RESUMO
OBJECTIVE: To investigate whether prophylactic amiodarone infusion prevents ventricular fibrillation after aortic cross-clamp release and attenuates cytokine production in patients with left ventricular hypertrophy undergoing cardiac surgery. DESIGN: Prospective, randomized controlled trial. SETTING: A public hospital. PARTICIPANTS: The study comprised 68 patients undergoing aortic valve replacement for severe aortic stenosis. INTERVENTIONS: Patients were randomly assigned to receive a 150mg bolus then 30mg/h continuous infusion of amiodarone (amiodarone group) or a 1 mg/kg bolus then 1 mg/kg/h continuous infusion of lidocaine (lidocaine group). The primary outcome was the ventricular fibrillation incidence rate after aortic cross-clamp release. Secondary outcomes included perioperative serum interleukin-6 and tumor necrosis factor-alpha levels. MEASUREMENTS AND MAIN RESULTS: The ventricular fibrillation incidence rate was significantly lower in the amiodarone than in the lidocaine group (20.6% v 50%, relative risk 0.41; 95% confidence interval [CI] 0.20-0.86; pâ¯=â¯0.021). Interleukin-6 levels 1hour after aortic cross-clamp release and at intensive care unit admission were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 117.4pg/mL [87.1-158.4] v 339.5pg/mL [210.6-547.2]; p < 0.01 and 211.1pg/mL [162.8-73.6] v 434.1pg/mL [293.7-641.5]; p < 0.01, respectively). Tumor necrosis factor-alpha levels 1hour after aortic cross-clamp release were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 1.624pg/mL [1.359-1.940] v 2.283pg/mL [1.910-2.731]; pâ¯=â¯0.02). CONCLUSIONS: Amiodarone prevented reperfusion ventricular fibrillation in patients with left ventricular hypertrophy undergoing aortic valve replacement to a greater extent than did lidocaine. Furthermore, amiodarone inhibited postoperative interleukin-6 and tumor necrosis factor-alpha production.
Assuntos
Amiodarona/administração & dosagem , Antiarrítmicos/administração & dosagem , Estenose da Valva Aórtica/terapia , Implante de Prótese de Valva Cardíaca/tendências , Hipertrofia Ventricular Esquerda/terapia , Reperfusão Miocárdica/métodos , Fibrilação Ventricular/terapia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/fisiopatologia , Método Duplo-Cego , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Hipertrofia Ventricular Esquerda/fisiopatologia , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Reperfusão Miocárdica/tendências , Profilaxia Pós-Exposição/métodos , Profilaxia Pós-Exposição/tendências , Estudos Prospectivos , Resultado do Tratamento , Fibrilação Ventricular/fisiopatologiaRESUMO
OBJECTIVES: To clarify the relationship between right and left ventricular (RV and LV) diastolic function and postoperative atrial fibrillation (POAF). The early effects of major lung surgery on cardiac function in the intraoperative period during lung surgery were evaluated, using transesophageal echocardiography. DESIGN: Single-center prospective observational study. SETTING: A public hospital. PARTICIPANTS: Patients undergoing elective lobectomy with lymph node dissection for lung cancer (n = 116). INTERVENTIONS: Transesophageal echocardiography examination was performed under general anesthesia before skin incision (preoperative) and after chest closure (postoperative). According to measured echocardiographic variables, ventricular systolic and diastolic functions were classified at each time point. MEASUREMENTS AND MAIN RESULTS: Of the 116 patients, 24 (20.7%) experienced POAF. Preoperative RV and LV diastolic dysfunction were more common in patients with POAF than in those without POAF (58.3 v 28.3%, p = 0.008; 54.2 v 19.6%, p = 0.001, respectively). Among patients without preoperative diastolic dysfunction, a small number developed RV and LV diastolic dysfunction immediately after surgery (9.2% and 16.5%, respectively) and these distributions were comparable between patients with POAF and those without POAF. RV systolic dysfunction was observed in 6.5% of patients immediately after surgery and was not related to the occurrence of POAF. Multivariate analysis revealed older age, chronic obstructive pulmonary disease (COPD), and preoperative biventricular diastolic dysfunction as risk factors for POAF. CONCLUSIONS: Preoperative biventricular diastolic dysfunction, as well as older age and COPD, are associated with POAF in patients undergoing lobectomy. Major lung surgery has minimal early effects on postoperative systolic and diastolic functions.
