Local anaesthesia for endovascular repair of infrarenal aortic aneurysms.

OBJECTIVE: The study aimed to analyse and report the results of a 'local anaesthesia first' approach in elective endovascular aneurysm repair (EVAR) patients. MATERIAL AND METHODS: Between January 2007 and August 2010, a total of 217 continuous patients (187 men, median age 76 years, range 52-94 years) underwent elective EVAR using this approach, with predefined exclusion criteria for local anaesthesia (LA). A retrospective analysis regarding technical feasibility, mortality, complication and endoleak rate was performed. The results are reported as an observational study. RESULTS: LA was applied in 183 patients (84%), regional anaesthesia (RA) in nine patients (4%) and general anaesthesia (GA) in 25 patients (12%). Anaesthetic conversion from LA to GA was necessary in 14 patients (7.6%). Airway obstruction (n = 4) and persistent coughing (n = 3) were the most common causes for conversion to GA. Thirty-day mortality in the LA group was 2.7%, with 16/183 patients (8.7%) experiencing postoperative complications. All type I endoleaks (n = 5, 2.7%) occurred in patients with LA and challenging aneurysm morphologies. CONCLUSIONS: A 'local anaesthesia first' strategy can successfully be applied in 75% of patients undergoing EVAR. The use of LA can impact imaging quality and thus precise endograft placement, which should be considered in patients with challenging aneurysm morphologies.

Maternal age and the duration of the second stage of labor.

The purpose of this study was to investigate the relationship between parity, maternal age at delivery, gestational age, and duration of the second stage of labor. In this article a retrospective analysis of deliveries during the period from 2000 to 2005 in our Institution was made. We recorded 208 pregnant women under the age of 20 years, 6,115 between 20 and 40 years, and 188 over the age of 40 years considering parity, duration of second stage of labor, birth weight, and gestation age. The correlation of the above parameters was statistically analyzed. In primigravidas, under the age of 20 years, the second stage of labor was significantly shorter compared to women aged over 40 years, and significantly shorter compared to women between the age of 20 and 40 years. Gestational age at delivery was significantly shorter in women aged over 40 years compared to those under the age of 20 years as well as to those between 20 and 40 years of age. Age was positively correlated to the duration of the second stage of labor and negatively correlated to the gestation age at delivery. In multigravidas, age was negatively correlated to the gestational age at delivery. In primigravidas, maternal age was positively correlated with the duration of the second stage of labor. On the contrary, gestational age at delivery was negatively correlated with maternal age. In multigravidas, a negative correlation between maternal age and gestational age at delivery was statistically significant.

Simultaneous aortic replacement and renal artery revascularization: the influence of preoperative renal function on early risk and late outcome.

PURPOSE: We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (S(Cr)) and other baseline risk factors. METHODS: A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative S(Cr) was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL). RESULTS: Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P = .019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P = .008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P = .004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P = .005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their S(Cr) appeared to decline with time. CONCLUSION: The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated S(Cr), bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magnitude of the planned surgical procedure and thus enhance the overall outcome.

Four year follow up of aortic valve replacement for isolated aortic stenosis: a link between reduction in pressure overload, regression of left ventricular hypertrophy, and diastolic function.

