Comparison of Proseal Laryngeal Mask Airway with the I-Gel Supraglottic Airway During the Bailey Manoeuvre in Adult Patients Undergoing Elective Surgery.

OBJECTIVE: Since the inception of Bailey manoeuvre, various authors have advocated for the substitution of endotracheal tube (ETT) with a supraglottic airway device (SAD) before the emergence from anaesthesia. There is scant information about the ideal supraglottic device in the literature. The present study compared the Proseal laryngeal mask airway (LMA) with the I-gel SAD during the Bailey manoeuvre. The primary objective was to compare these for ease of insertion and adequate placement of supraglottic airway, whereas the secondary objective was comparison of haemodynamics following the Bailey manoeuvre. METHODS: A total of 100 patients aged 18-60 years who were scheduled for elective surgery under general anaesthesia were randomised into 2 groups: group I (Bailey manoeuvre using Proseal LMA) and group II (Bailey manoeuvre using I-gel). The Bailey manoeuvre was performed 15 min before the end of surgery using the chosen supraglottic airway as per randomisation. We measured the ease of insertion (number of attempts required for insertion) and adequate placement (Brimacombe scoring) of SADs (fibre-optic bronchoscopy). Haemodynamic parameters were recorded until 10 min after the Bailey manoeuvre. RESULTS: The groups were comparable in terms of demographic parameters. Both the devices were comparable in terms of ease of insertion (p>0.05). Significantly higher (p<0.05) Brimacombe scores were seen with the I-gel. Significant (p<0.05) rise in systolic blood pressure, diastolic blood pressure, and mean arterial pressure was observed at the insertion of SAD, removal of ETT, and at 1 min after the Bailey manoeuvre in Proseal LMA in contrast to the I-gel. CONCLUSION: This study showed that the I-gel provides a better glottic visualisation and haemodynamically superior profile compared with the Proseal LMA during the Bailey manoeuvre.

Left ventricular endocardial and epicardial border length delineation with perflutren contrast during transthoracic echocardiography.

OBJECTIVE: Precise estimation of wall motion abnormalities during routine echocardiography rests on optimal endocardial border visualization. Endocardial "dropout" may result in the misinterpretation of regional wall motion. Left ventricular opacification (LVO) with intravenous contrast improves the visualization of the left ventricular endocardial border length (EnBL). The purpose of this study was to determine if contrast also improves the visualization of the epicardial border length (EpBL) in addition to the EnBL. METHOD: This is a single center retrospective observational study. From 200 consecutive patients referred to the Echocardiography Laboratory for the assessment and evaluation of coronary artery disease, 73 patients who received contrast were enrolled. All the images were standardized using offline software. The visualized segments of the epicardium and endocardium were measured in diastole and systole, without and with contrast-enhancement and these segments were summed to provide the total visualized EnBL and EpBL. RESULTS: Contrast enhanced imaging improved EnBL by 65% and 45% in end-diastolic and end-systolic views, respectively. Similarly, EpBL was improved by 61% and 57% in end-diastolic and end-systolic views, respectively (all P values <0.05). CONCLUSION: Contrast LVO improves the EnBL as previously reported. Additionally, based upon the blinded review of 1,752 regional myocardial wall segments, this study is the first to suggest that contrast also enhances the visualization of the EpBL. This finding has direct clinical implications as the improvement in both EnBL and EpBL with contrast may assist in evaluation of regional left ventricular wall thickening which is a critical parameter used to assess for myocardial ischemia.

A case of heterotopic heart transplant as a "biologic left ventricular assist" in restrictive cardiomyopathy.

Heterotopic heart transplant (HHT) has traditionally been thought of as creating 2 parallel circulations. We present a case of using the donor heart as a "biologic left ventricular assist" (bio-LVA). The heterotopic technique used consisted of 4 anastomoses: the donor heart pulmonary artery (PA) to the native heart right atrium, the superior vena cava to superior vena cava, the left atrium to left atrium, and the aorta to aorta. A 9-year-old boy with restrictive cardiomyopathy, a PA pressure of 85/53 mmHg, received a HHT because he would probably not be able to tolerate an orthotopic heart transplant secondary to elevated PA pressure. He is currently alive 14 years post-transplantation.

Update on tetralogy of Fallot for the adult cardiologist including a brief historical and surgical perspective.

