Radiofrequency maze ablation for atrial fibrillation in a patient undergoing atrial septal defect repair.

Chronic atrial fibrillation affects over 2.2 million people and is associated with complications including heart failure, stroke, and exercise intolerance. Since drug therapy and cardioversion have been only partially successful in restoring sinus rhythm, surgical procedures were developed for medically refractory atrial fibrillation (1). We report a case of successful left atrial radiofrequency ablation for chronic atrial fibrillation in a patient who had a large secundum atrial septal defect.

Effect of anesthetic management on resource utilization and outcome in carotid endarterectomy patients.

Several well-controlled randomized trials have demonstrated the efficacy of carotid endarterectomy for prevention of stroke in patients with symptomatic, severe (> 70%) internal carotid artery stenosis. This benefit has resulted in a significant increase in the number of carotid endarterectomies performed annually. However, the benefit of carotid endarterectomy depends on low perioperative stroke, death and complication rates. This fact has drawn the attention of third party payers and there is considerable emphasis on further decreasing complications and medical expenditures. Implementations of clinical pathways and preventive strategies to obviate complications that increase length of stay and hospital costs have been critical. Although the incidence of perioperative stroke has decreased considerably over the recent years, cardiac and other systemic complications have remained relatively stable. Even though there is no unequivocal evidence of one anesthesia technique over another, several trials have suggested suggested improved clinical outcomes and economic benefit for carotid endarterectomies performed under regional anesthesia. This article describes a study at West Virginia University to assess the role of anesthetic management upon resource utilization and outcome in patients undergoing carotid endarterectomy.

The neuropathologic effects in rats and neurometabolic effects in humans of large-dose remifentanil.

UNLABELLED: Given in clinically relevant large doses to rats, mu-opioids produce limbic system hypermetabolism and histopathology. This investigation extends these observations, in both rats and humans, for the short-acting drug remifentanil, which allows more precise control and assessment of the effects of duration of opioid exposure. We performed two series of experiments: one in rats for neuropathologic effects and the second in humans for neurometabolic effects. Fifty mechanically ventilated rats received saline solution or remifentanil 20-160 microg x kg(-1) x min(-1) for 3 h, followed by neuropathologic evaluation 7 days later. Four volunteers underwent induction of anesthesia and endotracheal intubation with propofol and rocuronium administration followed by remifentanil infusion at 1-3 microg x kg(-1) x min(-1) with positron emission tomography evaluation of cerebral metabolic rate for glucose. In rats, dose-related electroencephalogram activation was evident and 19 of 40 remifentanil-treated rats showed brain damage, primarily in the limbic system (P < 0.01). In humans, cerebral metabolic rate for glucose in the temporal lobe increased from 6.29 +/- 0.32 to 7.68 +/- 1.05 mg x 100 g(-1) x min(-1) (P < 0.05). These data indicate that prolonged large-dose remifentanil infusion is neurotoxic in rats with congruent metabolic effects with brief infusion in humans and suggest that some adverse effects reported in rats may be clinically relevant. IMPLICATIONS: This study demonstrates dose-related remifentanil neurotoxicity in physiologically controlled rats with congruent brain metabolic effects in four humans undergoing positron emission tomography evaluation during brief large-dose remifentanil anesthesia. These data suggest that some adverse effects reported in rats may be clinically relevant.