Ketamine reduce left ventricular systolic and diastolic function in patients with ischaemic heart disease.

OBJECTIVE: Ketamine may be followed by a general increase in haemodynamics and oxygen consumption, which may be of concern in patients with ischaemic heart disease. The purpose of this study was to evaluate the effect of ketamine on left ventricular (LV) systolic and diastolic function by different modalities of echocardiography and tissue Doppler imaging in patients with ischaemic heart disease. METHODS AND RESULTS: Prospective observational study of 11 patients acting as own control based on echocardiographic imaging before and after bolus ketamine 0.5 mg/kg. Simpson's 2 D-volumetric method was used to quantify left ventricular volume and ejection fraction. General global LV deformation was assessed by Speckle tracking ultrasound, systolic LV longitudinal displacement was assessed by Tissue Tracking score index and the diastolic function was evaluated from changes in early-(E') and atrial (A') peak velocities during diastole. Average heart rate (34%) and blood pressure (35%) increased significantly after ketamine (P<0.0001). Mean tissue tracking score index decreased from 11.2 ± 2.3 to 8.3 ± 2.6 (P=0.005) and Global Speckle tracking 2D strain from 17.7 ± 2.7 to 13.7 ± 3.6 (P=0.0014) indicating a decrease in LV global systolic function. The E'/A' ratio decreased from 1.11 ± 0.43 to 0.81 ± 0.46 (P=0.044) indicating impaired relaxation. CONCLUSION: Different modalities of echocardiography in combination with tissue Doppler indicate both diminished systolic and diastolic function after ketamine administration in patients with ischaemic heart disease.

High thoracic epidural analgesia improves left ventricular function in patients with ischemic heart.

BACKGROUND: In patients with ischemic heart disease, high thoracic epidural analgesia (HTEA) has been proposed to improve myocardial function. Tissue Doppler Imaging (TDI) is a tool for quantitative determination of myocardial systolic and diastolic velocities and a derivative of TDI is tissue tracking (TT), which allows quantitative assessment of myocardial systolic longitudinal displacement during systole. The purpose of this study was to evaluate the effect of thoracic epidural analgesia on left ventricular (LV) systolic and diastolic function by means of two-dimensional (2D) echocardiography and TDI in patients with ischemic heart disease. METHODS: The effect of a high epidural block (at least Th1-Th5) on myocardial function in patients (N=15) with ischemic heart disease was evaluated. Simpson's 2D volumetric method was used to quantify LV volume and ejection fraction. Systolic longitudinal displacement was assessed by the TT score index and the diastolic function was evaluated from changes in early (E'') and atrial (A'') peak velocities during diastole. RESULTS: After HTEA, 2D measures of left ventricle function improved significantly together with the mean TT score index [from 5.87 +/- 1.53 to 6.86 +/- 1.38 (P<0.0003)], reflecting an increase in LV global systolic function and longitudinal systolic displacement. The E''/A'' ratio increased from 0.75 +/- 0.27 to 1.09 +/- 0.32 (P=0.0026), indicating improved relaxation. CONCLUSION: A 2D-echocardiography in combination with TDI indicates both improved systolic and diastolic function after HTEA in patients with ischemic heart disease.

Hypertrophied hearts: what of sevoflurane cardioprotection?

BACKGROUND: Recent studies have demonstrated that inhalation anaesthetics, like sevoflurane, confer cardioprotection both experimentally and clinically. However, coexisting cardiac disease might diminish anaesthetic cardioprotection and could partly explain why the clinical results of cardioprotection with anaesthetics remain controversial--in contrast to solid experimental evidence. Concomitant left ventricular hypertrophy is found in some cardiac surgery patients and could change cardioprotection efficacy. Hypertrophy could potentially render the heart less susceptible to sevoflurane cardioprotection and more susceptible to ischaemic injury. We investigated whether hypertrophy blocks sevoflurane cardioprotection, and whether tolerance to ischaemia is altered by left ventricular hypertrophy, in an established experimental animal model of ischaemia-reperfusion. METHODS: Anaesthetized juvenile pigs (n=7-12/group) were subjected to 45 min distal coronary artery balloon occlusion, followed by 120 min of reperfusion. Controls were given pentobarbital, while sevoflurane cardioprotection was achieved by 3.2% inhalation throughout the experiment. Chronic banding of the ascending aorta resulted in left ventricular hypertrophy development in two further groups and these animals underwent identical ischaemia-reperfusion protocols, with or without sevoflurane cardioprotection. Myocardial infarct sizes were compared post-mortem. RESULTS: The mean myocardial infarct size (% of area-at-risk) was reduced from mean 55.0 (13.6%) (+/-SD) in controls to 17.5 (13.2%) by sevoflurane (P=0.001). Sevoflurane reduced the infarct size in hypertrophied hearts to 14.6 (10.4%) (P=0.001); however, in hypertrophic controls, infarcts were reduced to 34.2 (10.2%) (P=0.001). CONCLUSION: Sevoflurane abrogated ischaemic injury to similar levels in both normal and left ventricular hypertrophied hearts.

