Ecological and ecotoxicological responses in the assessment of the ecological status of freshwater systems: A case-study of the temporary stream Brejo of Cagarrão (South of Portugal).

The objective of the study was to assess the integrated use of macroinvertebrate indexes and ecotoxicological parameters in the evaluation of the ecological status of a temporary stream with a strong agricultural influence. Water quality was analysed at two sampling sites along the stream, considering: chemical supporting parameters; hazardous substances (pesticides); benthic macroinvertebrate communities, through quality (Iberian Biological Monitoring Working Party and Iberian Average Score Per Taxon) and multi-metric indices (Southern Portuguese Index of Invertebrates and Ecological Quality Ratio); and ecotoxicological responses using lethal and sub-lethal bioassays. The water chemical characterization showed high levels of organic matter and nutrients, mainly in the dry period ((biochemical oxygen demand (BOD5): 18.5-25.5mgL-1, chemical oxygen demand (COD): 60.8-193.7mgL-1; total phosphorus (TP): 0.17-0.33mgL-1)), which may compromise the support of biological life. In accordance with the physicochemical results, the stream had an ecological status less than good. Of the 25 pesticides analysed, only five, namely terbuthylazine, 2-methyl-chlorophenoxyacetic acid, bentazone, mecoprop and metolachlor were quantified. In general, the concentrations of pesticides detected were low, except at the source of the stream in January 2012 (sum of pesticides 2.29µgL-1), mainly due to the concentration of bentazone (1.77µgL-1), both values surpassing the European Commission threshold values. The analysis of benthic macroinvertebrates showed low levels of abundance and family diversity, with communities dominated by resistant groups to organic pollution and pesticides, such as the Chironomidae family. In general, the reproduction ecotoxicological results showed a very marked decrease in the number of juveniles per female. The Spearman correlation identified pesticides, namely MCPA (R=-0.89; p<0.05), as the main responsible for the observed effect. The results showed the linearity and complementarity of the two groups of biological responses, allowing to cover the interactions between the ecosystem's species and the different types of pollutants.

McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology. / Signo de McConnell en isquemia aguda de ventrículo derecho intraoperatoria: una etiología poco reconocida.

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia.

Occurrence and potential risk of currently used pesticides in sediments of the Alqueva reservoir (Guadiana Basin).

The evaluation of sediments, concerning to pesticides, constitutes an important step for the understanding of the principal sources of contamination of the surface water. Hence, the purpose of this study was to evaluate for the first time the occurrence, distribution and risk of pesticides in sediments of the Alqueva reservoir, the largest reservoir in the Europe. For this purpose, the occurrence of 22 pesticides and some of their degradation products was determined in surficial sediments of the Alqueva reservoir. To assess the potential risk on ecosystem, the measured concentrations of pesticides were compared with regulatory and toxicological benchmarks. Of the 22 pesticides analysed, only 8 were detected. Diuron was the pesticide detected in greater concentration, followed by terbuthylazine and chlortoluron. The sediments most polluted by pesticides were from Lucefécit, constituted totally by fine particles (<0.063 mm) and with high values of organic matter, and are located nearby large agricultural fields. The risk assessment allowed us to conclude that the sediments from the Alqueva reservoir presented low risk, concerning to pesticides, for the various communities that integrate the aquatic ecosystems. However, some of the compounds detected present a high potential for bioaccumulation that may lead to their bioamplification in the trophic chain, reaching concentrations higher than their acceptable daily intake, putting, in this way the populations at risk.

Risk assessment of pesticides detected in surface water of the Alqueva reservoir (Guadiana basin, southern of Portugal).

