[Laparoscopic cholecystectomy in patients previously treated with heart transplantation. A clinical case]. / Colecistectomia per via laparoscopica in paziente precedentemente sottoposto a trapianto cardiaco. Caso clinico.

A 46-years old patient who had already undergone cardiac transplantation was scheduled for laparoscopic cholecystectomy following a diagnosis of cholelithiasis. In this particular case we were not faced with any problems even in presence of a denervated heart. Since the patient was immnosuppressed, we had to look for the best compromise between the need of monitoring closely the most important vital parameters and contemporarily reducing invasivity as much as possible. Capnometry was of paramount importance, enabling us to prevent and to correct high paCO2 values. The rapid recovery of the patient allowed us to begin with food intake and oral immunosuppressive therapy already 24 hours after the operation and to discharge the patient on the third day after surgery. Laparoscopic cholecystectomy represented a successful choice and a satisfying procedure both for the anaesthesiologist and for the patient, particularly regarding the minimal invasivity and the rapid recovery, which were considered of great importance in the immunodepressed patient.

[Clinical usefulness of transesophageal echocardiography in heart surgery complications]. / Utilità clinica dell'ecocardiografia transesofagea nelle complicanze della chirurgia cardiaca.

The role of monoplane transesophageal echocardiography (TEE) in rapid decision making process was investigated in 115 critically ill patients (pts) with early postoperative complications after cardio-thoracic surgery (hypotension, central venous pressure and/or wedge pressure elevation, electrocardiographic S-T segment elevation). Systolic and diastolic function of left ventricle, left ventricular wall motion abnormalities, right ventricular function, valves or prosthetic valves function, left ventricular outflow tract and morphologic changes were evaluated. Echocardiographic diagnoses were classified as: useful, incomplete, not diagnostic, misleading, unexpected. Echocardiographic diagnoses were confirmed by surgical or pathologic findings in all patients operated or dead. All but one patients, who needed surgical therapy, were operated on the basis of echo-diagnosis alone. Therapeutic changes induced by echo-diagnosis were evaluated and classified as major and minor. Diagnosis was fast (7 +/- 2 m) and sure (no complication). TEE was useful in 91% of cases (105/115 pts), incomplete in 2.3% (3/115 pts), not diagnostic in 2.3% (3/115 pts) and misleading in 3.4% of cases (4/115 pts). TEE findings made major therapeutic changes necessary in 66.9% (77/115 pts); there was a shift from medical to surgical therapy in 28% (41/115 pts); in 14.7% (17/115 pts) minor changes in drug therapy were made. TEE was also useful in quick and safe placement of devices (Swan-Ganz catheter, intra aortic balloon pump, endocardial pace maker, ventricular assist device) and in guiding urgent pericardiocentesis. The effects of medical therapy and evolution of ventricular dysfunction were well monitored by TEE. In our experience TEE was a very useful tool for management of early complications after cardio-thoracic surgery.

A prospective study of the clinical benefits of prostacyclin in 554 cardiopulmonary bypass procedures.

Abnormal bleeding after cardiopulmonary bypass (CPB) may result from incomplete neutralization of heparin, increased fibrinolytic activity, consumption of coagulation factors, or from a reduction in the number of circulating platelets together with impairment of platelet function. Although researchers have reason to believe that hemostasis after CPB could be improved with prostacyclin (PGI(2)), a potent inhibitor of platelet aggregation, the drug's clear-cut benefits in this respect have not yet been confirmed. After conducting an initial study concerning the fate of platelets during CPB, in which we determined that PGI(2) had a protective effect, we investigated the effects of PGI(2) infusion during CPB on postoperative blood loss in 554 open-heart surgery patients, 200 of whom underwent valve replacement, 200 of whom had coronary artery bypass grafting (CABG), and 154 of whom underwent repeat valve replacement or CABG. The patients were divided into 2 groups: 277 patients (the study group) received both heparin and PGI(2) during CPB, whereas the remaining 277 patients (the control group) were given heparin alone. Of the patients who underwent surgery for the first time, those treated with PGI(2) had a reduced mean blood loss (p < 0.05 only in CABG patients) in comparison with those who received heparin alone. Of the patients who underwent redo operations, those who received PGI(2) had a nonsignificant tendency toward reduced blood loss. The mean difference in blood loss between the study group and the control group had no clinical relevance, however, because it was less than the smallest practical unit of measurement (i.e., 1 unit of blood).