Intracardiac air clearing in valvular surgery guided by transesophageal echocardiography.

BACKGROUND AND AIMS OF THE STUDY: Air embolism during open heart surgery seems to be a common occurrence and may be responsible for neuropsychological deficit or myocardial damage. MATERIAL AND METHODS: Forty-two consecutive patients undergoing valvular surgery were studied using the long axis view of the heart by two dimensional transesophageal echocardiography (TEE). The patients were randomized into two groups of 21 each. In group 1, the routine air evacuation method was used. In group 2, the same air evacuation method was used and controlled with a Doppler ultrasonic probe adjusted around the root of the aorta. At the end of air evacuation, intracardiac microbubbles and retained air were analyzed with TEE and when air was founded, its location was communicated to the surgeons who tried to remove it by shaking the heart and tilting the operating table for 15 minutes. The patients were assessed for detection of cardiac or neurological postoperative complications. RESULTS: The incidences of microbubbles and retained air were 57% and 43% in group 1, and 62% and 38% in group 2 respectively (ns). The mean grade of microbubbles was lower in group 2: 1.4 +/- 0.8 vs. 2.2 +/- 0.9, p < 0.05. TEE allowed to significantly decrease (p < 0.05) retained air and mean grade of microbubbles to 14% and 1.3 +/- 0.8 in group 1, and to 10% and 0.8 +/- 0.8 in group 2, without statistical difference between the two groups. Despite the help of TEE, manual attempts to eradicate retained air were unsuccessful in five patients (three in group 1, two in group 2). CONCLUSIONS: The use of aortic ultrasonic probe allowed to reduce the amount of microbubbles. TEE was a useful tool not only for the detection of retained air but also for locating it, and guiding the procedure to eliminate it.

[Anaesthesia and intensive care for cardiac surgery in France: results of the three days national survey realised in 2001 by the club of Anaesthesia, Intensive Care and Technics in Cardiac Surgery (ARTECC)]. / L'anesthésie en chirurgie cardiaque adulte en France en 2001: résultats de l'enquête nationale de trois jours du club Anesthésie-Réanimation-Techniques en Chirurgie Cardiaque (ARTECC).

OBJECTIVES: Ageing of the surgical population and the evolution in anaesthetic techniques have led the Club d'anesthésie-réanimation et techniques en chirurgie cardiaque (ARTECC) to conduct a survey among French cardiac surgery centers. The aim was to profile patient population undergoing cardiac surgery and perioperative techniques employed. STUDY: National prospective study including all adult patients undergoing cardiac surgery on January 23rd, 24th and 25th, 2001. Data were collected during the first 48 postoperative hours. MATERIAL AND METHODS: Seven referent centers drafted a record form. Sixty-one centers sent back 425 patient forms, 399 were analyzed. The following were statistically studied: type of surgery, patient characteristics, preoperative treatment, monitoring, anaesthesia, cardio-pulmonary bypass (CPB) characteristics, duration of mechanical ventilation, length of stay in intensive care unit, postoperative complications. RESULTS: Patient mean age was 64.3 +/- 13.3 years. Patients over 80-year-old represented 2.5% of the population. Beating heart coronary aortic bypass grafts (13% surgery) and preoperative transoesophagal echography were not frequent. Propofol and sufentanil were the main anaesthetic agents used. There was a marked trend for fast-track procedures. CONCLUSIONS: The ARTECC study pointed out some reserve in practices and that the impact of new techniques seems limited. Regular use of studies of that kind will provide an effective tool to compare national practices.

[Role of urapidil in the treatment of acute hypertension]. / Place de l'urapidil dans le traitement de l'hypertension artérielle aiguë.

Urapidil is a vasodilator acting on peripheral vessels by alpha-1 adrenoceptor blockade, and on central nervous system by alphaadrenoceptor blockade on the tractus solitarius nuclei and stimulation of serotoninergic receptors. Its hepatic metabolism and central action explain the absence of rebound effect when treatment is stopped. Urapidil is an arterial and venous vasodilator in systemic and pulmonary circulation. Therefore urapidil decreases systemic and pulmonary arterial pressures and left and right ventricular preload. These effects are accompanied by moderate effects on heart rate, and increased cardiac output in patients with heart failure. Some adverse effects observed with other vasodilators are absent (increased intracranial pressure and intrapulmonary shunt, negative inotropic effect, tachycardia). IV urapidil is used to treat systemic arterial hypertension perioperatively and hypertensive emergencies. Moreover urapidil has been administered to treat pulmonary artery hypertension in chronic pulmonary disease. Its haemodynamic effects seem proportional to the basal activity of alpha-adrenoceptors. Therefore, wide individual variations in active doses are observed from 12.5 to 50 mg as i.v. bolus in adults. Thereafter i.v. continuous administration or oral treatment may be necessary, depending on the cause of hypertension.

[Aberrant left pulmonary artery and tracheal abnormality]. / Artère pulmonaire gauche aberrante et malformation trachéale.

A case of left pulmonary artery sling and tracheobronchial tree malformation is reported in a 3 month-old infant. Acute respiratory presenting symptoms required mechanical ventilatory support. The malformation was suspected because of ventilatory support difficulties. Barium oesophagogram showed an anterior indentation, fiberoptic bronchoscopy and tracheobronchography showed a severe tracheal stenosis from a right bronchus lobaris superior to the carina. This was worsened by the right side compression of trachea end part, due to the abnormal left pulmonary artery as demonstrated by pulmonary angiography. A surgical left artery transposition relieved lateral compression and allowed weaning of ventilatory support. After a 27 month-follow-up, the girl's respiratory status is satisfactory.