There has been a steady rise in the prevalence of severe congenital heart disease (CHD) in adults because of improved treatment and survival during childhood. This has resulted in a shift in CHD morbidity and mortality beyond 18 years of age. The healthcare community must be prepared to meet this new challenge. Adult cardiologists need to be aware of common CHD, such as tetralogy of Fallot (TOF), as they will encounter adults with this CHD in their practice. With routine monitoring, cardiac imaging, early intervention, and treatment as highlighted in this report, continued improvement in the long-term fitness and avoidance of late complications for adult TOF patient is anticipated.

Tricuspid regurgitation after orthotopic heart transplantation.

BACKGROUND: Tricuspid regurgitation (TR) is a relatively common abnormality in normal adults as well as after orthotopic heart transplantation (OHT). A few studies have shown reduction in the incidence of TR after OHT by total bicaval surgical anastomosis technique. Other studies reported no significant difference in the rates of TR between the standard and bicaval techniques. OBJECTIVE: Evaluate and compare the degree of TR after OHT by standard and bicaval anastomosis techniques. METHOD: Echocardiograms from the first 56 consecutive patients that had the total bicaval surgical technique performed were retrospectively reviewed and compared with the last 57 consecutive patients who had the standard biatrial technique performed. Patients with adequate two-dimensional and Doppler echocardiograms were included. RESULTS: No statistical difference was observed for each grade of TR at both early and late time points. No significant difference was observed between the TR velocities of both biatrial and bicaval anastomosis patients at different periods. CONCLUSION: There appears to be no difference between the TR severity and TR velocity at early and late time points regardless of anastomotic technique.

Left atrial appendage aneurysm-a rare anomaly with an atypical presentation.

Left atrial appendage aneurysm (LAAA) is a rare condition caused by congenital dysplasia of the atrial muscles. Patients usually present with atrial tachyarrhythmias as a result of ectopic foci of atrial rhythm generation or systemic thromboembolism. We report a case of a 38-year-old Native American female presenting with 1-month history of cough, in sinus rhythm, and found to have a large cyst-like structure next to the left ventricular lateral wall on transthoracic echocardiography. This structure was later confirmed as a LAAA on cardiac magnetic resonance imaging. Patient underwent aneurysmectomy without any complications.

Comparison of LVEF obtained with single-plane RAO ventriculography and echocardiography in patients with and without obstructive coronary artery disease.

The left ventricular ejection fraction (LVEF) determined by invasive ventriculography (routine cardiac cath; LV-gram) was compared with that determined by echocardiography in 100 patients scheduled for angiography (86% had LV-gram and 2DE during same hospital admission). Seventy percent of patients had at least single-vessel obstructive coronary artery disease, defined as more than 50% stenosis. By all estimates, the LVEF was higher in patients without coronary artery disease (CAD) compared to patients with CAD. There was an excellent correlation between the LVEF by cath and echo, but this correlation was noticeably less strong in patients with CAD, especially with involvement of the left circumflex artery.

Extensive recurrent cardiac lipoma.

A 56-year-old woman with a history of surgical removal of a invasive myocardial lipoma presented with progressive dyspnea. Transthoracic echocardiogram showed severe mitral and tricuspid regurgitation and severely impaired biventricular systolic function. Cardiac computed tomography was performed, showing extensive biventricular basal and mid-myocardial replacement by an infiltrating tumor that had the density of fat resulting in large aneurysms of the basal segments of both the ventricles. The patient is currently awaiting orthotopic heart transplantation.

Compelling argument for an agitated saline bubble study prior to cardiac transplantation.

Cardiac transplant recipients with patent foramen ovale (PFO) are at risk for right-to-left shunting. Failure to identify this abnormality can have serious posttransplant consequences. In this article, we describe a cardiac transplant recipient with hypoxemia where a PFO was diagnosed postoperatively despite direct surgical investigation at the time of orthotopic heart transplantation (OHT). Transthoracic echocardiography with bubble study is relatively inexpensive, noninvasive, and simple and can be a useful method to identify PFO/atrial septal defect. Thus, authors recommend critically screening both donor and recipient hearts prior to OHT.

Prognostic value of megatroponinemia after myocardial infarction.