Assuntos
Fibrilação Atrial/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Pulmonares/efeitos adversos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Direita/diagnóstico por imagem , Idoso , Fibrilação Atrial/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/cirurgia , Disfunção Ventricular Direita/epidemiologia , Disfunção Ventricular Direita/cirurgiaRESUMO
An 84-year-old woman with pulmonary hypertension (PH) secondary to chronic pulmonary thromboembolism suffered from continuous warfarin dependent bleeding from sigmoid colon cancer. Sigmoidectomy was scheduled to control continuous bleeding. Six hours after discontinuation of anticoagulant therapy for elective sigmoidectomy, the patient showed hypoxia, pulmonary thromboembolism and pulmonary hypertension with right ventricular systolic pressure (RVSP) of 81 mmHg. The operation was postponed and heparin was infused. Since two-day heparinization therapy did not improve PH, oral administration of sildenafil citrate 60 mg daily was initiated. Seven days after initiation of sildenafil administration, RVSP decreased to 49 mmHg without improvement of hypoxia. Sigmoidectomy was performed under general anesthesia. The patient showed severe hypotension managed with noradrenaline and dopamine infusion during and after surgery, resulting from interaction between sildenafil and vasodilators. The patient was discharged 36 days after the operation without complications.
Assuntos
Colo Sigmoide/cirurgia , Hipertensão Pulmonar/complicações , Piperazinas/uso terapêutico , Embolia Pulmonar/complicações , Sulfonas/uso terapêutico , Vasodilatadores/uso terapêutico , Idoso de 80 Anos ou mais , Feminino , Humanos , Assistência Perioperatória , Purinas/uso terapêutico , Citrato de SildenafilaAssuntos
Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Cardiopatias Congênitas/diagnóstico por imagem , Hemodinâmica , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Músculos Papilares/diagnóstico por imagem , Função Ventricular Esquerda , Idoso , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/fisiopatologia , Implante de Prótese de Valva Cardíaca , Humanos , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Masculino , Valva Mitral/anormalidades , Valva Mitral/fisiopatologia , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/cirurgia , Músculos Papilares/anormalidades , Músculos Papilares/fisiopatologia , Valor Preditivo dos TestesRESUMO
A 66-year-old man with a history of longtime smoking, untreated hypertension, hyperlipidemia, and impaired glucose tolerance but no history of myocardial infarction or angina pectoris was scheduled for right aortofemoral bypass and thromboembolectomy for arteriosclerosis obliterans with right common iliac and right popliteal arterial thrombus. Epidural anesthesia and general anesthesia were administered without obvious ECG changes. Just after skin incision, ST elevation in leads II and V5 and a short run of ventricular tachycardia with frequent premature ventricular contractions (PVCs) were recorded on the ECG monitor, and the patient's blood pressure suddenly decreased within a few seconds. On noticing these changes, we suspected coronary artery spasm (CAS) and rapidly administered vasodilators and vasopressors to stabilize hemodynamics and ECG changes. Transesophageal echocardiography (TEE) showed basal to mid- and anteroseptal to inferior wall motion hypokinesis that gradually returned to normal during observation. Even in patients without coronary disease but with systemic arteriosclerosis, it is important to consider the possibility of perioperative CAS and not to overlook ECG changes. Immediate diagnosis and treatment are essential.
