The Beneficial Effect of Renin-Angiotensin-Aldosterone System Blockade in Marfan Syndrome Patients after Aortic Root Replacement

PURPOSE: In this study, we evaluated the long term beneficial effect of Renin-Angiotensin-Aldosterone System (RAAS) blockade therapy in treatment of Marfan aortopathy. MATERIALS AND METHODS: We reviewed Marfan syndrome (MFS) patients who underwent aortic root replacement (ARR) between January 1996 and January 2011. All patients were prescribed beta-blockers indefinitely. We compared major aortic events including mortality, aortic dissection, and reoperation in patients without RAAS blockade (group 1, n=27) to those with (group 2, n=63). The aortic growth rate was calculated by dividing the diameter change on CT scans taken immediately post-operatively and the latest scan available. RESULTS: There were no differences in clinical parameters except for age which was higher in patients with RAAS blockade. In group 1, 2 (7%) deaths, 5 (19%) aortic dissections, and 7 (26%) reoperations occurred. In group 2, 3 (5%) deaths, 2 (3%) aortic dissections, and 3 (5%) reoperations occurred. A Kaplan-Meier plot demonstrated improved survival free from major aortic events in group 2. On multivariate Cox, RAAS blockade was an independent negative predictor of major aortic events (hazard ratio 0.38, 95% confidence interval 0.30-0.43, p=0.002). Mean diameter change in descending thoracic and supra-renal abdominal aorta was significantly higher in patients without RAAS blockade (p<0.05). CONCLUSION: In MFS patients who underwent ARR, the addition of RAAS blockade to beta-blocker was associated with reduction of aortic dilatation and clinical events.

Transcatheter Aortic Valve Implantation in a Patient with Previous Mitral Valve Replacement

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or are unsuitable candidates for open heart surgery. However, concerns exist over treating patients who have previously undergone mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement who was successfully treated with TAVI using a CoreValve.

Successful Treatment of Severe Aortic Stenosis With Transcatheter Aortic Valve Implantation in a Centenarian Patient

Transcatheter aortic valve implantation (TAVI) is a less invasive procedure to treat severe aortic valve stenosis than conventional surgical aortic valve replacement. Furthermore, TAVI has shown similar clinical outcomes as surgical treatment with less mortality and morbidities in elderly patients at high risk for conventional surgery. In this report, we describe case of successful TAVI using a CoreValve in a 103-year-old patient with symptomatic severe aortic valve stenosis.

Transcatheter Aortic Valve Implantation by Transfemoral Approach in a Patient with Bilateral Iliac Artery Disease / 대한내과학회지

Transcatheter aortic valve implantation (TAVI) is an alternative treatment modality for surgical aortic valve replacement in patients at high surgical risk. Transfemoral access is not feasible in many cases with unfavorable iliofemoral anatomy or severe peripheral arterial disease (PAD). Elderly patients with severe aortic valve stenosis have a higher prevalence of PAD due to atherosclerotic degenerative changes in the large and small vessels. Transsubclavian, transapical, and direct access to the ascending aorta by thoracotomy are alternative routes for the TAVI procedure. In this case, we describe a patient with a previous coronary artery bypass graft and bilateral iliac artery stenosis who successfully underwent TAVI using a CoreValve(R) by transfemoral approach after balloon angioplasty of iliac artery stenosis.

Transcatheter Aortic Valve Implantation Using CoreValve by Transaortic Approach

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is now considered as an alternative treatment option for severe aortic stenosis (AS) patients who cannot undergo surgical aortic valve replacement (AVR). CASE REPORT: We describe the first Korean case of transaortic TAVI with mini-sternotomy using CoreValve. A 83-year-old woman with severe AS and recent history of non-ST elevation myocardial infarction was referred to our institution for TAVI intervention. There was no amenable peripheral vascular access for transfemoral or trans-subclavian approach. Considering the relatively high procedural risk of transapical approach in this patient, we performed transaortic TAVI with mini-sternotomy. CONCLUSION: The present case suggests transaortic approach may be an effective and safe strategy for TAVI in high risk severe AS patients without eligible femoral or subclavian access routes.