The purpose of this study was to evaluate the potential impact of the pesticides detected in the Alqueva reservoir (Guadiana Basin, South Iberian Peninsula) on the aquatic organisms belonging to this ecosystem. For this purpose, the occurrence and risk assessment of 25 pesticides and of a number of their degradation products were determined in the Alqueva surface waters. The areas (sampling stations) most polluted by pesticides were Sra. Ajuda, Lucefecit and Álamos in the northern and in the middle portions of the reservoir, respectively. The aquatic risk assessment revealed that from the various compounds analysed terbuthylazine, chlorfenvinphos and diazinon presented non-acceptable risk when maximum concentrations were used as the measured environmental concentrations (MEC). The locations that had more samples with risk quotients higher than 1 (high risk) were Sra. Ajuda followed by Lucefécit. The use of risk assessment allowed us to conclude that, despite that the pesticides' concentrations in the water column fulfil the European environmental quality standards, a number of the compounds show a high ecotoxicological risk for the aquatic organisms in the Alqueva ecosystem. The results thereby demonstrate that to have an efficient risk management process, the regulatory authorities of each country must consider an integrative chemical and ecotoxicological approach.

Effects of pesticides and pharmaceuticals on biofilms in a highly impacted river.

We investigated the effects of pharmaceuticals and pesticides detected in a Mediterranean river, on fluvial biofilms by translocation experiments performed under controlled conditions. Water was sampled from three sites along a pollution gradient. Biofilms grown in mesocosms containing relatively clean water were translocated to heavily polluted water. Several biofilm descriptors were measured before and after translocations. Fifty-seven pharmaceuticals and sixteen pesticides compounds were detected in river waters. The translocation from less to more polluted site was the most effective. Autotrophic biomass and peptidase increased while phosphatase and photosynthetic efficiency decreased. Multivariate analysis revealed that analgesics and anti-inflammatories significantly affected biofilm responses. Ibuprofen and paracetamol were associated with negative effects on photosynthesis, and with the decrease of the green algae/cyanobacteria ratio, while diclofenac was associated with phosphatase activity. The effects of these emerging compounds on biofilms structure and function may cause important alterations in river ecosystem functioning.

Good prognostic value of the intraoperative tissue Doppler-derived index E/e' after non-cardiac surgery.

BACKGROUND: The index E/e' derived from tissue Doppler imaging and pulsed Doppler is the ratio of the early transmitral flow velocity and the early mitral annular velocity and it correlates with left ventricular filling pressure. The purpose of this study was to investigate the relationship between intraoperative E/e' and postoperative cardiovascular complications and length of ICU and hospital stays after a non cardiac surgery. METHODS: This observational study investigated a total of 82 patients with cardiac disease undergoing non cardiac surgery. Diastolic function was evaluated by conventional echocardiographic pulsed-wave Doppler and TDI. The early peak (E) as well as the late peak (A) filling velocity of the left ventricle (LV) were measured at the mid-esophageal four-chamber at the mitral leaflet tips. Early Peak diastolic filling velocity (e'), Late peak diastolic filling velocity (a') and systolic velocity (s') were obtained from the mid-esophageal four-chamber view placed in the septal and lateral mitral annular sites. RESULTS: Patients were divided into three groups: E/e'<8 (normal LV filling pressure= 24 patients), E/e' 8-15 (moderately increased =35 patients) and E/e'>15 (severely increased = 23 patients). An elevated E/e' ratio was significantly associated with increased postoperative cardiovascular events, pulmonary congestion (P<0.05) arrhythmias (P<0.05) and with longer ICU and hospital stays (P<0.05). CONCLUSION: This data suggests that the tissue Doppler index E/e' may be a useful indicator for predicting morbid events after non-cardiac surgery. Furthermore, patients with an elevated intraoperative E/e' may need more careful postoperative management.

Estimación de la fracción de eyección intraoperatoria: comparación entre método de Simpson y Doppler tisular / Intraoperative ejection fraction: estimation with Simpson’s rule vs tissue

