Early postpartum mitral valve thrombosis requiring extra corporeal membrane oxygenation before successful valve replacement.

Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. We present the case of a 29-year-old woman who developed early postpartum mitral valve thrombus after an elective cesarean delivery. The patient had a mechanical mitral valve and was treated with warfarin in the second trimester, which was replaced with high-dose dalteparin during late pregnancy. Elective cesarean delivery was performed under general anesthesia at 37weeks of gestation. The patient was admitted to the intensive care unit for postoperative care and within 30min she developed dyspnea and hypoxia requiring mechanical ventilation. She deteriorated rapidly and developed pulmonary edema, worsening hypoxia and severe acidosis. Urgent extra corporeal membrane oxygenation was initiated. Transesophageal echocardiography revealed a mitral valve thrombus. The patient underwent a successful mitral valve replacement after three days on extra corporeal membrane oxygenation. This case highlights the importance of multidisciplinary care and frequent monitoring of anticoagulation during care of pregnant women with prosthetic heart valves.

Versatility of the endoventricular patch technique in repair of postinfarction left ventricular rupture.

Surgical ventricular restoration by the endoventricular patch technique (Dor procedure) is a surgical option designed to restore left ventricular shape and volume in patients with ischaemic heart disease and heart failure. Surgical ventricular restoration includes complete revascularisation, left ventricular reconstruction to restore near-normal shape and volume, and when necessary, mitral valve repair and surgery for ventricular tachycardia. However, the endoventricular patch technique is versatile and can also be used in other cases. We report the successful use of this technique in two emergent postinfarction cases, one with left ventricular free-wall rupture and one with ventricular septal defect. The aim of these case reports is to illustrate the flexibility of the endoventricular patch technique.

Use of conventional ECG electrodes for depth of anaesthesia monitoring using the cerebral state index: a clinical study in day surgery.

BACKGROUND: The cost-benefit relationship for depth of anaesthesia monitors is complicated by the high cost of specially designed EEG electrodes. The cerebral state index (CSI) monitor will accept regular ECG electrodes with snap connectors. The purpose of this study was to determine if generic ECG electrodes could replace the more expensive proprietary EEG electrodes for the CSI monitor. METHODS: Two identical cerebral state monitors were used simultaneously during sevoflurane anaesthesia for knee arthroscopy in 14 ASA I-II patients. One monitor used proprietary (Danmeter) EEG electrodes and the other used ECG electrodes (3M Red Dot Diagnostic ECG Electrodes). Paired CSI values were recorded every other minute. Anaesthetic depth was titrated clinically. Sedation depth was scored according to the Observer's Assessment of Alertness/Sedation (OAAS) scale. RESULTS: The agreement between the two measures was found to be high, mean difference--0.23, and the overall repeatability mean bias was 6.6 and 153/163 pairs (94%) were located within the 95% limits of agreement. No major difference was noted in impedance, noise, or artifacts. A large overlap in CSI was noted for each level of the OAAS scale; patients with CSI values as low as 40-50 responded whereas patients not responding to surgical stimulation had CSI values as high as 75. The direct cost of disposables decreased from 4euro to 0.50euro per patient by using ordinary ECG electrodes. CONCLUSIONS: Switching from proprietary EEG electrodes to ordinary generic ECG electrodes maintains the same accuracy at about a 10th of the cost when measuring CSI during day surgery with sevoflurane anaesthesia.

Successful off pump coronary artery bypass grafting in a patient with an undiagnosed pheochromocytoma.

We report a successful off pump coronary artery bypass case in a patient with a pre-operatively undiagnosed pheochromocytoma. The patient had no signs of ischemia intra- or post-operatively due to aggressive antihypertensive treatment. We would also like to emphasize the importance of using an adequate stabilizing device in order to safely perform anastomoses in a situation like this.