OBJECTIVE: To evaluate changes in left ventricular function and the impact of ventricular hypertrophy and pressure gradient early and late after aortic valve replacement in patients with isolated aortic stenosis. DESIGN: 41 patients with isolated aortic stenosis and normal systolic function underwent cross sectional and Doppler echocardiography two months before and two weeks and four years after aortic valve replacement. RESULTS: Early after the operation, left ventricular mass index (mean (SD)) decreased from 187 (44) g/m(2) to 179 (46) g/m(2), because of a reduction in end diastolic diameter (p < 0.05). Aortic pressure gradients were reduced, as expected. Isovolumic relaxation time was reduced from 93 (20) ms to 78 (12) ms, and deceleration time from 241 (102) ms to 205 (77) ms (p < 0.05). At four years, left ventricular mass index was further reduced to 135 (30) g/m(2) (p < 0.01) as a result of wall thickness reduction in the interventricular septum (from 14 (1.6) mm to 12 (1.4) mm, p < 0.01) and the posterior wall (from 14 (1.6) mm to 12 (1.3) mm, p < 0.01). Diastolic function, expressed by a reduction in isovolumic relaxation time from 93 (20) ms to 81 (15) ms (p < 0.01) and deceleration time from 241 (102) ms to 226 (96) ms (p < 0.05), remained improved. Prolonged isovolumic relaxation time was associated with significant septal and posterior wall hypertrophy (wall thickness > 13 mm) (p < 0.05), whereas prolonged deceleration time was related to high residual gradient (peak gradient > 30 mm Hg ) (p < 0.01). CONCLUSIONS: Left ventricular diastolic function improves early after surgery for aortic stenosis in parallel with the reduction in the aortic gradient. However, prolongation of Doppler indices of myocardial relaxation and ventricular filling is observed in patients with significant left ventricular hypertrophy and a residual pressure gradient early after surgery. At four years postoperatively, diastolic function remains improved.

Aortic transsection after blunt chest trauma.

We report a case of an 18-year-old female who developed an extensive hemothorax after blunt chest trauma. Transesophageal echocardiography (TEE) showed transsection of the aorta at the level of the isthmus and turbulent flows in several places around the aorta. We discuss the contribution of TEE for detecting traumatic injuries to the thoracic aorta.

Myocardial contusion presented as acute myocardial infarction after chest trauma.

A 46-year-old male patient developed an acute myocardial infarction and congestive heart failure following blunt chest trauma. Electrocardiogram (ECG) revealed acute anterior myocardial infarction. Echocardiography showed akinesis of interventricular septum, dyskinesis in apical anterior wall, and severe impairment of left ventricular overall systolic function. Coronary angiography revealed normal coronary arteries. The patient followed a low-intensity physical medicine rehabilitation program. Follow-up was without new complications or deterioration of congestive heart failure. Five months later the patient presented with fulminant acute pulmonary edema and cardiogenic shock. Cardiopulmonary resuscitation was unsuccessful.

Expression of FAS adjacent to fibrotic foci in the failing human heart is not associated with increased apoptosis.

Fibrosis in the heart may result from loss of myocytes, which are replaced by collagens. Apoptosis is now known to contribute to myocyte loss in the failing human heart. The mechanisms underlying the induction of cardiomyocyte apoptosis, and thus the expansion of fibrotic foci in the failing heart, are poorly understood. We hypothesized that viable heart cells adjacent to fibrotic foci might become "predisposed" to apoptosis by expression of the receptor FAS (APO1, CD95). We therefore studied the spatial relationship of FAS expression and fibrosis in patients with heart failure. Left ventricular biopsies were obtained from seven patients undergoing coronary artery bypass grafting. All patients had reduced ejection fraction but varied in New York Heart Association class score at the time of surgery. Heart cell apoptosis, fibrosis, and FAS expression were studied by propidium iodide and in situ end labeling (ISEL) of DNA, Picrosirius red staining, and immunohistochemistry. All patient samples exhibited, albeit to varying degrees, apoptosis detected by ISEL, chromatin condensation, and nuclear fragmentation. In all samples, fibrosis (collagen) was evident both perivascular and in isolated regions of scarring. Regardless of the extent of fibrosis or detectable apoptosis, FAS expression was observed in regions immediately adjacent to the fibrosis, but not in regions distal to fibrosis, nor in fibrotic areas devoid of nuclei. Expression of FAS was found adjacent to both perivascular and diffuse fibrosis, and ISEL-positive nuclei were found within cells reacting positively with anti-FAS antibodies. However, ISEL-positive nuclei were no more abundant in FAS-positive regions (67.6 +/- 5.8% of total nuclei) than in FAS-negative areas (69.5 +/- 9.8%). We conclude that expression of FAS occurs in remaining heart cells adjacent to fibrosis of either perivascular or presumed reparative origin. Although this phenomenon could contribute to the expansion of fibrotic foci, FAS-induced apoptosis in the failing heart may not be more prevalent than apoptosis initiated by other signaling mechanisms.