PURPOSE: The purpose of this study is to investigate the prognostic value of megatroponinemia (troponins >100 ng/mL), as a predictor of major adverse cardiac events such as recurrent angina, myocardial infarction, and death in patients presenting with acute myocardial infarction. METHODS: Over a period of 2 years, we identified 27 patients admitted with acute myocardial infarction and troponin I values >100 ng/mL. These patients were followed-up for the short term during their hospitalization as well as for an intermediate term of 18+/-14 months after their initial presentation with acute myocardial infarction for major adverse cardiac events including recurrent angina, myocardial infarction, and death. RESULTS: Of the 27 patients, one died 5 days after myocardial infarction and 26 were discharged home in stable condition, with few requiring timely intervention. Six patients were lost to follow-up. Five patients died during follow-up, 4 from recurrent myocardial infarction and 1 died from metastatic renal cell carcinoma. Twelve patients had non-fatal myocardial infarction, with 10 being acute ST elevation; 3 patients had recurrent angina. CONCLUSION: Patients presenting with an acute myocardial infarction and troponins >100 ng/mL have continued incremental risk of excessive major adverse cardiac events during short and intermediate follow-up period.

Cardiac imaging in right ventricular cardiomyopathy/dysplasia--how does cardiac imaging assist in understanding the morphologic, functional, and electrical changes of the heart in this disease?

Arrhythmogenic right ventricular dysplasia/cardiomyopathy is a complex disease and a difficult diagnosis to make that requires a multifaceted approach. Genetic mutations in proteins that alter the cardiomyocyte gap junction formation, stabilization, and general function lead to electrical and structural disturbances. The electrocardiogram (ECG) remains an excellent barometer of severe disease, but there is a large variation in the electroanatomic relationship and the ECG is less sensitive for detection of concealed early disease. With added knowledge of the genotypic/phenotypic expressions of this disease, continued experience with and development of current imaging modalities, and greater use of quantitative, 3-dimensional interpretative techniques, it seems clear that imaging will continue to play a pivotal role in collaborating with the ECG findings for the screening, diagnostic, prognostic, and serial assessment of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy.

Prognostic value of echocardiography with particular reference to patients with valvular heart disease.

Echocardiography is comparatively inexpensive relative to other modern cardiovascular imaging tools. It is widely available, even in poor countries, and provides a comprehensive evaluation of cardiac structure and function. It is an ideal tool for the evaluation of patients with valvular heart disease and provides important prognostic information. This review of recent literature highlights reports on outcomes data and provides a clinically valuable summary in table format.

Transient severe mitral regurgitation after mitral valve repair is associated with a poor clinical outcome: a small case series.

BACKGROUND: During mitral valve repair, patients with transesophageal echo-detected immediate postoperative systolic anterior motion of the mitral valve (SAM) and mitral regurgitation (MR) are successfully medically managed. They have been shown to do well in a short-term follow-up. However, the long-term outcome has not been investigated. The objective of this project was to investigate the long-term outcome of these patients. METHODS: This is an observational, retrospective study of 385 patients who underwent MVR. All cases of SAM and MR in this report were successfully medically managed with conservative therapy preventing the need for immediate surgical reintervention. Patients were divided into two groups based on the severity of MR. Group I had grade or= 3+(moderate or severe). Repeat MV surgical procedure or admission to the hospital for congestive heart failure with New York Heart Association (NYHA) Class III or Class IV was identified as a poor outcome. RESULTS: Twelve patients (3.1 %) were identified as having SAM with MR, which was medically managed intraoperatively. Patients were followed an average of 35 months. There were four patients (33.3%) in Group II. None of the eight patients (0%) in Group I had a poor outcome whereas three of the four patients (75%) in Group II had a poor outcome (OR = 3; P value = 0.018). CONCLUSION: These data suggest that despite the immediate improvement in MR and SAM, it is the degree of transient MR that further stratifies patients into good or poor long-term outcomes.

Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment.

Gemcitabine-induced hemolytic uremic syndrome in ovarian carcinoma.

Multiple chemotherapeutic agents, either alone or in combination, have been implicated in causing hemolytic uremic syndrome (HUS). Gemcitabine has been reported to cause this condition rarely. A 48-year-old Caucasian woman, gravida 3, para 3 (G3P3), was diagnosed with stage III C ovarian carcinoma and after completing numerous chemotherapeutic regimens, she was started on gemcitabine. During her fourth cycle of gemcitabine, she developed generalized anasarca and presented to hospital with hemolytic anemia, thrombocytopenia, and renal failure. A diagnosis of HUS was made, which was confirmed by renal biopsy, and the patient was started on hemodialysis and plasmapheresis. We conclude if a patient has advanced-stage disease and has been heavily treated with chemotherapy before, there is a high risk that, on gemcitabine monotherapy, the patient can develop HUS earlier than expected.