The First Case of Successful Transcatheter Aortic Valve Implantation Using CoreValve in Korea

Surgical replacement of the aortic valve is the standard therapy for severe aortic valve stenosis. However, it is generally associated with increased mortality and morbidities in older individuals. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure and has shown similar clinical outcomes as surgical treatment in elderly patients at high risk for conventional surgery. In this report, we describe the first case of TAVI using a CoreValve in Korea. An 84-year-old man with symptomatic severe aortic valve stenosis was successfully treated by transfemoral TAVI. The patient was discharged without any significant complications and remained free of adverse clinical event for a follow-up duration of 6 months.

The First Korean Patient With Severe Aortic Stenosis and Bilateral Iliofemoral Artery Disease Treated With Transcatheter Aortic Valve Implantation by Transsubclavian Approach

Transcatheter aortic valve implantation (TAVI) is indicated as an alternative treatment modality to surgical aortic valve replacement for high risk patients. The standard retrograde approach through the femoral artery is not feasible in the case of unfavorable iliofemoral anatomy or severe peripheral arterial disease (PAD). However, patients with aortic stenosis (AS) have a higher prevalence of for PAD because both diseases are consequences of atherosclerotic degenerative changes. Transsubclavian, transapical, and direct access to the ascending aorta by thoracotomy are alternative routes for the TAVI procedure. In this report, we present the first Korean patient with symptomatic severe AS and bilateral iliofemoral artery disease who was successfully treated with TAVI using a CoreValve (Medtronic, Minneapolis, MN, USA) by transsubclavian approach.

Effects of Fentanyl on Relaxation in Smooth Muscle of the Rat Aorta / 대한마취과학회지

The mechanism of vasodilation induced by fentanyl was investigated using isolated rat thoracic aortic rings. Rings were contracted with norepinephrine(10(-7) M, NE) and potassium chloride(40 mM, KC1) with and without endothelium Fentanyl (10(-9)-10(-5) M) produced dose-dependent relaxation and had no significant effect from endothelium(intact and denuded rings, test with 3X10(-4) M LNAME, N-nitro-L-arginine methyl ester). Pretreatment of indomethacin(2.5X10(-3) M, inhibitor of cyclooxygenase) failed to influence of cumulative dose-response curves. RD(50)(50% relaxation dose) and KC1/NE ratio as potency difference of fentanyl, verapamil(10(-8)-10(-5) M, Ca2+ channel blocker), nitroglycerin(10(-10)-10(-5) M, activator of guanylate cyclase) were not similar. Fentanyl and control(distilled water) were not demonstrated any different contraction produced by incremental addition of Ca2+ to aortic rings exposed to Ca2+ free, K+ -depolarized(100 mM KCl) solution(extracellular Ca2+ influx). But fentanyl had effect on intracellular Ca2+ release elicited by caffeine(20 mM) and NE(10(-7) M) indicated by dose-dependent inhibition of contraction in Ca2+ free solution. We conclude that, in rat aorta, fentanyl-induced relaxation is endothelium-independent but mediated by inhibition of alpha-adrenoceptors operated intracellular Ca2+ release (inhibition of contraction by NE) and caffeine-induced Ca2+ release from store.

Single Caudal Anesthesia for Total Hip Replacement in Geriatric Patients / 대한마취과학회지

Caudal anesthesia for total hip replacement in geriatric patients has been evaluated clinically. The caudal epidural puncture was performed by a 22 G short needle through sacral hiatus with a lateral decubitus position. 1.5% lidocaine 20 mL and 0.5% bupivacaine 15 mL mixed with 1:200,000 epinephrine and 2 mg morphine was used as an anesthetics. The results were follows ; 1) The onset of caudal anesthesia was 7.9+/-4.5 min (2-20 min) and the duration was 4.8+/-3.0 hrs (1-12 hrs). 2) Anesthetic sensory level was not related with the patient's weight or height. 3) The failure rate including systemic toxicity was 13%. 4) The most common complication was hypotension and its incidence was 26.6%. 5) Time to first analgesics was 8.3+/-3.6 hrs. These results indicate that caudal anesthesia in lateral decubitus position is a recommendable anesthetic technique for total hip replacement in geriatric patients. However, the further studies for the determinations of the optimum dose of local anesthetics are needed.

