Fast-track anesthesia with remifentanil and spinal analgesia for cardiac surgery: the effect on pain control and quality of recovery.

OBJECTIVES: To assess pain intensity and quality of postoperative recovery in patients given fast-track anesthesia and spinal analgesia versus patients treated with standard anesthesia. DESIGN: A prospective, randomized, controlled study. SETTING: A private institution. PARTICIPANTS: Eighty-three patients who underwent cardiac surgery with cardiopulmonary bypass were analyzed. INTERVENTIONS: General anesthesia consisted of remifentanil and spinal analgesia (low-dose morphine and clonidine) for the fast-track group (FTG) and sufentanil without spinal analgesia for the control group (CG). During the postoperative period, paracetamol and patient-controlled intravenous analgesia (PCA) with morphine were given. MEASUREMENTS AND MAIN RESULTS: Postoperative pain intensity was evaluated during 48 hours with visual analog scale scores and intravenous morphine consumption. Pain impact on quality of life was assessed with the brief pain inventory (BPI) score (days 1-8), and recovery was evaluated with the quality of recovery score (QoR-40, day 4). Compared with the CG, FTG pain intensity was significantly lower 0 to 4 (p < 0.01) and 6 to 12 hours (p < 0.05) after surgery, as was their cumulative intravenous PCA morphine consumption (p = 0.01). BPI scores supported that FTG patients had significantly (p < 0.01) less "pain at its worst" on days 1 and 2, their BPI-assessed pain interfered significantly less with daily life on day 1 (p < 0.001), and their global QoR-40 score (day 4) was significantly higher (p < 0.05). CONCLUSIONS: Fast-track anesthesia combined with morphine-clonidine spinal analgesia controlled postoperative pain better and obtained a better QoR than conventional analgesia.

Transcatheter valve-in-valve implantation in a degenerated very small Mitroflow prosthesis.

OBJECTIVES: To assess the feasibility and results of 'valve-in-valve' implantation using the 23-mm CoreValve for the treatment of degenerated 19-mm and 21-mm Mitroflow bioprostheses. METHODS: We retrospectively analysed all consecutive patients who underwent transcatheter aortic valve implantation for 19-mm and 21-mm Mitroflow bioprostheses. The height of implantation with respect to the ring of the Mitroflow prosthesis was targeted at -6 mm for the first 3 cases. In the following cases, the target was higher to promote free supra-annular movement of the leaflets. RESULTS: The procedure was successful in 17 of 18 patients (94%). For implantations above the limit of -6 mm, the mean gradient was 10.4 ± 2.6 mmHg compared with 28.1 ± 11.6 mmHg for implantations below the limit of -6 mm (P < 0.01). For patients with severe stenosis as main mechanism of failure of the bioprosthesis, the mean post-procedural gradient was 31.2 ± 11.8 mmHg compared with 12.7 ± 6 mmHg in the absence of severe stenosis (P < 0.01). Patient-prosthesis mismatch (indexed effective orifice area ≤ 0.85 cm2/m2) and severe mismatch (indexed effective orifice area ≤ 0.65 cm2/m2) were present in 83% (15 of 18) and 27% (5 of 18) of patients, respectively. We did not notice any complications following the procedures. Six months after the procedure, functional status was improved in all patients. CONCLUSIONS: Our short series demonstrates the ability to perform transcatheter 'valve-in-valve' implantation in 19-mm and 21-mm Mitroflow prostheses with satisfactory results, but high post-procedural gradients and patient-prosthesis mismatch remain a relatively frequent problem mostly when severe stenosis is the main mechanism of failure. Implantation in a high position is critical to decrease the rate of high postimplantation gradients.

Remifentanil versus propofol for radio frequency treatment of atrial flutter.

PURPOSE: Radio frequency treatment in cardiology generates short acute pain during the heating process. The present study evaluates two techniques used for sedation/analgesia for this procedure. METHODS: Two groups of 20 patients each were studied prospectively. Patients were randomized to receive sedation for the procedure using either a patient-controlled analgesia device with remifentanil (Group R), or a target controlled infusion of propofol (Group P). Patients in Group R had a basal infusion of remifentanil 0.02-0.04 microg x kg(-1) x min(-1) with self administered bolus doses of 0.3 microg x kg(-1) i.v. every minute as required, with a delivery time greater than 30 sec. Patients in Group P had an initial plasma target concentration set at 3-4 microg x mL(-1). RESULTS: Sedation scores were significantly higher in Group P, and two patients required supplementation with remifentanil and insertion of an laryngeal mask airway. Pain scores were higher in Group R, and two patients experienced muscular rigidity, one with transient apnea. Systolic blood pressure decreased significantly in Group P, and at the end of the procedure, PaCO(2) values were higher in that group (P < 0.01). Recovery time was significantly longer in Group P. Patient and physician satisfaction scores were similar in the two groups. CONCLUSIONS: A basal infusion of remifentanil plus remifentanil patient controlled analgesia and target controlled infusion of propofol were adequate but not optimal techniques for sedation/analgesia for radio frequency treatment of atrial flutter.