Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: a prospective study of 203 patients.

OBJECTIVE: To determine the usefulness of systematic intraoperative transesophageal echocardiography in a cardiac surgical unit. DESIGN: Open prospective observational survey. SETTING: University Hospital. PARTICIPANTS: Consecutive adult patients (n = 203) undergoing elective or urgent cardiac operations. MEASUREMENTS AND MAIN RESULTS: Pre-cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Transesophageal echocardiography modified the diagnosis in eight patients (17%) operated on for mitral valvulopathy, in seven patients (15.5%) with aortic valvular disease, in four patients (4.6%) with coronary artery disease, in five patients operated on for thoracic aorta diseases regardless of their localization (18.5%), and in two miscellaneous cases. On the basis of the data obtained from the transesophageal echocardiography carried out at the end of cardiopulmonary bypass, an immediate reintervention was required in five cases (2.5%). CONCLUSIONS: It is concluded that systematic intraoperative transesophageal echocardiography significantly affected decision making in this cardiac surgical unit. Its routine use in all cardiac surgical patients is recommended.

Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases.

BACKGROUND: In patients after lung transplantation, dysfunction of pulmonary venous and artery anastomoses leading to reoperation is described. METHODS AND RESULTS: Pulmonary artery and vein anastomoses were evaluated intraoperatively by monoplane transesophageal echocardiography (TEE) in 18 patients undergoing lung transplantation (nine right, five left single lung transplantations, and four bilateral transplantations). All 13 right pulmonary artery anastomoses and all 22 pulmonary vein anastomoses could be visualized by TEE. None of the nine left pulmonary anastomoses could be visualized. Of the 13 right pulmonary anastomoses, 12 were considered normal, their diameter ranging from 1 to 1.7 cm (mean, 1.26 +/- 0.24 cm). A moderate stenosis of one pulmonary artery anastomosis was identified but did not require reoperation. Of the 22 pulmonary vein anastomoses, 16 were considered normal, their diameter being > 0.5 cm and the peak systolic flow velocity < or = 1 m/s at the location of the anastomoses. In five cases, the anastomoses were not considered normal, but reoperation was not indicated. In one case, a severe stenosis of pulmonary vein associated with graft dysfunction led to an early reoperation. CONCLUSION: Intraoperative TEE during lung transplantation contributes to the immediate evaluation of pulmonary vein and right pulmonary artery anastomoses and allows immediate surgical correction. Further investigations are necessary to establish threshold values requiring reoperation.

Clonidine premedication for coronary artery bypass grafting under high-dose alfentanil anesthesia: intraoperative and postoperative hemodynamic study.

The purpose of this study was to assess the efficacy of clonidine in achieving perioperative hemodynamic stability in patients undergoing coronary artery bypass grafting performed under high-dose alfentanil anesthesia. Twenty-four patients with left ventricular ejection fraction greater than 0.5 were prospectively studied in a double-blind manner; those requiring emergency procedures were excluded. They were randomized to receive either oral clonidine or placebo together with their premedication. Induction of anesthesia was achieved with 10 mg of alfentanil infused over 5 minutes followed by a continuous infusion of 60 mg/h during 1 hour, or until sternotomy, and then 30 mg/h until the end of surgery. Hemodynamic responses to noxious stimuli were treated with additional alfentanil boluses and isoflurane when these were unsuccessful. Intraoperative hemodynamic profile analyses showed a continuous increase in systemic vascular resistance and mean arterial pressure in the clonidine group from the time of skin incision until the onset of bypass, whereas the cardiac output profiles remained similar in the two groups. The number of additional alfentanil boluses was similar. Isoflurane requirements (1/11 v 4/13) were not significantly different, but only a few patients required this therapy. The postbypass hemodynamic profiles were similar. Severe hemodynamic impairment occurred in the clonidine group during warming in the postoperative period: this group showed a drop in systemic vascular resistance index (1276 +/- 347 v 1757 +/- 415 dyn.sec.cm-5.m2) that could not be compensated for by an increase in cardiac output despite normal filling pressures, causing hypotension (66 +/- 10 v 79 +/- 16 mmHg). This hemodynamic status led to greater requirements for vasoactive agents and inotropics in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Etomidate modifies hemodynamic response to fentanyl in patients with impaired left ventricular function]. / L'étomidate modifie la résponse hémodynamique au fentanyl chez des patients à fonction ventriculaire gauche altérée.

The haemodynamic effects and the side-effects of anaesthesia using high doses of fentanyl were compared in two groups of 12 patients each. All the patients had poor left ventricular function and were scheduled for elective coronary artery bypass graft surgery or valvular replacement. Patients were randomly assigned to either group. In group EF, patients were given 5 micrograms.kg-1 of fentanyl, followed by 0.3 mg.kg-1 of etomidate. Once they had lost consciousness, they were given 15 mg of pancuronium and 25 micrograms.kg-1 of fentanyl over a 5 min period. Patients in group F received the full 30 micrograms.kg-1 dose of fentanyl over a 5 min period, followed by 15 mg of pancuronium. The patients were intubated 2 min after the end of the fentanyl infusion. They were mechanically ventilated with 100% oxygen. Anaesthesia was maintained with a continuous infusion of fentanyl (total dose 100 micrograms.kg-1). The usual haemodynamic parameters were monitored and calculated, as well as pain during injection of the drugs, myoclonia, chest wall rigidity and the time to loss of consciousness. The two groups were comparable with respect to age, weight, height and surgery. One third of the patients in group EF complained of pain during etomidate injection. The time required to loose consciousness was shorter in group EF (55 +/- 16 sec) than in group F (177 +/- 56 sec) (p < 0.001). The cardiac index decrease in group EF (2.0 +/- 0.4 l.min-1.m-2 vs. 1.9 +/- 0.4 l.min-1.m-2) (p < 0.05), respectively between the time just before tracheal intubation (T1), and 10 min after tracheal intubation (T3).(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose alfentanil for myocardial revascularization: a hemodynamic and pharmacokinetic study.

It has been suggested that high plasma levels of alfentanil are required in order to control hemodynamic responses to noxious stimuli in patients undergoing myocardial revascularization. The present study was designed to determine the hemodynamic profile in 10 patients and the time course of alfentanil plasma concentrations and pharmacokinetics (7 patients) during and following coronary artery surgery using alfentanil administration based on an overdosage principle. Premedication consisted of lorazepam, 0.07 mg/kg, given 2 hours before surgery. Ten milligrams of alfentanil was given over 5 minutes for anesthesia induction, followed by an infusion of 60 mg/h until sternotomy and 30 mg/h up to skin closure. Additional 5-mg boluses were given prior to noxious intraoperative events. Hemodynamic measurements were performed prior to cardiopulmonary bypass. Blood was sampled simultaneously prebypass and then during the postbypass period for determination of alfentanil plasma levels. The very high alfentanil plasma concentrations achieved provided satisfactory intraoperative conditions in most, but not all, patients. Recovery time was short, despite the large amounts of narcotic used. It is concluded that very high doses of alfentanil associated with lorazepam premedication resulted in hemodynamic stability and markedly elevated narcotic plasma concentrations in most patients. Such plasma levels seem to provide satisfactory anesthetic conditions.