Echocardiography and excision of lipomatous hypertrophy of the interatrial septum.

We present a case of massive lipomatous hypertrophy of the interatrial septum, in which transesophageal echocardiography was used to guide surgical resection. Tissue removal was undertaken without entering either the left or right atrium, thereby obviating the need for atrial septal reconstruction.

Large pulmonary embolus without systemic hemodynamic consequences during cemented hip arthroplasty.

A case is presented in which a large embolus was detected passing through the right side of the heart during total hip arthroplasty. Although tricuspid regurgitation and an elevated right ventricular pressure resulted, there was no perturbation in systemic hemodynamics or gas exchange. The emboli detected during total hip arthroplasty are most likely composed of fat. No specific treatment is required, although heightened vigilance for disturbances in systemic hemodynamics is important.

The effects of midazolam on propofol-induced anesthesia: propofol dose requirements, mood profiles, and perioperative dreams.

UNLABELLED: This study examined the effects of midazolam on the doses of propofol required for the induction of hypnosis and the maintenance of propofol/nitrous oxide anesthesia. In addition, the effects of midazolam on the time to patient recovery, perioperative mood profiles, incidence of perioperative dreams, patient satisfaction scores, and requirement for postoperative analgesics were assessed. This investigation was a prospective, randomized, and double-blind study of female patients undergoing dilatation and curettage. Patients received midazolam (30 microg/kg, n = 30) or an equal volume of placebo (n = 30) immediately before the induction of anesthesia. Recall of dreams was assessed immediately postoperatively, in the postanesthesia care unit (PACU), and on the day after surgery using a questionnaire designed for surgical patients. Mood profiles were quantified using the Multiple Affect Adjective Check List-Revised, which was completed preoperatively and 1 h postoperatively. The Client Satisfaction Questionnaire-8, an eight-item self-administered version of the Client Satisfaction Questionnaire, was used to assess patient satisfaction on the day after surgery. Our results indicate that although the time to the loss of the lid reflex was significantly shorter in patients receiving midazolam (43.8 +/- 2.7 vs 74.7 +/- 7.6 s, P < 0.0003), there was no significant difference in the dose of propofol required to induce hypnosis or maintain anesthesia. There were no group differences in postoperative sedation and orientation scores, perioperative mood profiles, incidence of dreams, and patient satisfaction scores. More patients who received midazolam requested analgesics in the PACU (11 vs 4, P < 0.05). In conclusion, midazolam did not reduce the anesthetic dose requirement of propofol in patients undergoing anesthesia with nitrous oxide, nor did it accelerate patient recovery. Our results call into question the benefit of coinducing anesthesia with propofol and midazolam. IMPLICATIONS: Midazolam, administered immediately before anesthetic induction with propofol, did not decrease the dose of propofol necessary for hypnosis, nor the maintenance of surgical anesthesia, in female patients undergoing diagnostic dilatation and curettage. In addition, midazolam did not alter patient recovery characteristics, postoperative mood, incidence of perioperative dreams, or patient satisfaction. The use of midazolam was associated with an increased need for postoperative analgesics. Our study calls into question the benefit of administering midazolam immediately before anesthetic induction with propofol.

Is this the natural history of the retention wire? A case report.

We report on a 71-year-old man who had a dual chamber pacemaker implanted in 1991. A Class IV fracture of the Telectronics Accufix 330-801 atrial lead was observed on a chest X ray in December 1993. Serial chest X ray and fluoroscopy documented stable position of the migrated fractured J wire. The patient remained asymptomatic and a decision for conservative monitoring was made. A subsequent finding of a right atrial mass on echocardiography and evidence of pulmonary embolism on lung scan prompted a change of strategy. The patient underwent atriotomy, and a right atrial thrombus was discovered associated with the fractured J retention wire, both of which were extracted uneventfully. This case is illustrative that despite apparent stability of a Class IV fracture, it may result in endothelial injury with a thrombogenic nidus and resultant complications.

Technique for reconstruction of the sinotubular junction.