Introducción: La ecocardiografía transesofágica permite una adecuada monitorización de la hemodinamia intraoperatoria. Un parámetro frecuentemente utilizado es la fracción de eyección medido con método de Simpson. Con el advenimiento de Doppler tisular y la medición de onda s’, que corresponde a la velocidad de la perfusión del tejido miocárdico durante la sístole, podría estimarse la fracción de eyección de manera más rápida y fácil durante una cirugía. Objetivos: Comparar la fracción de eyección calculada con método de Simpson con las mediciones intraoperatorias de la velocidad de la onda s’ medida con Doppler tisular. Material y método: Se estudiaron pacientes afectos de patología cardiovascular crónica sometidos a cirugía cardiaca y no cardiaca electiva. Se excluyeron pacientes en ritmo no sinusal y con enfermedad mitral. Se midió en 4 y 2 cámaras volumen de fin de diástole y volumen de fin de sístole para calcular la fracción de eyección con método de Simpson. Este grupo fue dividido en aquéllos con fracción de eyección normal (> 50%) y un segundo grupo con fracción de eyección disminuida (< 49%) Luego se utilizó Doppler tisular de anillo mitral para medir la velocidad de la onda s’. Para estimar la fracción de eyección con s’ se utilizó la fórmula: FE = 5,5 x s’ + 8. Resultados: Fueron estudiados 92 pacientes, 51 (55%) casos con fracción de eyección normal y 41 (45%) disminuida. El grupo con fracción de eyección < 49% tuvo una buena correlación con la calculada mediante la velocidad de la onda s’ del Doppler tisular (r = 0,91, p < 0,01). En cambio en el grupo con fracción de eyección normal esta correlación fue menor (r = 0,61, p > 0,5). Conclusión: La estimación de la fracción de eyección con Doppler tisular es una técnica fácil y reproducible. Su utilidad podría ser mayor especialmente en aquellos pacientes que tienen un ventrículo izquierdo alterado(AU)

Background: Transesophageal echocardiography is appropriate for intraoperative monitoring of hemodynamics. The parameter often estimated is ejection fraction (EF) by means of Simpson’s rule. With the advent of tissue Doppler imaging and measurement of the systolic (S) wave, corresponding to the rate of myocardial perfusion during the systole, it is possible to estimate the EF more easily and rapidly during surgery. Objective: To compare EF estimates obtained by Simpson’s rule to those based on intraoperative tissue Doppler measurements of S-wave velocity (S'). Material and methods: Patients with chronic cardiovascular disease undergoing scheduled cardiac and noncardiac surgery were studied. Patients in nonsinus rhythm and with mitral valve disease were excluded. To apply Simpson's rule for calculating the EF, we measured end-diastolic volume in 4- and 2-chamber views. The group was divided into patients with normal ( 50%) and diminished ( 49%) ejection fraction. Tissue Doppler imaging of the mitral annulus was then used to measure S'. Ejection fraction was calculated according to the formula EF = 5.5 x S' + 8. Results: Ninety-two patients were studied; in 51 (55%) the EF was normal and in 41 (45%) it was reduced. In patients whose EF was 49% according to Simpson’s rule, the correlation between that measurement and EF based on tissue Doppler estimate of S' was good. The correlation was lower, however, in the group with normal EF (r=0.61; P>0.5). Conclusions: EF is easy to estimate with tissue Doppler imaging and the procedure is reproducible. This approach is probably more useful in patients with left ventricular dysfunction(AU)

Cirugía no cardíaca en angioplastia coronaria reciente: alta utilidad de ecocardiografía transesofágica para monitorización intraoperatoria / No disponible

No disponible

Taller teórico práctico de ecografía transtorácica y vascular en anestesiología / Workshop on transthoracic and vascular echocardiography in anesthesiology

La ecografía corresponde a un significativo e interesante avance en la anestesiología moderna que permite la visualización de diferentes estructuras (corazón, nervios y vasos) aumentando la calidad y la seguridad de los procedimientos. Debido a esto se ha generado un gran interés entre los anestesiólogos por aprender y desarrollar esta tecnología en sus lugares de trabajo. Así, un hecho fundamental para realizar ecografía es aprender a reconocer las estructuras y para esto se requiere de la familiarización del anestesiólogo con los diferentes planos e imágenes ecográficos. Una forma didáctica y entretenida de aprender los principios básicos es participando en talleres teórico prácticos. Por esto, el Comité Organizador del XVII Congreso Uruguayo de Anestesiología incluyó un taller teórico práctico de ecografía dentro de su programa. Dado lo extenso del tema se seleccionaron en este taller dos tópicos que fueron la ecocardiografía transtorácica y la ecografía para punciones vasculares. Con un cupo para 20 anestesiólogos se desarrolló con éxito, cumpliéndose con todos los objetivos planteados.