Aneurysm of the mitral-aortic intervalvular fibrosa as a rare cause of angina pectoris: angiographic demonstration.

Aneurysms of the mitral-aortic interventricular fibrosa (MAIF) are exceptionally rare complications, commonly following aortic valve endocarditis. This report describes the angiographic findings of such an aneurysm, in a patient who developed an uncommon symptomatology of unstable angina pectoris, caused by the aneurysm's expansion against the coronary arteries. Surgical treatment is also discussed.

Total occlusion of the left main coronary artery with preserved left ventricular function.

Two patients with total occlusion of the left main coronary artery and well preserved left ventricular function are reported. Twenty one similar cases have been reported in the world literature. All the patients had angina pectoris. Twenty one of the 23 patients (including our cases) underwent coronary artery bypass graft surgery while the other two received medical treatment. All are alive for a follow-up period of 0.4-67 months. It is concluded that in patients with chronic total occlusion of the left main coronary artery and well preserved left ventricular function, collateral flow is always extensive but insufficient to prevent angina. Functional status is greatly improved by surgery, although survival is excellent in both treated and non-treated surgically patients.

Significance of persistent left ventricular dysfunction during recovery after dobutamine stress echocardiography.

OBJECTIVES: This study sought to determine the duration of new or worsening left ventricular regional wall motion abnormalities (RWMAs) after dobutamine stress echocardiography (DSE) and their relation to the extent of coronary artery disease (CAD). BACKGROUND: Despite extensive reports on DSE, little is known about the duration of new or worsening RWMAs during recovery. We hypothesized that the persistence of RWMAs during recovery may be associated with the extent of CAD and therefore ischemia. METHODS: Sixty-five consecutive patients with positive results on DSE and angiographically documented CAD were studied. Each patient underwent 12-lead electrocardiography and two-dimensional echocardiography at rest, during dobutamine infusion and continuously during recovery to assess the recovery time of ischemic myocardial regions. RESULTS: All patients had at least one ischemic region during DSE. Complete resolution of RWMAs occurred within 25 min in patients with multivessel CAD, within 20 min in those with two-vessel disease and within 15 min in those with single-vessel disease (p < 0.001). The greater the wall motion score index at peak stress, the longer the duration of RWMAs into the recovery phase (p < 0.01). RWMAs persisted long after normalization of each patient's symptoms, electrocardiographic (ECG) changes, heart rate and rate-pressure product during recovery. CONCLUSIONS: We demonstrated that normalization of left ventricular RWMAs occurs after resolution of symptoms and ECG changes during recovery. The time to recovery is related to the extent of CAD and myocardial ischemia as well as to the presence or absence of collateral circulation. These findings may represent stunned myocardium after brief period of ischemia.

Routine arterial oxygen saturation monitoring is not necessary during transesophageal echocardiography.

