Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: a prospective study of 203 patients.

OBJECTIVE: To determine the usefulness of systematic intraoperative transesophageal echocardiography in a cardiac surgical unit. DESIGN: Open prospective observational survey. SETTING: University Hospital. PARTICIPANTS: Consecutive adult patients (n = 203) undergoing elective or urgent cardiac operations. MEASUREMENTS AND MAIN RESULTS: Pre-cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Transesophageal echocardiography modified the diagnosis in eight patients (17%) operated on for mitral valvulopathy, in seven patients (15.5%) with aortic valvular disease, in four patients (4.6%) with coronary artery disease, in five patients operated on for thoracic aorta diseases regardless of their localization (18.5%), and in two miscellaneous cases. On the basis of the data obtained from the transesophageal echocardiography carried out at the end of cardiopulmonary bypass, an immediate reintervention was required in five cases (2.5%). CONCLUSIONS: It is concluded that systematic intraoperative transesophageal echocardiography significantly affected decision making in this cardiac surgical unit. Its routine use in all cardiac surgical patients is recommended.

Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases.

BACKGROUND: In patients after lung transplantation, dysfunction of pulmonary venous and artery anastomoses leading to reoperation is described. METHODS AND RESULTS: Pulmonary artery and vein anastomoses were evaluated intraoperatively by monoplane transesophageal echocardiography (TEE) in 18 patients undergoing lung transplantation (nine right, five left single lung transplantations, and four bilateral transplantations). All 13 right pulmonary artery anastomoses and all 22 pulmonary vein anastomoses could be visualized by TEE. None of the nine left pulmonary anastomoses could be visualized. Of the 13 right pulmonary anastomoses, 12 were considered normal, their diameter ranging from 1 to 1.7 cm (mean, 1.26 +/- 0.24 cm). A moderate stenosis of one pulmonary artery anastomosis was identified but did not require reoperation. Of the 22 pulmonary vein anastomoses, 16 were considered normal, their diameter being > 0.5 cm and the peak systolic flow velocity < or = 1 m/s at the location of the anastomoses. In five cases, the anastomoses were not considered normal, but reoperation was not indicated. In one case, a severe stenosis of pulmonary vein associated with graft dysfunction led to an early reoperation. CONCLUSION: Intraoperative TEE during lung transplantation contributes to the immediate evaluation of pulmonary vein and right pulmonary artery anastomoses and allows immediate surgical correction. Further investigations are necessary to establish threshold values requiring reoperation.

Anesthesia for bilateral lung transplantation without cardiopulmonary bypass: initial experience and review of intraoperative problems.

Bilateral lung transplantation (BLT) is a recently described procedure based on two sequential single-lung transplantations (SLT), which are performed by a transverse sternobithoracotomy. It does not require either cardiac arrest or routine use of cardiopulmonary bypass (CPB). The intraoperative management of 10 patients suffering from end-stage pulmonary disease is reported. Implantation of the first graft is quite similar to a SLT. Problems encountered during this procedure (ie, hypoxemia, hypercapnia, or low cardiac output) were due to restricted pulmonary and cardiac reserve. Preoperative and intraoperative assessment of the recipient's respiratory and cardiac status was, therefore, of prime importance. Mild preoperative pulmonary hypertension, well-preserved right ventricular function, and removal of the less well-perfused lung limited these difficulties; no patient required partial CPB at this stage. During the second lung implantation, gas exchange was provided by the first grafted lung. Measurements of pulmonary vascular resistance (PVR), venous admixture (Qva/Qt), and dead space (VD/VT) assessed with the arterial-to-end-tidal CO2 difference were used to confirm the adequacy of perfusion and V/Q matching. In one patient, partial CPB was instituted because of surgical difficulty related to inadequate size matching of the lungs. In the other patients, first graft function was satisfactory and the second graft was implanted without CPB. With chest closure, PVR returned to nearly normal values (range, 57-293, mean 167 dynes.s.cm-5) and Qva/Qt increased (range, 3 to 36, mean 20%). This limited series demonstrates that CPB is optional during this procedure. Good selection of recipients and donors, good lung preservation methods, and a short duration of cold ischemia are essential to success.

Severe hypertension during postpartum haemorrhage after i.v. administration of prostaglandin E2.

Severe hypertension with arterial spasm was observed after i.v. administration of prostaglandin E2 (PGE2) during uterine exploration under general anaesthesia for control of postpartum haemorrhage. This hypertension was exceptional because PGE2 is known to cause a decrease in systemic arterial pressure. Different hypotheses for this paradoxical hypertensive crisis after PGE2 administration are discussed.