusside effectively reduced LV-EDWS, 2 (50%) of sodium nitroprusside-treated pigs developed profound systemic hypotension. A significant correlation was observed between the infarct MP and EDWS (r2=0.43, P=0.03), suggesting an important role of EDWS in regulating MP during LV unloading in the infarcted myocardium. CONCLUSIONS: LV unloading using an Impella decreased EDWS and increased infarct MP without hemodynamic decompensation. Mechanical LV unloading is a novel and efficient approach to increase infarct MP in patients with subacute myocardial infarction.

Intracardiac thrombosis and acute right ventricular failure following complex reoperative cardiac surgery with aprotinin and deep hypothermic circulatory arrest.

Although coagulopathy and bleeding are common in the setting of cardiac surgery, a growing number of case reports in the literature suggest that hypercoagulability may also result in significant morbidity and mortality. We present a case of apparent hypercoagulability with formation of thrombus in the cardiac chambers following reoperative cardiac surgery using cardiopulmonary bypass, aprotinin, and deep hypothermic arrest. A review of those hypercoagulable disorders with reported impact on cardiac surgery and a discussion follow the case presentation.

[Successful airway management using a Cook airway exchange catheter as an emergent dilator for life-threatening neoplastic stenosis of the trachea: a case report].

A 68-year-old male patient was referred to our hospital for his intractable and progressive dyspnea. Chest roentgenography and computerized tomography revealed severe lower tracheal stenosis due to neoplastic invasion. The tumor completely surrounded his trachea for 5 cm length and the remaining internal diameter of the trachea was less than 5 mm. To avoid fatal asphyxia, emergency airway security was required. After placing both femoral arterial and venous cannulae for percutaneous cardiopulmonary support system, we dilated the stenotic trachea using a Cook airway exchange catheter (CAEC), and then an armored tube of 7 mm inner diameter was introduced through the CAEC. The maneuver was smoothly completed within one minute without any complications. His dyspnea was completely relieved. Following chemotherapy and radiotherapy were so effective that the endotracheal tube was extubated two weeks later uneventfully. After several series of chemotherapy and 50 Gy irradiation, the patient was discharged three months later without symptoms. We concluded that CAEC could be one of the life-saving instruments for emergent airway management in case of severe organic tracheal stenosis.

Dexmedetomidine controls twitch-convulsive syndrome in the course of uremic encephalopathy.

An 85 year old man with a history of chronic renal insufficiency was admitted to the cardiothoracic intensive care unit after aortic valve replacement. His postoperative course was marked by acute oliguric renal failure for high blood urea nitrogen (BUN) and acute hyperactive delirium. At this time he also developed tremors with muscle twitching; he received no other form of sedatives. A neurology consult made the diagnosis of twitch-convulsive syndrome associated with uremic encephalopathy. While the patient was receiving the dexmedetomidine infusion, the signs of the twitch-convulsive syndrome, particularly the twitching and tremors, disappeared. Within 30 minutes of the end of the dexmedetomidine infusion, symptoms of the twitch-convulsive syndrome returned, manifesting as acute tremulousness. After several dialysis treatments, his BUN decreased and the dexmedetomidine was weaned, without return of the symptoms of twitch-convulsive syndrome.

Effects of landiolol on hemodynamic response and seizure duration during electroconvulsive therapy.

PURPOSE: This study was done to evaluate the effect of landiolol, an ultra-short-acting beta-blocker, on the hemodynamic response and the duration of seizure activity during electroconvulsive therapy (ECT). METHODS: We designed a prospective, randomized, double-blinded, placebo-controlled, crossover study. Fourteen psychiatric patients participated. Landiolol (0.1 mg x kg(-1) or 0.2 mg x kg(-1)) or saline (placebo) was administered IV 1 min before the induction of anesthesia. Unconsciousness was induced with propofol 1.0 mg x kg(-1) IV, and muscle paralysis was produced with succinylcholine 0.6 mg x kg(-1) IV. Subsequently, electrical stimulus was administered to elicit a seizure, and the duration of the motor seizure activity was noted. RESULTS: The heart rate (HR) and rate-pressure product (RPP) before ECT were significantly decreased in the 0.2 mg x kg(-1) landiolol group compared with these parameters in the placebo and 0.1 mg x kg(-1) landiolol groups. Both the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses significantly attenuated the degree of tachycardia and RPP after ECT in comparison with the placebo group. Pretreatment with 0.2 mg x kg(-1) landiolol resulted in a significantly shorter duration of motor seizure than that in the placebo group (21 +/- 13 s vs 27 +/- 12 s). CONCLUSION: As the landiolol dose of 0.2 mg x kg(-1) caused shorter seizure duration, and because the hemodynamic effects after ECT of the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses were similar, it was concluded that a 0.1 mg x kg(-1) landiolol bolus was the appropriate dose pretreatment before ECT.