Right ventricular function is reduced during cardiac surgery independent of procedural characteristics, reoperative status, or pericardiotomy.

OBJECTIVES: Long-axis right ventricular (RV) function, which provides nearly 80% of RV ejection, acutely decreases during cardiac surgery. RV dysfunction increases risk for perioperative morbidity and mortality. Our objective was to characterize the change in perioperative RV long-axis and global function by determining the influence of procedure type, surgical approach, and reoperative status and examining its temporal relationship to pericardiotomy versus cardiopulmonary bypass (CPB) and cardioplegia. METHODS: Standardized transesophageal echocardiographic examinations (TEEs) were prospectively performed in 109 patients undergoing coronary artery bypass grafting, mitral or aortic valve surgery, and/or aortic surgery via full sternotomy, mini-sternotomy, or right thoracotomy. Mid-esophageal, 4-chamber views centered on the RV were recorded at 4 intraoperative time points, following: (1) anesthetic induction; (2) pericardiotomy; (3) CPB; and (4) chest closure. Long-axis RV function was assessed by tricuspid annular plane systolic excursion and 2-dimensional longitudinal RV strain, and global RV function by fractional area change (FAC), calculated off-line from 2-dimensional TEE images. RESULTS: TEE measures of RV function were significantly reduced after CPB compared with baseline (baseline vs after CPB: TAPSE 2.2 [Q1, Q3: 1.8, 2.5] vs 1.5 [1.1, 1.7] mm; RV strain -22 [-24, -18] vs -16 [-20, -14] %; FAC 45 [35, 51] vs 42 [34, 49] %), but not after pericardiotomy. Reduced RV function persisted after chest closure: tricuspid annular plane systolic excursion 1.3 [1.0, 1.6] mm, RV strain -16 [-18, -13]%, FAC 38 [31, 46] %. Reduced function was demonstrated across cardiac surgical procedures, approaches, and primary and reoperative surgery. CONCLUSIONS: Acute intraoperative reduction in RV function occurs following CPB, independent of procedural characteristics and pericardiotomy. Etiology and clinical implications of reduced perioperative RV function remain to be determined.

Continuous Erector Spinae Plane Blocks for Adult Pectus Excavatum Repair.

Use of continuous erector spinae plane (ESP) blocks for pectus excavatum repair may be a valuable alternative to thoracic epidural placement. This report describes the successful use of bilateral ESP blocks in 2 patients with complex medical histories in which thoracic epidural placement was either contraindicated or unsuccessful. The benefits of continuous ESP blocks in this subset of patients include pain control with a focus on opioid sparing, early extubation, decreased atelectasis, improved mobilization and physical therapy, and decreased length of hospital stay.

Delayed lethal pulmonary air embolism after a gunshot head injury.

We present a case of a young male patient with a fatal pulmonary air embolism following a penetrating gunshot head injury. He suffered from severe head trauma including a laceration of the superior sagittal sinus. Operative neurosurgical intervention did not establish a watertight closure of the wounds. Eight days after the trauma, the patient suddenly collapsed and died after an attempt to mobilise him to the vertical. Forensic autopsy indicated pulmonary air embolism as the cause of death. Retrospectively, we postulate an entry of air to the venous system via the incompletely occluded wounds and the lacerated superior sagittal sinus while mobilisation to the vertical created a negative pressure in the dural sinus.

Recommendations for genetic testing and counselling after sudden cardiac death: practical aspects for Swiss practice.

There is a need to standardise, within a coordinated Swiss framework, the practical aspects of genetic testing and genetic counselling on possibly inherited cardiovascular disorders in relatives of a sudden cardiac death (SCD) victim. Because of the major advances in genetic investigation techniques and recent publication of international guidelines in the field of cardiology, genetics and pathology, we consider it important to summarise the current evidence and propose an optimal approach to post-mortem genetic investigation for SCD victims and their families in Switzerland. In this article, we discuss important technical, financial and medico-ethical aspects, and provide updated information on specific situations in which forensic pathologists, general practitioners and cardiologists should suspect a genetic origin of the SCD. At present, the principles of benefit, the duty to warn and the impact of genetic information for family members at risk are considered as strong justifications for post-mortem disclosure and prevail over the arguments of respect for a deceased person's privacy and confidentiality. This paper underlines also the need to update and improve the general knowledge concerning the genetic risk of cardiovascular pathologies, the importance to perform an autopsy and post-mortem genetic testing in SCD victims, and to develop standardized post-mortem disclosure policy at national and international levels for SCD cases and relatives.

Sudden cardiac death in forensic medicine ­ Swiss recommendations for a multidisciplinary approach.