Correct geometric relationships between the annulus and sinotubular junction during stentless valve implantation are critical to minimize the development of insufficiency. Some patients with aortic valve disease have dilatation of the sinotubular junction and are unable to have a stentless valve placed by standard techniques. We recently encountered such a patient and reconstructed the sinotubular junction by aortic crenation. Multiple interrupted plicating sutures were used to reduce the aorta from a diameter of 42 mm to 28 mm. This method allows tailoring of the aorta to appropriate size by varying the number of crenating sutures.

Adipose tissue and lipid droplet embolism following periurethral injection of autologous fat: case report and review of the literature.

The authors present a case of a death associated with pulmonary adipose tissue and lipid droplet embolism following autologous fat harvesting, periurethral injection and videocystourethroscopy for the treatment of recurrent genuine stress incontinence.

Echocardiographic assessment of left ventricular filling during isoflurane anaesthesia.

PURPOSE: To determine the effect of isoflurane on left ventricular diastolic function, as assessed by Doppler echocardiography. METHODS: Ten patients with normal cardiovascular function were enrolled. Doppler measurements of mitral inflow velocities, and pulmonary venous blood flow velocities were measured preoperatively (transthoracic echocardiography), and intraoperatively (transesophageal echocardiography) at isoflurane MAC 1 and MAC 1.5. Heart rate and blood pressure were measured concomitantly. Variables were compared with repeated measures ANOVA. RESULTS: Isoflurane at both doses caused equal decreases in mitral inflow A(atrial systole) velocity (control: 43 +/- 12.3 cm.sec-1 vs MAC 1: 31 +/- 6.0 cm.sec-1 and MAC 1.5: 31.3 +/- 7.9 cm.sec-1 P < 0.01), the deceleration time of the mitral inflow E (early) velocity (control: 178 +/- 31.7 msec versus MAC 1: 127 +/- 38.3 msec and MAC 1.5: 137 +/- 28.4 msec, P < 0.01), and mean blood pressure (control: 91.1 +/- 15.4 mmHg versus MAC 1: 76.1 +/- 8.8 mmHg and MAC 1.5: 71.9 +/- 6.2 mmHg, P < 0.002). Isoflurane at both doses caused an equal increase in the E/A ratio (control: 1.5 +/- 0.57 vs MAC 1: 2.0 +/- 0.6 and MAC 1.5: 2.2 +/- 0.78, P < 0.01). No changes in mitral inflow E or pulmonary venous velocities were seen. CONCLUSION: The changes in Doppler velocities of mitral inflow and pulmonary venous flow with isoflurane are not consistent with prolonged left ventricular relaxation nor increased myocardial restriction, but are more likely the result of alterations in left ventricular loading conditions and atrial systolic function.

An introduction to transoesophageal echocardiography: II. Clinical applications.

PURPOSE: As progress has been made in the acquisition of cardiac images with transoesophageal echocardiography, the technique has moved from the confines of the cardiology laboratory into the operating room, the intensive care unit, and the emergency department. This has afforded anaesthetists the opportunity to become familiar with, and develop expertise in its practice. The purpose of this article is to present a review of transoesophageal echocardiography with reference to anaesthetic practice. SOURCE: The principle source of material was a computerized MedlineTM search of the English language literature from 1986 to 1995. PRINCIPLE FINDINGS: After discussing the technique of probe insertion, and describing some of the standard images, transoesophageal echocardiography's clinical utility is critically assessed. Comparisons with available monitoring techniques are made with reference to ventricular function, valvular heart disease, pericardial, aortic and congenital heart disease, and the management of the multiple traumatized patient. Issues of certification and maintenance of competence are also discussed. CONCLUSION: Although the benefit of transoesophageal echocardiography is intuitive in many clinical situations, in others, it has not been shown to improve upon presently existing monitoring techniques. The need for adequate training and collaboration with cardiology colleagues is emphasized.

Traumatic aortic disruption: false positive diagnosis on transesophageal echocardiography.

A case is described in which there was a high index of suspicion for traumatic aortic disruption. Because angiography was equivocal, transesophageal echocardiography was performed, and interpreted as showing a noncircumferential aortic tear. At thoracotomy, however, no tear was seen. The false positive interpretation was caused by a crescent-shaped atherosclerotic plaque.