BACKGROUND: Transesophageal echocardiography (TEE) is now an established adjunct to routine echocardiography, its diagnostic impact making it an invaluable first-line diagnostic procedure in many cardiac conditions. However, there is no unanimity in the way the transesophageal procedure is carried out, especially with regard to the need for antibiotic prophylaxis, sedation, and the monitoring of oxygen saturation. HYPOTHESIS: This study was prospectively undertaken (1) to determine the presence and magnitude of oxygen desaturation and (2) the changes in heart rate and blood pressure following sedation for routine TEE in an unselected and consecutive group of patients to identify those at high risk. METHODS: Arterial oxygen saturation, heart rate, and systolic, diastolic, and mean blood pressure were monitored in 106 consecutive patients undergoing routine transesophageal echocardiography. Ninety-four (89%) patients received intravenous sedation with midazolam. RESULTS: Three min after midazolam administration there was a drop in oxygen saturation from 97 +/- 2.5 to 95 +/- 2.9 (p < 0.001), in systolic blood pressure from 139 +/- 19.5 to 124.8 +/- 22.2 mmHg (p < 0.001), in diastolic blood pressure from 86.6 +/- 19.9 to 77.5 +/- 17.7 mmHg (p < 0.001), and in mean blood pressure from 108.3 +/- 18 to 95.6 +/- 28.8 mmHg (p < 0.001). After introduction of the transesophageal probe and during the examination, there was a further drop in oxygen saturation with a maximum drop at the 15th min of the examination (93.7 +/- 3.7 vs. 97 +/- 2.5, p < 0.001). The maximum blood pressure drop occurred at the 12th min into recovery: systolic blood pressure dropped from 139 +/- 19.5 to 118 +/- 20.8 mmHg (p < 0.001), diastolic blood pressure from 86.6 +/- 16.9 to 75.8 +/- 17.9 mmHg (p < 0.005), and mean blood pressure from 108.3 +/- 18 to 92.5 +/- 19.4 mmHg (p < 0.01). Patients with congestive heart failure had a greater drop in oxygen saturation compared with patients who were not in heart failure (p < 0.01). Twelve patients did not receive any sedation; however, they all showed a drop in oxygen saturation from 97.8 +/- 2.3 to 94.6 +/- 3.4 (p < 0.001), with a maximum drop at the 15th min during the transesophageal examination. CONCLUSION: In patients with no chronic obstructive airway disease who are not in congestive heart failure, routine oxygen saturation monitoring is not deemed necessary during transesophageal examination. The cause of hypoxemia during the procedure is not only related to sedation but also to esophageal intubation.

Communication between a nongrafted left internal mammary artery and left anterior descending coronary artery following saphenous vein bypass grafting.

A case is described in which a pericardial branch of a nongrafted left internal mammary artery communicated directly with the distal left anterior descending artery, following saphenous vein bypass grafting. This type of collateralization following coronary artery bypass surgery seems to be very rare, and perhaps could protect the myocardium from severe ischemia.

Fifteen year surveillance of echinococcal heart disease from a referral hospital in Greece.

Ten cases of hydatid heart disease were treated over a 15-year period (1980-1995). Cysts were located in the left ventricular wall (four patients), right ventricular wall (one patient), interventricular septum (one patient), interatrial septum (one patient), right atrium (one patient), pericardial cavity (one patient) and in multiple loci (one patient). Apart from two asymptomatic cases, clinical manifestations included chest pain (four patients), anaphylactic shock (one patient), constrictive pericarditis (one patient), congestive heart failure (one patient) and arterial embolism (one patient). Computed tomography was found useful in the detection of hydatid cysts and also in the determination of their morphology. Magnetic resonance was performed in three patients, with satisfactory imaging. Three out of the 10 patients died: rupture of pulmonary echinococcal cyst (one patient), massive pulmonary hydatid embolism (one patient) and rupture of an undiagnosed hydatid cyst of the right atrium during cannulation for cardiopulmonary bypass (one patient). One other patient experienced recurrent systemic embolism and became hemiplegic. Six patients were successfully treated. In five patients, the cysts were excised by open heart surgery, while in one by pericardiectomy. In addition, antiparasitic drugs were successfully used in two patients with long-term satisfactory results. In conclusion, cardiac echinococcosis is associated with an increased risk of potentially lethal complications. Newer techniques of cardiac imaging have helped locate the cysts while surgical removal may offer cure. Some patients responded to specific long-term drug treatment.

Short-term exercise training effect after myocardial infarction on myocardial oxygen consumption indices and ischemic threshold.

