Multiplane transoephageal echocardiography [TEE] advantages in assessment of prosthetic mitral and aortic valves intraoperatively [IOTEE], early and late after open surgical replacement follow up of complications

Two-dimensional echocardiography can identify gross [cardiosurgeon] structural abnormalities of a prosthesis, such as dehiscence, vegetation, thrombus, or degeneration of a tissue prosthesis, but its sensitivity for cardiac prosthetic dysfunction is hampered by the difficulty with visualizing structures around and behind the cardiac prosthesis. TEE has become an integral part of cardiovascular surgery for identifying a previously unrecognized abnormality that may affect the surgical procedure or the patient's Outcome and for assessing the result of the operation [1, 3]. lntraoperative transesophageal echocardiography [IOTEE] has become a routine addition to most cardiac operations [12-21]. Although epicardial scanning is still used in a few specific situations[12], IOTEE has become the more commonly used method for visualizing cardiac structures in the operating room. Adults and adolescence undergoing mitral or aortic valve replacement or both were subjected to IOTEE, early or late TEE after surgery to clearly assess the prosthetic valve function and detect complications. Randomized study in 25 cases 13 females and 12 males with mean age 31 years youngest 19 years old and eldest 41 years old, referred to the National Heart Institute for surgical replacement of the mitral or aortic valve or both. Patients with resistant heart tailure were excluded from the study. 6 patients had atrial fibrillation. All patients were excluded from rheumatic activity or infective endocarditis. Transthoracic echocardiography was used to assess the mitral and aortic valves by apical 4 chamber, apical 2 chamber, parasternal and subcostal views, and blood flow by Doppler. Transoephageal echocardiography was done before surgery in all patients to further assess the valves [valve stenosis and valve regurge], absence of thrombi or vegetations. IOTEE was done during surgery and prosthetic valve was assessed for valve opening and valve closure, paravalvular leak. TEE [early 6 weeks and late 6 months] is useful in the evaluation of dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. Intra-operatively the prosthetic valve is considered successful with good opening and closure and absence of paravalvular leak. Early after surgery [6 weeks], success was considered if there is no or minute paravalvular leak and no thrombi, vegetations, valvular leak or obstruction. Late after surgery [6 months] success considered no or minute paravalvulaj leak and no thrombi, vegetations, valvular leak or obstruction beside we searched for dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve, All patients have done IOTEE and no complications were detected during surgery namely valvular or paravalvular leak and prosthetic valve obstruction. After 6 weeks, 3/25 significant paravalvular leak, 2/25 fresh thrombus, 0/25 vegetations, 0/25 valvular leak, and 0/25 prosthetic valvular obstruction. Late after surgery [6 months], 5/25 significant paravalvular leak, 2/25 fresh thrombus, 1/25 vegetations, 1/25 valvular leak, and 4/25 prosthetic valvular obstruction, 3/25 valve dehiscence, 0/25 abscess, and 2/25 intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. All results were statistically non significant p>0.001, however, all complications must be considered and correlated to medical treatment especially anticoagulation. Multiplane TEE remains the gold standard in proving efficacy of prosthetic valve function and detection of complications both intraoperatively [IOTEE], early and late alter surgery. All complications may be related to anticoagulation

Comparison between preconditioning of the myocardium by sevoflurane and propofol in coronary artery surgeries

The brief period of ischemia appear to precondition the myocardium against the reversible and irreversible tissue injury, including stunning, infarction and development of malignant arrhythmias. On the other hand, exposures of myocardium to volatile anesthetics induce similar cardioprotective effect against ischemia activating the same mediators and receptors of ischemic preconditioning [ICP], enhance and augment ICR Anesthetic preconditioning [APC] is a well documented phenomenon with effective cardioprotection against ischemia in experimental studies applied on different animal species, also on isolated human myocardium independent of improvement in oxygen demand -supply ratio. Recurrently, APC was reported with few clinical studies using different parameters to evaluate the preconditioning or the cardioprotective effect. The aim of the work is to evaluate the cardioprotective effect [APC] of sevoflurane against ischemia induced by aortic crossclamping in comparison to propofol in coronary artery bypass graft surgeries. This study was conducted on 38 patients admitted to National Heart Institute undergoing elective coronary artery bypass graft surgeries [CABG]. Patients were randomly equally allocated to one of two groups [19/ group]: Sevoflurane G [G1] and Propofol G [G2]. There was no statistical significant difference between both groups regarding demographic data [age, sex height, BSA], preoperative medications, diseases or echo findings, time of CPB time and aortic crossclamping or number of coronary grafts. There was no statistical significant difference between both groups regarding: HR. MPA, SVRI or CVP. There was no statistical significant difference between both groups regarding ventricular fibrillation or ECG ischemic changes. Post bypass-CI in G1 [2.6 +/- 0.3 L/min/ m[2]] was statistically significantly higher in G2 [2.1 +/- 0.1 L/min /m[2]]. There was high statistical significant difference between both groups, P-Value= [0.0009] < [0.001]. Average of adrenaline support in G1 was [75 +/- 25 ng/kg/min] and in G2 was [150 +/- 50 ng/kg/min] with high statistical significant difference between both groups, P-Value= [0.0001] < [0.001]. Number of patients who received adrenaline in G1 was equal 8 [42%] while in G2 was 13 [68%] with statistical significant difference between both groups, P-Value = [0.0128] < [0.5]. Exposure of the myocardium to sevoflurane [anesthetic preconditioning] before aortic cross clamping induce significant reduction in myocardial damage and dysfunction in comparison to the propofol during coronary artery bypass graft surgeries using the cardiopulmonary bypass. Giving the upper hand of volatile anesthetics in the CABG surgeries and minimizing the use of intravenous anesthetics