[Intraoperative ejection fraction: estimation with Simpson's rule vs tissue Doppler imaging]. / Estimación de la fracción de eyección intraoperatoria: comparación entre método de Simpson y Doppler tisular.

BACKGROUND: Transesophageal echocardiography is appropriate for intraoperative monitoring of hemodynamics. The parameter often estimated is ejection fraction (EF) by means of Simpson's rule. With the advent of tissue Doppler imaging and measurement of the systolic (S) wave, corresponding to the rate of myocardial perfusion during the systole, it is possible to estimate the EF more easily and rapidly during surgery. OBJECTIVE: To compare EF estimates obtained by Simpson's rule to those based on intraoperative tissue Doppler measurements of S-wave velocity (S'). MATERIAL AND METHODS: Patients with chronic cardiovascular disease undergoing scheduled cardiac and noncardiac surgery were studied. Patients in nonsinus rhythm and with mitral valve disease were excluded. To apply Simpson's rule for calculating the EF, we measured end-diastolic volume in 4- and 2-chamber views. The group was divided into patients with normal (> or = 50%) and diminished (< or = 49%) ejection fraction. Tissue Doppler imaging of the mitral annulus was then used to measure S'. Ejection fraction was calculated according to the formula EF = 5.5 x S' + 8. RESULTS: Ninety-two patients were studied; in 51 (55%) the EF was normal and in 41 (45%) it was reduced. In patients whose EF was < or = 49% according to Simpson's rule, the correlation between that measurement and EF based on tissue Doppler estimate of S' was good. The correlation was lower, however, in the group with normal EF (r=0.61; P>0.5). CONCLUSIONS: EF is easy to estimate with tissue Doppler imaging and the procedure is reproducible. This approach is probably more useful in patients with left ventricular dysfunction.

[Spinal anesthesia may diminish left ventricular function: a study by means of intraoperative transthoracic echocardiography]. / La anestesia subaracnoidea (espinal) podría disminuir la función ventricular izquierda: estudio con ecocardiografía transtorácica intraoperatoria.

BACKGROUND: Spinal anesthesia reduces arterial blood pressure mainly because of vasodilation secondary to blocking preganglionic fibers in the sympathetic nervous system. It is hypothesized, however, that spinal anesthesia may also be a direct cause of some degree of myocardial depression. These factors may be studied by means of transthoracic echocardiography to detect changes in left ventricular function following start of spinal anesthesia. MATERIAL AND METHODS: Left ventricular function was assessed in ASA 1 patients before spinal anesthesia, by means of measurements of left ventricular systolic and diastolic volumes, ejection fraction, the Doppler transmitral (E and A) and tissue (E', A', and Sm) inflow velocities, and the left ventricular outflow tract velocity. The measurements were repeated after the start of spinal anesthesia. RESULTS: Fifty-five patients (58% men; mean [SD] age, 46.9 [15.7] years) were studied. The spinal block caused a significant reduction in systolic and diastolic arterial blood pressures (P < .0009). Diastolic function also decreased (the E wave from 69.52 [11.24] to 61.59 [10.82] cm x s(-1) and the A wave from 50.18 [10.69] to 43.67 [13.75] cm x s(-1); P < .0001). Also reduced was the left ventricular outflow tract velocity, from 18.77 (4.89) to 15.64 (4.75) cm x s(-1) (P < .00001). There were no significant changes in systolic and diastolic volumes or ejection fraction. There was no correlation between the level of spinal block and the magnitude of changes. CONCLUSIONS: Left ventricular function was compromised after spinal anesthesia without significant changes in left ventricular volumes. We can infer that the reduction in arterial blood pressure after a spinal block might be due to some degree of direct ventricular depression.

