LOEYS-DIETZ SYNDROME: PERIOPERATIVE ANESTHESIA CONSIDERATIONS.

Loeys-Dietz syndrome (LDS) is a rare autosomal dominant disease related to genetic mutations in receptors for the cytokine transforming growth factor-receptor type 1 (TGFB-R1) or 2 gene (TGFB-R2) on the cell surface. LDS results in abnormal protein synthesis and dysfunctional connective tissue, which can result in unique cardiovascular anesthesia challenges related to perioperative management. Patients with LDS may manifest hypertelorism, bifid uvula or cleft palate, and arterial tortuosity. Virtually all LDS patients show some type of abnormal skin findings and bleeding tendency. These patients may show a rapid progression of aortic dilation, regurgitation, and a propensity towards rupture and/or dissection at a much earlier age and smaller aneurysm size. LDS patients who require surgical intervention require meticulous vigilance from the anesthesiologist. We describe a 26 year old patient with documented LDS type 1 who presented for repair of an ascending/root aneurysm in this case report. Recognition of LDS and intra-operative management of the cardiovascular manifestations of this disease is paramount in ensuring successful surgical outcome and to limit morbidity and mortality.

Risk factors for human heartworm infections (dirofilariasis) in the South.

Human pulmonary dirofilariasis (HPD) is caused by the transmission of infective third stage larvae of the canine heartworm, Dirofilaria immitis, during blood-feeding by several species of infected mosquitoes. Since humans are incidental hosts and cannot support the parasite's life cycle, infective larvae die after migrating to the pulmonary vascular bed, where an initial subclinical inflammatory reaction is typically followed by a single pulmonary granuloma. The resulting nodular granuloma is described radiographically as a "coin lesion" that resembles a neoplastic lesion, which must be ruled out by invasive lung biopsy. Since HPD cases have been reported mainly from regions with high canine heartworm prevalence, such as the southern United States (US), the objectives of this review were (1) to describe the microbiology of the parasite; (2) to resolve any misconceptions regarding the pathophysiology and outcomes of canine versus human heartworm infections; (3) to describe the prevalence and parasite burden of canine dirofilariasis in the South compared to other areas; (4) to describe the prevalence of HPD in the South; (5) to identify the most important species of mosquito vectors of dirofilariasis based on seroprevalence rates of infection and transmission efficiency; (6) to identify the key risk factors for HPD in the South; and (7) to recommend new strategies for the diagnosis, management, control, and prevention of HPD. Future investigations should focus on targeting specific mosquito species for improved vector control of D. immitis transmission and on developing new immunologic and molecular methods for diagnosing HPD and eliminating the need for invasive diagnostics for differential diagnosis of innocuous, parasitic "coin lesions".

Combined off-pump coronary revascularization: ascending aorta to carotid bypass.

A 76-year-old man with symptomatic cerebral vascular disease and coronary artery disease was treated with simultaneous off-pump bypass and cerebral revascularization. With the emergence of off-pump coronary artery operation as a viable option for coronary revascularization we believe that this procedure will become our method of choice for combined cerebral and coronary artery disease.

Leukocyte-reduced transfusions in cardiac surgery results of an implementation trial.

An implementation trial of leukocyte-reduced transfusions in cardiac surgery (primary coronary artery bypass graft and valve replacement) was performed from July to December 1998; comparisons were made with data from the same period in 1997. Patients from both periods were similar in important preoperative and intraoperative variables (age, sex, weight, number of units of RBCs transfused, ejection fraction). The mean total number of complications was statistically significantly decreasedfrom 0.26 complications per patient in the non-leukocyte-reduced to 0.19 in the leukocyte-reduced recipients. Overall, the mean +/- ISD costs of care per patient decreasedfrom 1997 ($27,615 +/- $33,973) to 1998 ($27,038 +/- $24,107). Mean costs decreased $1,700 per patient for recipients of leukocyte-reduced blood in 1998 compared with recipients of non-leukocyte-reduced blood in 1997 Mean costs increased $4,000 per patient in patients who did not receive transfusions in 1998 compared with 1997. Hospitalization costs decreased when leukocyte-reduced transfusions were implemented for patients undergoing cardiac surgery in our institution. Implementation of leukocyte reduction may be cost neutral or cost saving in at least some settings.