Assuntos
Arteriosclerose Obliterante/complicações , Arteriosclerose Obliterante/cirurgia , Vasoespasmo Coronário/terapia , Complicações Intraoperatórias/terapia , Idoso , Anestesia Epidural , Angiografia Coronária , Vasoespasmo Coronário/etiologia , Ecocardiografia Transesofagiana , Eletrocardiografia , Humanos , Masculino , Monitorização Intraoperatória , Isquemia Miocárdica/prevenção & controle , Vasoconstritores/uso terapêutico , Vasodilatadores/uso terapêuticoRESUMO
A 77-year-old patient suffering from a giant right coronary artery aneurysm with coronary arteriovenous fistula was admitted to our hospital. The fistula could not be documented preoperatively by computed tomography or coronary angiography but was documented intraoperatively by transesophageal echocardiography (TEE). However, TEE was unable to visualize the draining site of the fistula. Direct palpation by the surgeon ultimately confirmed that the fistula was draining into the coronary sinus. The fistula was closed and the volume of the aneurysm reduced by partial resection. The postoperative course of the patient was uneventful. Giant aneurysms occasionally displace cardiac structures. In such cases, combined imaging technologies, including TEE, may be needed for precise assessment of the giant aneurysm and fistula.
Assuntos
Fístula Arteriovenosa/diagnóstico por imagem , Aneurisma Coronário/diagnóstico por imagem , Seio Coronário/diagnóstico por imagem , Idoso , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/cirurgia , Aneurisma Coronário/diagnóstico , Aneurisma Coronário/cirurgia , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Seio Coronário/cirurgia , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Cuidados Pós-Operatórios/métodos , Tomografia Computadorizada por Raios X/métodosAssuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Cardiopatias Congênitas/diagnóstico por imagem , Insuficiência da Valva Tricúspide/congênito , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/anormalidades , Valva Tricúspide/diagnóstico por imagem , Idoso , Valvuloplastia com Balão , Anuloplastia da Valva Cardíaca , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca , Hemodinâmica , Humanos , Masculino , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Resultado do Tratamento , Valva Tricúspide/fisiopatologia , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
Gastric bleeding during cardiopulmonary bypass (CPB) is a rare but life-threatening complication for patients undergoing cardiac surgery. We present a case of a patient undergoing coronary bypass grafting in whom we detected gastric bleeding by transesophageal echocardiography (TEE) during CPB. After separation from CPB, bleeding was stopped by endoscopic clipping of the mucosa. If a fluid deficit is noted and TEE reveals a hypoechoic space within the stomach, gastric bleeding might be suggested.
Assuntos
Ponte Cardiopulmonar/efeitos adversos , Ecocardiografia Transesofagiana , Hemorragia Gastrointestinal/diagnóstico por imagem , Complicações Intraoperatórias , Gastropatias/diagnóstico por imagem , Idoso , Ponte de Artéria Coronária , Hemorragia Gastrointestinal/patologia , Hemorragia Gastrointestinal/cirurgia , Gastroscopia , Hemostasia Cirúrgica , Humanos , Masculino , Monitorização Intraoperatória , Gastropatias/patologia , Gastropatias/cirurgia , Resultado do TratamentoAssuntos
Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco/métodos , Seio Coronário/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/instrumentação , Seio Coronário/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , UltrassonografiaAssuntos
Aneurisma Aórtico/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Idoso , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Bioprótese , Ecocardiografia , Ecocardiografia Tridimensional , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Monitorização IntraoperatóriaAssuntos
Ecocardiografia Tridimensional/métodos , Ecocardiografia/métodos , Átrios do Coração/patologia , Veia Cava Inferior/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia Transesofagiana/métodos , Veias Hepáticas/patologia , Humanos , Processamento de Imagem Assistida por Computador/métodos , Masculino , Isquemia Miocárdica/patologia , Veias Pulmonares/patologiaRESUMO
BACKGROUND: Changes in heart position are occasionally observed on the transesophageal echocardiography (TEE) image screen after changing the body position from supine to lateral, although the magnitude of change in cardiac position varies individually. We hypothesized that this variation is associated with certain patient characteristics and evaluated how lateral positioning affects visualization of the heart on TEE and whether the magnitude of change in the heart position correlates with patient characteristics. METHODS: Fifty-three lung resection patients were enrolled. Two angle and two length parameters (DqTV , DqAP , DL TV , and DL AP ) were defined to describe location change of the lateral tricuspid annulus and right ventricular apex on the TEE image between supine and lateral position. The correlation coefficients were calculated between these four parameters and patient characteristics, including age, body mass index (BMI), epicardial fat thickness, and pulmonary function variables. RESULTS: The DqTV correlated positively and inversely with BMI in both right and left lateral patients (right: r = 0.6365, P = 0.0034; left: r = -0.6616, P < 0.0001, respectively). In left lateral patients, the DqTV correlated inversely with epicardial fat thickness (r = -0.4879, P = 0.0182), and the DL AP correlated positively with the forced vital capacity percent predicted (r = 0.5736, P = 0.0082). CONCLUSIONS: Lateral body positioning affects cardiac visualization on TEE, and the BMI, epicardial fat thickness, and pulmonary function moderate this effect.