La anestesia subaracnoidea (espinal) podría disminuir la función ventricular izquierda: Estudio con ecocardiografía transtorácica intraoperatoria / Spinal anesthesia may diminish left ventricular function: a study by means of intraoperative transthoracic echocardiography

INTRODUCCIÓN: La anestesia subaracnoidea (espinal)produce disminución de la presión arterial y su principalcausa sería la vasodilatación secundaria al bloqueo defibras preganglionares simpáticas. Se postula, sinembargo, que también podría producir algún grado dedepresión miocárdica directa. Para determinar estos factoresse pueden estudiar con ecocardiografía transtorácica(ETT) los cambios en la función del ventrículoizquierdo (VI) de una anestesia espinal.MATERIAL Y MÉTODOS: Se evaluó la función ventricular depacientes ASAI previa a la anestesia espinal. Se midió el volumensistólico del ventrículo izquierdo (VSFVI), volumen diastólico(VDFVI), fracción de eyección (FE), Doppler llenadotransmitral (E, A), Doppler tisular (E’, A’ y Sm) e integral develocidad del tracto de salida del VI (ITV). Este mismo examense repitió después de instaurarse la anestesia espinal.RESULTADOS: Se estudiaron 55 pacientes, 58% hombres,edad 46,9 ± 15,7 años. El bloqueo espinal produjouna disminución significativa de presión arterial sistólicay diastólica (p < 0,0009), de la función diastólica, dondela onda E disminuyó desde 69,52 ± 11,24 a 61,59 ±10,82 cm seg–1 y la onda A desde 50,18 ± 10,69 a 43,67 ±13,75 cm seg–1 (p < 0,0001) y de ITV desde 18,77 ± 4,89a 15,64 ± 4,75 cm seg–1 (p < 0,00001) sin cambios significativosen el VDF, VSF y FE. No existió correlación entreel nivel del bloqueo con la magnitud de estos cambios.CONCLUSIÓN: Los resultados demostraron que tras laanestesia espinal se comprometió la función ventricularizquierda, sin que cambiaran los volúmenes del VI enforma significativa. A partir de estos resultados puedeinferirse que la disminución de la presión arterial luegode un bloqueo espinal podría deberse también a algúngrado directo de depresión ventricular(AU)

BACKGROUND: Spinal anesthesia reduces arterialblood pressure mainly because of vasodilation secondaryto blocking preganglionic fibers in the sympatheticnervous system. It is hypothesized, however, that spinalanesthesia may also be a direct cause of some degree ofmyocardial depression. These factors may be studied bymeans of transthoracic echocardiography to detectchanges in left ventricular function following start ofspinal anesthesia.MATERIAL AND METHODS: Left ventricular functionwas assessed in ASA 1 patients before spinal anesthesia,by means of measurements of left ventricular systolicand diastolic volumes, ejection fraction, the Dopplertransmitral (E and A) and tissue (E', A', and Sm) inflowvelocities, and the left ventricular outflow tract velocity.The measurements were repeated after the start ofspinal anesthesia.RESULTS: Fifty-five patients (58% men; mean [SD]age, 46.9 [15.7] years) were studied. The spinal blockcaused a significant reduction in systolic and diastolicarterial blood pressures (P<.0009). Diastolic functionalso decreased (the E wave from 69.52 [11.24] to 61.59[10.82] cm·s–1 and the A wave from 50.18 [10.69] to 43.67[13.75] cm·s–1; P<.0001). Also reduced was the leftventricular outflow tract velocity, from 18.77 (4.89) to15.64 (4.75) cm·s–1 (P<.00001). There were no significantchanges in systolic and diastolic volumes or ejectionfraction. There was no correlation between the level ofspinal block and the magnitude of changes.CONCLUSIONS: Left ventricular function wascompromised after spinal anesthesia without significantchanges in left ventricular volumes. We can infer that thereduction in arterial blood pressure after a spinal blockmight be due to some degree of direct ventricular depression(AU)

[Echocardiography-derived Tei index during surgery, a predictor of postoperative cardiovascular complications]. / Indice ecocardiográfico de Tei durante cirugía no cardiaca como predictor de complicaciones cardiovasculares postoperatorias.