The Effects of Cholestasis and Hepatic Failure on Vecuronium - induced Neuromuscular Blockade in the Cat / 대한마취과학회지

To determine th effects of experimental extrahepatic cholestasis in the pharmacodynamics of vecumnium, the author administered vecuronium 500 ug/kg intravenously to six normal cats(control group), and into each of six cats with hepatic failure (hepatic failure group) and cholestasis (cholestasis group). The hepatic failure was induced with galactosamine hydrochloride and the cholestasis with the ligation of the common bile duct and cystic duct, 16 hours and 8 days prior to the neuromuscular study, respectively. The force of the anterior tibialis muscle in response to supramaximal common peroneal nerve stimulations were recorded. The time intervals from vecuronium administration to attain 100% twitch depression (onset time), from vecumnium administration to recovery of 25% twitch tension (duration) and from 25% to 75% twitch recovery (recovery index) were compared among the three groups. The results are as follows: 1) There were no significant differences between the groups with respect to rectal temperature, heart rate and mean arterial pressure immediately before vecuronium administration. 2) According to the differences of base excesses, the pH of arterial blood was significantly lower in the hepatic failure and cholestasis groups than in the control groups. 3) After induction of the hepatic failure and cholestasis group, SGOT, SGPT and prothrombin time were significantly increased when compared to the preinduction data in the two groups and data from the control group. Total bilirubin, BUN and creatinine concentration after cholestasis was significantly higher than those of the control group and the hepatic failure group. 4) The onset time in the hepatic failure and cholestasis group was slightly prolonged as compared with that in the control group. However, there was no statistical significance. The duration was significantly longer in hepatic failure and cholestasis than in the control group, and also the recovery index was significantly increased in the hepatic failure and cholestasis groups, as compared with the control group, There were no significant differences between the hepatic failure and cholestasis groups. These vesults indicate that experimental extrahepatic cholestasis induced by complete obstruction of biliary tract prolongs the duration and recovery index of vecuronium, and the effects may be caused by the impairment of direct biliary excretion, hepatic dysfunction and renal impairment.

Optimum Concentration of Lidocaine in Pediatric Caudal Anesthesia for Inguinal Herniorraphy / 대한마취과학회지

To determine the best concentration of lidocaine for caudal anesthesia under supplementary general inhalation anesthesia via faee mask, 85 children aged 1 month to 12 years scheduled for inpatients or outpatients inguinal herniorraphy were randomiaed to receive caudal anesthesia with lidocaine in one of four concentrations(0.5, 0.75, 1.0 or 1.5%) mixing l: 200,000 epinephrine. After incision, gradual reduction in inspired halothane resulted, if tolerated by subject, in an inspired concentration of 0.5% at 10 minutes after incision. Percents of patients who received more than 0.5% of endtidal halothane concentration at hernia sac ligation were 30.0, 28.6, 16.7 and 20.0% in the subjeets receiving 0.5, 0.75, 1.0 and 1.5% lidocaine, respectively. There was no significant differences among groups in pain/discomfort scores and caudal effectiveness scores. A subject receiving 1.5 % lidocaine complained of leg weakness and another of retching. About ninety percents of all subjects could gain the analgesic levels at T dermatome although most of subjects receiving 0.5% lidocaine had the short duration less than 1 hour. Postoperative analgesic effects in the subjects receiving 1.0% lidocaine were superior to those receiving 0.5 and 0.75% solution. Although all concentrations were effective for combined general-caudal anesthesia in children, we conclude that 1.0% lidocaine offers the best combination of effectiveness, postoperative analgesia, adequate anesthetic levels and less complication for pediatric inguinal herniorraphy.