Assuntos
Ecocardiografia Transesofagiana/estatística & dados numéricos , Posicionamento do Paciente/estatística & dados numéricos , Postura , Fatores Etários , Idoso , Índice de Massa Corporal , Feminino , Humanos , Masculino , Estudos Prospectivos , Testes de Função Respiratória/estatística & dados numéricosAssuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Periférico/efeitos adversos , Ecocardiografia Transesofagiana , Implante de Prótese de Valva Cardíaca , Artéria Pulmonar/diagnóstico por imagem , Ultrassonografia de Intervenção , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Ponte Cardiopulmonar , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/instrumentação , Remoção de Dispositivo , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/fisiopatologia , Pressão Propulsora Pulmonar , Índice de Gravidade de Doença , Resultado do TratamentoAssuntos
Transplante de Fígado , Propofol/sangue , Choque Hemorrágico/sangue , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Frequência Cardíaca/efeitos dos fármacos , Frequência Cardíaca/fisiologia , Humanos , Transplante de Fígado/efeitos adversos , Propofol/administração & dosagem , Ligação Proteica/efeitos dos fármacos , Ligação Proteica/fisiologiaRESUMO
PURPOSE: We sought to examine what factors, including cerebrovascular carbon dioxide (CO(2)) reactivity, are related to a decrease in internal jugular venous oxygen saturation (SjvO(2)) during normothermic cardiopulmonary bypass (CPB) in patients with diabetes mellitus. METHODS: Twenty-three diabetic patients scheduled to undergo elective coronary artery bypass grafting were studied. As a control, 27 age-matched control patients without diabetes mellitus were also examined. After the induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to continuously monitor SjvO(2). Arterial and jugular venous blood gases were measured during CPB. The cerebrovascular CO(2) reactivity was measured after the induction of anesthesia and before the start of surgery using a 2.5-MHz pulsed transcranial Doppler probe. RESULTS: The SjvO(2) values in the diabetic group were lower than those in the control group at the initiation of CPB and at 20, 40, and 60 min after the start of CPB. The values for pre- and post-CO(2) reactivity in the control group did not significantly differ (pre-CPB: 4.8% +/- 2.3% mmHg(-1); post-CPB: 5.9% +/- 4.4% mmHg(-1)). In contrast, the values for CO(2) reactivity were lower post CPB than pre-CPB in the diabetic group (Pre-CPB: 6.3% +/- 2.9% mmHg(-1); post-CPB: 4.7% +/- 2.6% mmHg(-1); P < 0.05). In the diabetic group, glycosylated hemoglobin A1c (HbA1c) is considered to be a factor related to a decrease in SjvO(2) during CPB. CONCLUSIONS: Cerebrovascular CO(2) reactivity in diabetic patients decreased after the cessation of CPB but not in the control patients. In addition, HbA1c is also thought to be a factor related to a decrease in SjvO(2) in diabetic patients.