Perioperative feasibility of imaging the heart and pleura in patients with aortic stenosis undergoing aortic valve replacement.

BACKGROUND: The postoperative monitoring and treatment of the patient undergoing aortic valve replacement is a complex challenge. Echocardiography is the only method which provides dynamic and real-time bedside imaging of the heart. Focused assessed transthoracic echocardiography has been shown to provide a usable window for cardiac imaging in a mixed ICU population. The aim of this study was to evaluate the feasibility of perioperative imaging of the heart and pleura according to the focused assessed transthoracic echocardiography protocol in patients scheduled for aortic valve replacement. METHOD: Thirty-five adult patients scheduled for aortic valve replacement were followed perioperatively with focused assessed transthoracic echocardiography examinations. A Vivid-7 echo-machine and a 2.5 MHz matrix transducer with second-harmonic imaging were used for data acquisition. The image quality for the cardiac window was graded 1-5 (1 = no image, 2 = poor and unusable image quality, 3 = usable image quality, 4 = good image quality and 5 = perfect image quality). A score >or=3 equalled an image quality judged to be of sufficient quality to be interpreted and thereby to contribute to clinical decision-making. RESULTS: All patients had at least one usable window preoperatively. At least one usable window was obtained in 88% of patients on the first postoperative day, and in 97% at discharge. The image quality changed over time, with the poorest quality being observed on the first postoperative day. The apical view with the patient in the left lateral position provided the best cardiac window on all occasions. The presence of drains did not significantly affect the achievability of a satisfactory examination. The number of patients with pleural effusion was relatively high. On the first postoperative day, 10 subjects had unilateral and one subject had bilateral pleural effusions. At discharge, 14 patients had unilateral and four patients had bilateral effusions. CONCLUSIONS: We conclude that the image quality of the heart and pleura, according to the focused assessed transthoracic echocardiography concept, is sufficient to undergo interpretation and thereby contribute to the perioperative clinical decision-making in patients with aortic stenosis.

Propofol reduces tissue-Doppler markers of left ventricle function: a transthoracic echocardiographic study.

BACKGROUND: Propofol is thought to minimally depress myocardial function, but mainly to reduce blood pressure by vasodilation. Transthoracic tissue-Doppler echocardiography (TDE) is a novel, validated method of quantifying myocardial function. It provides new insight into myocardial function by measuring myocardial motion. We examined the effects of propofol upon myocardial function by measuring changes in left ventricle function by TDE. METHODS: We assessed change in myocardial function in propofol anaesthetized ASA I patients tissue tracking displacement (TTD) before anaesthesia onset and repeated measurements after a single propofol bolus dose. Tissue tracking score (TTS), a marker of ejection fraction, was also used (n = 10). RESULTS: Propofol 1.5-2 mg kg(-1) significantly attenuated PSV from 5.64 (1.17) to 4.66 (0.55) cm s(-1) (P < 0.0001) and TTD from 10.2 (2.1) to 8.5 (1.4) mm (P = 0.0091), whereas TTP was unchanged [all data: mean (SD)]. TTS declined from 7.2 (1.3) to 6.1 (0.6) mm (P < 0.01). Non-invasive mean blood pressure declined 17% (P < 0.0001). CONCLUSIONS: The results indicate that myocardial contractile function is compromised concomitantly with reduced cyclic displacement after propofol dosing. Blood pressure declined accordingly. From these results, it is impossible to ascertain whether this was secondary to reduced cardiac filling or a consequence of a direct negative inotropic action of propofol, but it represents a left-shift of the Starling curve. The novel TDE yields new information on myocardial velocities and motion.

[Rat-bite fever]. / Rottebittfeber.

BACKGROUND: Rat bite fever and Haverhill fever are caused by Streptobacillus moniliformis which is part of the natural oral flora of rats and other rodents. Fever accompanied by headache, nausea and myalgia develops within ten days. Complications can be fatal. MATERIAL AND METHODS: A case of rat bite fever is described. A 48-year-old woman developed fever and malaise five days after being bitten by a pet rat. Two days later rash and arthritis in the hand and feet developed. Erythromycin was administered without effect. Ten days after the bite the patient was admitted to hospital and recovered after two weeks of intravenous penicillin therapy. RESULTS: S moniliformis was isolated from blood culture. On admission CRP was 231, ESR 88, ASAT 87, ALAT 218 and gamma-GT 461. Laboratory results normalized after therapy. INTERPRETATION: In cases of fever after rodent bites, S moniliformis infection should always be considered. Diagnosis is made by blood culture or cultivation from pus from the bite wound. First choice therapy is penicillin, or in case of intolerance, tetracycline.