Intra-aortic balloon pump associated with dynamic left ventricular outflow tract obstruction after valve replacement for aortic stenosis.

An unstable patient with critical aortic stenosis had an intra-aortic balloon pump placed preoperatively for hemodynamic support and alleviation of symptoms. After separation from cardiopulmonary bypass following aortic valve replacement, the patient was hypotensive with increased pulmonary artery pressures. Transesophageal echocardiography revealed left ventricular outflow tract obstruction associated with systolic anterior motion of the mitral valve and severe mitral regurgitation. This pathophysiology was present when ventricular systole was preceded by balloon counterpulsation, but was absent during unassisted systole. This case report demonstrates a potentially significant untoward effect of intra-aortic balloon pump augmentation after aortic valve replacement for aortic stenosis. The timely diagnosis of this iatrogenic condition in the operating room permitted the prompt implementation of appropriate management strategies and avoided unnecessary surgical intervention.

A rational approach to the cause, prevention and treatment of postdural puncture headache.

OBJECTIVE: To review the current research and formulate a rational approach to the cause, prevention and treatment of postdural puncture headache (PDPH). DATA SOURCES: Articles published from January 1980 to April 1992 were obtained through a search of MEDLINE and Index Medicus. Key reference articles published before 1980 were also reviewed. STUDY SELECTION: All pertinent studies were included and critically analysed. DATA SYNTHESIS: PDPH occurs when a slow leak of cerebrospinal fluid leads to contraction of the subarachnoid space and compensatory expansion of the pain-sensitive intracerebral veins. Female sex and an age between 20 and 40 years have been shown to be independent risk factors for PDPH, but pregnancy has not. The rate of PDPH is directly proportional to the diameter of the needle used and also depends on the design of the needle tip. Prophylactic epidural blood patching or saline infusion after dural puncture can decrease the incidence of PDPH, but both are invasive procedures. Intravenous caffeine sodium benzoate therapy effectively relieves PDPH, but the headache may recur. An epidural blood patch is an invasive but effective, permanent treatment for PDPH in most cases; resistant cases may respond to epidural saline infusion. CONCLUSION: The rate of PDPH after lumbar puncture can be minimized through strict attention to technique and the employment of a 25-gauge needle with the bevel parallel to the dural fibres. A reliable diagnosis and stepwise approach to treatment will minimize complications.