BACKGROUND AND OBJECTIVE: The Tei index is a Doppler echocardiographic parameter that reflects both systolic and diastolic myocardial function. Our aim was to monitor the Tei index by transesophageal echocardiography during noncardiac surgery to explore the correlation between this parameter and the incidence of postoperative cardiovascular complications. MATERIAL AND METHODS: Patients at risk of cardiovascular complications were enrolled. The Tei index was derived from the pattern of pulsed Doppler transmitral filling and aortic outflow, by dividing the sum of isovolumetric contraction and relaxation intervals by ejection time in milliseconds. RESULTS: Seventy-three patients (58% men) were enrolled. The mean (SD) age was 68 (12) years. Two groups were identified based on myocardial function. A Tei index over 0.35 defined group 2 (n = 25) and correlated with a larger number of postoperative cardiovascular events. In patients with a normal Tei index less than 0.35 (group 1, n = 48), the incidence of cardiovascular complications was lower. Hypotension occurred in 60% of patients in group 2 and 21% of those in group 1, hypertension in 24% of group 2 and 4.1% of group 1, and pulmonary edema in 8% of group 2 and 2.1% of group 1 (P < .05 for all comparisons). CONCLUSIONS: This pilot study found that patients with a high Tei index were more likely to develop postoperative cardiovascular complications. This index may provide a useful indicator to take into consideration in planning hemodynamic management when patients have a history of cardiovascular disease.

Índice ecocardiográfico de Tei durante cirugía no cardiaca comopredictor de complicaciones cardiovasculares postoperatorias / Echocardiography-derived Tei index during surgery, a predictor of postoperative cardiovascular complications

OBJETIVOS: El índice de función miocárdica (índice deTei) es un parámetro obtenido con ecocardiografíamediante Doppler, que estudia en forma conjunta e integradala sístole y la diástole. El objetivo del presenteestudio es evaluar si el índice de Tei medido con ecocardiografíatransesofágica (ETE) durante cirugía no cardiacase correlaciona con una mayor incidencia de eventoscardiovasculares postoperatorios.MATERIAL Y MÉTODOS: Se estudiaron pacientes conriesgo cardiovascular. El índice de Tei se midió con ETEdesde la curva de Doppler pulsado de llenado transmitraly de flujo aórtico, dividiendo la suma del tiempo decontracción y relajación isovolumétrica por el tiempo deeyección en milisegundos.RESULTADOS: Se incluyeron 73 pacientes, el 58% varones,con una edad promedio de 68 ± 12 años. Se determinódos grupos según el índice de función miocárdica. Uníndice de función miocárdica mayor de 0,35 (grupo 2, n= 25 pacientes) se correlacionó con un mayor número deeventos cardiovasculares postoperatorios. El grupo 1 (n= 48 pacientes) con índice de función miocárdica< 0,35 (normal) presentó una menor incidencia de eventos.Destacó la hipotensión en 60% de enfermos del grupo2 frente a 21% del grupo 1 (p < 0,05), hipertensión en24% de los casos del grupo 2 frente a 4,1% del grupo 1(p < 0,05) y congestión pulmonar 8% en el grupo 2 y2,1% del grupo 1 (p < 0,05).CONCLUSIONES: En este estudio preliminar se observóque pacientes con un índice de Tei patológico podríantener una mayor incidencia de complicaciones cardiovascularespostoperatorias. Este índice podría ser un factormás a considerar en el tratamiento hemodinámico depacientes con antecedentes de patología cardiovascular (AU)

