Texas Heart Institute journal
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There is an interest in the use of high thoracic epidural anesthesia in cardiac surgery, because experimental and clinical studies have suggested that central neuroaxial blockade attenuates the response to surgical stress and improves myocardial metabolism and perioperative analgesia-thus enabling earlier extubation and a smoother postoperative course. Matters of major concern in the adoption of high thoracic epidural anesthesia in cardiac surgery are neurologic injury secondary to neuroaxial hematoma and hypotension secondary to sympatholysis. The risk associated with possible neuraxial hematoma caused by high thoracic epidural anesthesia has been thoroughly investigated and largely discounted, but scant attention has been devoted to the onset of hypotensive episodes in the same setting. ⋯ Among the patient variables that we tested in a multivariate logistic-regression model, only female sex was found to be significantly correlated with hypotension. In order to decrease the incidence and severity of hypotensive episodes resulting from anesthetic blockade, anesthesiologists need to monitor, with special care, women patients who are under high thoracic epidural anesthesia. Further studies are needed in order to determine why women undergoing open heart surgery under high thoracic epidural anesthesia are at a relatively greater risk of hypotension.
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The clinical presentation of myocarditis is variable and often mimics myocardial infarction. The diagnosis of acute myocarditis is frequently empiric, and is made on the basis of the clinical presentation, electrocardiographic changes, elevated cardiac enzymes, and lack of epicardial coronary artery disease. ⋯ We present the case of a young woman who presented with chest pain and dramatic anteroseptal ST-segment elevation on electrocardiography. The diagnosis of acute myocarditis was eventually confirmed with use of cardiac magnetic resonance imaging.
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In order to determine the temporal pattern of weaning from mechanical ventilation for patients undergoing prolonged mechanical ventilation after cardiac surgery, we performed a retrospective review of 21 patients' weaning courses at our long-term acute care hospital. Using multiple regression analysis of an estimate of individual patients' percentage of mechanical ventilator support per day (%MVSD), we determined that 14 of 21 patients (67%) showed a statistically significant quadratic or cubic relationship between time and % MVSD. These patients showed little or no improvement in their ventilator dependence until a point in time when, abruptly, they began to make rapid progress (a "wean turning point"), after which they progressed to discontinuation of mechanical ventilation in a relatively short period of time. ⋯ Most patients in the study group weaned from the ventilator through a specific temporal pattern that is newly described herein. Data analysis suggested that the mechanism for the development of a wean turning point was improvement of pulmonary mechanics rather than improvement in gas exchange or respiratory load. Although these observations need to be confirmed by a prospective trial, they may have implications for weaning cardiac surgery patients from prolonged mechanical ventilation, and possibly for weaning a broader group of patients who require prolonged mechanical ventilation.
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We present a case of transient left ventricular outflow tract obstruction after mitral valve replacement with a high-profile bioprosthesis; only the posterior native mitral valve leaflet was preserved. A 76-year-old woman was admitted to our institution with pulmonary edema. Two weeks earlier, she had undergone mitral valve replacement at our hospital due to severe mitral stenosis and 2+ mitral regurgitation complicated by cardiac failure and atrial fibrillation. ⋯ Doppler echocardiography revealed a peak 64-mmHg gradient between the septum and the strut of the bioprosthesis. The patient was successfully treated medically. This case indicates that the risk of left ventricular outflow tract obstruction after bioprosthetic mitral valve replacement is not always eliminated by removal of the anterior mitral valve leaflet when the posterior mitral leaflet is preserved.
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Case Reports
Successful surgical treatment of massive pulmonary embolism after coronary bypass surgery.
Acute massive pulmonary embolism after cardiac surgery is very rare. Although accurate diagnosis and rapid treatment are crucial to a successful outcome, there is no standard treatment option. ⋯ Open pulmonary embolectomy may be the best choice for treating these patients. This report describes our use of emergency pulmonary embolectomy along with cardiopulmonary bypass as an effective therapeutic approach in 2 cases of massive pulmonary embolism that occurred after on-pump coronary artery bypass grafting.