Spinal arteriovenous fistula with progressive paraplegia after spinal anaesthesia.

A case of an iatrogenic spinal arteriovenous fistula with progressive paraplegia in a young woman is reported. The fistula was eventually created after repetitive lumbar punctures performed in the process of spinal anaesthesia. Her symptoms were progressed to paraplegia over a period of 2 years. The digital subtraction angiography demonstrated a single-hole fistula, involving the anterior spinal artery and vein. The lesion was occluded by embolization with immediate improvement. The potential mechanism is discussed.

The Nicks-Nunez posterior enlargement in the small aortic annulus: immediate-intermediate results.

OBJECTIVES: To avoid prosthesis-patient mismatch, posterior enlargement of the small aortic annulus using the Nicks-Nunez surgical approach was performed in fifteen patients and the immediate-intermediate results are reported retrospectively. METHODS: During the period November 1995 to June 2005, 220 patients underwent aortic valve replacement (AVR) for primary aortic stenosis (AS). Fifteen patients (15/220 - 6%), all women, 40-76 years old (mean age 65.8 years) with AS, underwent AVR applying the Nicks-Nunez posterior enlargement of the small aortic annulus with an effective aortic valve area 0.7+/-0.2 cm(2). In addition, mitral valve replacement (MVR) was performed in two patients and coronary artery bypass grafting (CABG) in three (2 grafts/pt). Endarterectomy of the ascending aorta was performed in one patient. With the exception of one patient, mechanical valves were used. In all cases, transesophageal echo (TEE), normothermic cardiopulmonary bypass (CPB), left ventricular venting, antegrade crystalloid cardioplegic arrest and local myocardial cooling, was used. The defect after the enlargement was closed with autologous pericardium in four and synthetic graft in eleven patients. The follow-up period was 5-120 months (mean 61.5 months). RESULTS: There was no operative or hospital mortality. The length of CPB and aortic crossclamping was increased as well as the duration of mechanical ventilation. In one, out of two patients, in whom the decision for enlargement was delayed, intraaortic balloon pump was used. However, there was no other morbidity and the final length of stay was 7-10 days (same as for routine AVR). One patient died five years later from lung cancer. Serial follow-up transthoracic echoes have shown statistically significant improvements in left ventricular-intraventricular septum thickness (LVIVS) (16.5+/-1.3 mm vs. 14.3+/-1.7 mm, P<0.01), left ventricular posterior wall thickness (LVPWT) (16.7+/-1.4 mm vs. 14.5+/-1.8 mm, P<0.01), left ventricular (LV) mass/g (415+/-33 vs. 388+/-41, P<0.01), peak gradient (98+/-10 mmHg vs. 48+/-7 mmHg, P<0.001) and in mean gradient (58+/-10 mmHg vs. 22+/-8 mmHg, P<0.001). The functional aortic valve orifice postoperatively was 1.4+/-0.5 cm(2). The ejection fraction (EF) and the left ventricular end-diastolic pressure (LVEDP) were unchanged. CONCLUSIONS: Immediate and intermediate results reveal the safety of the procedure and the significant functional and anatomical improvement of the left ventricle. Although the number of patients is small, female patients, small or large, seem to be the usual candidates for this procedure.

Low preoperative HSP70 atrial myocardial levels correlate significantly with high incidence of postoperative atrial fibrillation after cardiac surgery.

PURPOSE OF THE STUDY: Atrial fibrillation after cardiac surgery is still a frequent encountered complication and has been associated with increased hospital length of stay and numerous postoperative complications. The pathogenesis of atrial fibrillation involves an overall sequence of perioperative events, collectively termed as ischemia-reperfusion injury. Heat-shock proteins have been found to provide increased protection during ischemia-reperfusion as well as increased postischemic cardiac functional recovery. We sought to determine whether preoperative atrial heat shock levels were correlated with the appearance of postoperative atrial fibrillation. BASIC METHODS: Preoperative atrial myocardial samples obtained just before cannulation from 101 patients were used to detect immunohistochemically the expression of heat-shock proteins. The derived results were compared statistically with the incidence of postoperative atrial fibrillation, its time of appearance, duration and resistance to administered antiarrhythmics. PRINCIPAL FINDINGS: The overall incidence of postoperative atrial fibrillation was 22.3%. Of these patients, 58.3% had no detectable heat shock proteins in their cytoplasm, in sharp contrast with 100% of the patients with no atrial fibrillation who were positive for heat shock proteins (p<0.01). Four percent of our patient group had prolonged atrial fibrillation (defined as duration >48 h). These patients had significantly less (p<0.01) nuclear heat shock protein expression compared with the non-atrial fibrillation group. However, the difference of the heat shock protein expression between the prolonged atrial fibrillation and the rest of the atrial fibrillation patients was not significant (p=0.891). CONCLUSIONS: Our results indicate that patients with low preoperative atrial heat shock protein expression have a significantly greater incidence of postoperative atrial fibrillation. Heat shock protein expression did not, however, correlate with the onset of atrial fibrillation and the resistance to administered medications. Heat shock protein preoperative induction as a measure of myocardial preconditioning may potentially decrease the incidence of postoperative atrial fibrillation.