BACKGROUND AND OBJECTIVE: The Tei index is aDoppler echocardiographic parameter that reflects bothsystolic and diastolic myocardial function. Our aim wasto monitor the Tei index by transesophagealechocardiography during noncardiac surgery to explorethe correlation between this parameter and theincidence of postoperative cardiovascular complications.MATERIAL AND METHODS: Patients at risk ofcardiovascular complications were enrolled. The Teiindex was derived from the pattern of pulsed Dopplertransmitral filling and aortic outflow, by dividing thesum of isovolumetric contraction and relaxationintervals by ejection time in milliseconds.RESULTS: Seventy-three patients (58% men) wereenrolled. The mean (SD) age was 68 (12) years. Twogroups were identified based on myocardial function. ATei index over 0.35 defined group 2 (n=25) andcorrelated with a larger number of postoperativecardiovascular events. In patients with a normal Teiindex less than 0.35 (group 1, n=48), the incidence ofcardiovascular complications was lower. Hypotensionoccurred in 60% of patients in group 2 and 21% of thosein group 1, hypertension in 24% of group 2 and 4.1% ofgroup 1, and pulmonary edema in 8% of group 2 and2.1% of group 1 (P<.05 for all comparisons).CONCLUSIONS: This pilot study found that patientswith a high Tei index were more likely to developpostoperative cardiovascular complications. This indexmay provide a useful indicator to take into considerationin planning hemodynamic management when patientshave a history of cardiovascular disease (AU)

[Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery]. / Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca.

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The cause of this abnormal motion is still uncertain, although it is thought that changes in the shape and function of the left ventricle allow displacement of the mitral valve annulus so that 1 or more leaflets can be pulled toward the outflow tract and obstruct it during the systole. It is important to recognize and diagnose this phenomenon as a cause of hypotension during noncardiac surgery because it can be treated with volume replacement and beta-blockers. The results of such measures can be monitored on intraoperative echocardiographic images. Volume replacement should increase the size of the ventricle and the beta-blockers should decrease the hyperdynamic state. We report a case of abnormal systolic motion during noncardiac surgery that was managed with the help of echocardiography.

Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca / Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery

El fenómeno de movimiento sistólico anormal de la válvulamitral es una entidad clínica poco reconocida comocausa de hipotensión arterial sistémica aguda intraoperatoriadurante cirugía no cardíaca. Con el advenimiento dela ecocardiografía transesofágica intraoperatoria que permiteobtener imágenes anatómicas y funcionales cardíacasen tiempo real, este fenómeno dinámico se ha hecho evidente.Su etiología aunque poco clara, se piensa que sedebe a cambios morfológicos y funcionales del ventrículoizquierdo que permiten el desplazamiento del anillo valvularmitral lo que facilita que uno o ambos velos sean arrastradosdurante la sístole hacia el tracto de salida del ventrículoizquierdo, obstruyéndolo. La importancia que tienesu diagnóstico y reconocimiento como causa de hipotensióndurante el intraoperatorio de una cirugía no cardíacaes que su tratamiento se basa en el aporte de volumen y ala utilización preferente de betabloqueantes. La ecocardiografíaintraoperatoria permite la monitorización y visualizaciónde los resultados de esta terapia. Con el aporte devolumen aumenta el tamaño ventricular y con el uso debetabloqueantes se logra disminuir el estado hiperdinámico.Se presenta el siguiente caso clínico ocurrido duranteuna cirugía no cardíaca donde el manejo y la evolucióndependieron de las imágenes diagnósticas de movimientosistólico anormal realizadas con ecocardiografía

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The ;;cause of this abnormal motion is still uncertain, although it ;;is thought that changes in the shape and function of the left ;;ventricle allow displacement of the mitral valve annulus so ;;that 1 or more leaflets can be pulled toward the outflow ;;tract and obstruct it during the systole. It is important to ;;recognize and diagnose this phenomenon as a cause of ;;hypotension during noncardiac surgery because it can be ;;treated with volume replacement and Beta-blockers. The ;;results of such measures can be monitored on intraoperative ;;echocardiographic images. Volume replacement should ;;increase the size of the ventricle and the Beta-blockers should ;;decrease the hyperdynamic state. We report a case of ;;abnormal systolic motion during noncardiac surgery that ;;was managed with the help of echocardiography

[Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation]. / Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea.