This study was undertaken to determine whether adaptations to short-term exercise training after myocardial infarction, could affect the response of heart rate, blood pressure and double product at submaximal workload, and the behavior of electrocardiographic ST segment depression. We studied 60 patients (group A) who underwent a modest level exercise training for 3 months and 40 patients (group B) who did not participate in this program. All these subjects were involved in the trial 1 week after discharge from the hospital. Submaximal treadmill stress test was performed after the 3-month period. The stress test duration was longer (p < .01), heart rate (p < .001), systolic blood pressure (p < .01) and double product (p < .01) at submaximal workload were lower and the onset of ST depression of 1 mm was delayed (p < .01) in group A. In conclusion, postinfarction short-term exercise training increases the exercise tolerance, decreases the heart rate, systolic blood pressure, and double product response to exercise and improves the ischemic threshold.

A new canine model for evaluating blood prosthetic arterial graft interactions.

Various models have been proposed to examine blood-prosthetic materials interactions in terms of the effect of the prosthetic material on platelet structure and function, blood coagulation and fibrinolysis, and tissue infiltrates (cellular or acellular). In addition, these models have been used to examine the change in the graft surface over time. Particular difficulties in examining graft-materials interactions include species differences, short residence time for blood-materials interactions with commonly employed short grafts, and length of study limitations with ex vivo shunts. In this paper we report a canine, carotid-aorta subcutaneous prosthetic graft model. The specific advantages of this model are the length of the graft, which allows prolonged contact of blood with the prosthetic surface; the subcutaneous location of the graft, which allows repeated sampling of blood along the graft; and the healing characteristics of canine grafts. We selected the canine model because the healing characteristics are morphologically similar to those in humans in that endothelialization of the prosthetic surface is limited. Other models, such as the pig, are favored for use when examining blood coagulation, platelet, or fibrinolytic studies; however, these models can fully endothelialize prosthetic surfaces.

Angioscopically directed valvulotomy: a new valvulotome and technique.

Despite a large experience with "blind" retrograde valvulotomy in in situ vein bypass grafting, the incidence of residual competent valves remains high, and valvulotome-induced injury is common. In this study we describe a new valvulotome and technique of angioscopically directed valvulotomy and review the video tape recordings of 85 completion angioscopies of in situ femorodistal bypasses. Fifty-three vein grafts were prepared with the blind retrograde valvulotomy technique and 32 vein grafts with the new valvulotome and angioscopy. The use of the new valvulotome and technique is compared with that of the standard blind retrograde valvulotomy technique, and the normal endoluminal anatomy and incidence of primary disease in saphenous vein grafts was noted. The incidence of valvulotome-induced injury was 5/32 (15.6%) and 45/53 (85%) in vein grafts prepared with angioscopically directed valvulotomy and blind retrograde valvulotomy, respectively. Residual competent valves were found in 10/53 (18.9%) in blind retrograde valvulotomy and 0/25 of angioscopically directed valvulotomy vein grafts (p = 0.0114). In 22/53 vein grafts unsuspected primary disease was detected. Angioscopically directed valvulotomy with the new valvulotome and technique is feasible, reliable, and safe. It avoids residual competent valves, minimizes valvulotome-induced injury, and allows the detection and correction of unappreciated primary vein graft abnormalities. The new valvulotome and technique is a first step in the complete endoluminal preparation of the in situ vein graft.

Popliteal-to-distal bypass grafts for limb salvage in diabetics.

Between January 1984 and August 1989, 117 diabetic patients with a palpable popliteal pulse but distal limb threatening ischaemia underwent 124 popliteal artery (or below) to distal bypass grafts. All grafts were intra-operatively monitored. The operative mortality was 0.8% and the 30 day primary patency 93%. Primary patencies at 1 and 3 years were 88.6 and 85.2%, respectively. The results of using the popliteal artery as the proximal graft inflow site in diabetes are comparable to other patient groups and to alternative more proximal inflow sites, but require a shorter length of vein graft with a shorter vein harvesting incision, avoid groin disection and result in a more peripheral operation.