Sudden cardiac death (SCD) is by definition unexpected and cardiac in nature. The investigation is almost invariably performed by a forensic pathologist. Under these circumstances the role of the forensic pathologist is twofold: (1.) to determine rapidly and efficiently the cause and manner of death and (2.) to initiate a multidisciplinary process in order to prevent further deaths in existing family members. If the death is determined to be due to "natural" causes the district attorney in charge often refuses further examinations. However, additional examinations, i.e. extensive histopathological investigations and/or molecular genetic analyses, are necessary in many cases to clarify the cause of death. The Swiss Society of Legal Medicine created a multidisciplinary working group together with clinical and molecular geneticists and cardiologists in the hope of harmonising the approach to investigate SCD. The aim of this paper is to close the gap between the Swiss recommendations for routine forensic post-mortem cardiac examination and clinical recommendations for genetic testing of inherited cardiac diseases; this is in order to optimise the diagnostic procedures and preventive measures for living family members. The key points of the recommendations are (1.) the forensic autopsy procedure for all SCD victims under 40 years of age, (2.) the collection and storage of adequate samples for genetic testing, (3.) communication with the families, and (4.) a multidisciplinary approach including cardiogenetic counselling.

[Lethal atraumatic splenic rupture due to infectious mononucleosis]. / Letale atraumatische Milzruptur infolge infektiöser Mononukleose.

The authors report on the sudden and unexpected death of a 20-year-old man from atraumatic rupture of the enlarged spleen due to infectious mononucleosis. The case exemplifies the forensic relevance of infectious mononucleosis, atraumatic splenic rupture and post-mortem serological tests.

Elevated body core temperature in medico-legal investigation of violent death.

Pathologically elevated body core temperature, measured at the death scene, is an important finding in medico-legal investigation of violent deaths. An abnormally high rectal temperature at any death scene may point to an underlying pathology, the influence of certain drugs or a hidden cerebral traumatism, and death by suffocation which would remain undetected without further medico-legal investigations. Furthermore, hyperthermia and fever, if unrecognized, may result in an erroneous forensic estimation of time since death in the early postmortem period by the "Henssge method." By a retrospective study of 744 cases, the authors demonstrate that hyperthermia is a finding with an incidence of 10% of all cases of violent death. The main causes are: influence of drugs, malignant tumors, cerebral hypoxia as a result of suffocation, infections, and systemic inflammatory disorders. As a consequence it must be stated, that hyperthermia must be excluded in every medico-legal death scene investigation by a correct measurement of body core temperature and a comparison between the cooling rate of the body and the behavior of early postmortem changes, notably livor and rigor mortis.

Epi-LASIK versus epi-LASEK.

PURPOSE: To compare the possible advantages and disadvantages of adding an alcohol solution (20%) to the epi-LASIK procedure. This study focuses on flap making, haze, and pain with and without alcohol. METHODS: A prospective study was performed on 45 patients to compare epi-LASIK with epi-LASIK plus alcohol (ie, epi-LASEK). Alcohol (20%) was applied for 20 seconds before making the flap in the epi-LASEK treatment group. In each patient, one eye underwent epi-LASIK and the fellow eye had epi-LASEK. In the epi-LASIK treatment group, mean myopic (n = 40) spherical equivalent refraction was -5.60 +/- 3.30 diopters (D) and mean hyperopic (n = 5) spherical equivalent refraction was +2.90 +/- 1.80 D. Myopic mean astigmatism was 1.40 +/- 1.20 D, and hyperopic mean astigmatism was 0.60 +/- 0.60 D. In the epi-LASEK treatment group, myopic (n = 40) mean spherical equivalent refraction was -5.90 +/- 3.50 D and hyperopic (n = 5) mean spherical equivalent refraction was +3.00 +/- 1.90 D. Mean myopic astigmatism was 1.60 +/- 1.30, and mean hyperopic astigmatism was 0.60 +/- 0.90 D. No significant differences were noted between groups (P > .05). Refraction and topography were performed preoperatively and on postoperative days 6 (contact lenses just removed), 15, 30, 60, 120, and 360. RESULTS: The epi-LASEK treatment group had less postoperative astigmatism and irregularities than the epi-LASIK group. Alcohol addition in the epi-LASEK treatment group contributed to better flap and hinge creation. Pain and haze did not increase in the epi-LASEK treatment group (P > .05). CONCLUSIONS: Flap viability does not seem to be important postoperatively in reducing pain and speeding recovery time. Alcohol facilitates flap making and improves hinge quality, and does not increase postoperative pain or haze. Adding alcohol to the epi-LASIK procedure can be advantageous in obtaining an intact hinge and a perfect flap.

B0-->D(*-)a(+)(1): chirality tests and resolving an ambiguity in the CP violation parameter 2beta+gamma.

We point out that the decays of B mesons into a vector meson and an axial-vector meson can distinguish between left and right-handed polarized mesons, in contrast to decays into two vector mesons. Measurements in B0-->D(*-)a(+)(1) are proposed for testing factorization and the V-A structure of the b-->c current, and for resolving a discrete ambiguity in 2beta+gamma.