OBJECTIVE: Intraoperative transesophageal echocardiography can be a highly useful monitoring technique during myocardial revascularization surgery when extracorporeal circulation (ECC) is not being used. Transesophageal echocardiography provides real-time images on both volume status and segmental myocardial contractility without interfering with the surgical field. PATIENTS AND METHODS: A total of 25 patients undergoing myocardial revascularization by sternotomy without ECC were monitored by transesophageal echocardiography during surgery. RESULTS: The 18 men and 7 women studied had a mean (SD) age of 71.3 (8) years. A third of them had hypertension and diabetes, 3 had suffered a cerebrovascular accident, and 2 had renal failure. Nine patients had a history of acute myocardial infarction and 3 had undergone angioplasty. Baseline echocardiograms on all patients established that 6 had a low ejection fraction (<30%). Twelve had altered segmental contractility, which was transient in 11 cases. Six patients had improved ejection fraction at the final assessment. Transesophageal electrocardiography also monitored volume status and the effects of inotropic drugs and beta-blockers in 83% of the patients. CONCLUSION: Transesophageal electrocardiography is a minimally invasive, safe, and precise way to directly monitor the beating heart in real time during myocardial revascularization without ECC. Image quality is good.

Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea / Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation

OBJETIVO: La ecocardiografía transesofágica intraoperatoria(ETE) puede ser un sistema de monitorización dealta utilidad durante la revascularización miocárdica sincirculación extracorpórea (CEC), ya que permite obtenerimágenes en tiempo real tanto del estado de la volemiacomo de la contractilidad segmentaria miocárdica, sininterferir en el campo quirúrgico.PACIENTES YMÉTODOS: Se estudian 25 pacientes sometidosa revascularización miocárdica por esternotomía sinCEC monitorizados con ETE durante su intraoperatorio.RESULTADOS: 18 hombres y 7 mujeres, con edad promediode 71,3 ± 8 años fueron estudiados. Un tercio de ellospresentaba hipertensión arterial y diabetes, 3 habían tenidoun accidente vascular encefálico previo y 2 eran portadoresde insuficiencia renal. Un total de 9 pacientes teníahistoria de infarto agudo al miocardio y 3 casos de elloshabían sido sometidos a angioplastias previas. A todos lospacientes se les realizó ETE basal donde seis tenían malafracción de eyección (FE) < 30%. Se detectaron alteracionesde la contractilidad segmentaria en 12 pacientes, deéstos en 11 fueron alteraciones sólo transitorias. En la evaluaciónfinal se determinó que en 6 enfermos hubo unamejoría de la FE. La ETE permitió además evaluar elestado de la volemia, el efecto de fármacos inotropos y betabloqueadores en el 83% de los pacientes.CONCLUSIÓN: La ETE es un monitor mínimamenteinvasivo y en tiempo real que permite evaluar en formadirecta, segura y precisa al corazón latiendo durante larevascularización miocárdica sin CEC con buena calidadde imágenes

OBJECTIVE: Intraoperative transesophageal echocardiographycan be a highly useful monitoring techniqueduring myocardial revascularization surgery whenextracorporeal circulation (ECC) is not being used.Transesophageal echocardiography provides real-timeimages on both volume status and segmental myocardialcontractility without interfering with the surgicalfield.PATIENTS AND METHODS: A total of 25 patients undergoingmyocardial revascularization by sternotomy withoutECC were monitored by transesophageal echocardiographyduring surgery.RESULTS: The 18 men and 7 women studied had amean (SD) age of 71.3 (8) years. A third of them hadhypertension and diabetes, 3 had suffered a cerebrovascularaccident, and 2 had renal failure. Nine patientshad a history of acute myocardial infarction and 3 hadundergone angioplasty. Baseline echocardiograms on allpatients established that 6 had a low ejection fraction(<30%). Twelve had altered segmental contractility,which was transient in 11 cases. Six patients had improvedejection fraction at the final assessment. Transesophagealelectrocardiography also monitored volumestatus and the effects of inotropic drugs and ß-blockersin 83% of the patients.CONCLUSION: Transesophageal electrocardiography isa minimally invasive, safe, and precise way to directlymonitor the beating heart in real time during myocardialrevascularization without ECC. Image quality isgood