Bruno Mora

Cerebral desaturation during cardiac arrest: its relation to arrest duration and left ventricular pump function.

Objective:To determine the impact of brief periods of cardiac arrest (CA) on regional cerebral oxygen saturation (rSo2) in patients with low left ventricular ejection fraction (LVEF <30%). Design:Prospective observational study. Setting:Cardiac surgery room at a university hospital. Patients:Seventy-seven consecutive patients undergoing elective implantation of a cardioverter/defibrillator in monitored anesthesia care. According to preoperative assessments, left ventricular function was classified as normal (LVEF >50%), moderately impaired (LVEF 30%–50%), or severely reduced (LVEF <30%). Interventions:None. Measurements and Main Results:rSo2 was determined during threshold testing with concomitant induction of CA. In patients with LVEF <30%, mean baseline rSo2 (59%) was already below the lower range of normal despite normal arterial blood pressure, heart rate, and arterial oxygen saturation. rSo2 increased by 6% after 6 L/min oxygen insufflation (p < 0.05) and dropped again in each group after CA, reaching a nadir after successful defibrillation. Patients with LVEF <30% and baseline rSo2 ≤63% exhibited the lowest values. They also showed the highest incidence (11%) of critical cerebral desaturations (i.e., >20% drop from baseline or rSo2 value <50%). rSo2 in patients with LVEF <30% was always below that determined in patients with LVEF >30% (p < 0.05). There was a strong correlation between rSo2 values before CA and rSo2 nadir (p < 0.05). The drop in rSo2 was only moderately related to the brief CAs (p < 0.05). Conclusion:These findings demonstrate that severely compromised left ventricular pump function is associated with diminished rSo2. As these patients seem to be more susceptible to critical desaturations, they may be prone to severe tissue hypoxemia unless adequate oxygen delivery is reestablished rapidly. This may contribute to the poor neurologic outcome after successful resuscitation in patients with LVEF <30%.

Neuronal injury after repeated brief cardiac arrests during internal cardioverter defibrillator implantation is associated with deterioration of cognitive function.

To determine the degree of neurocognitive dysfunction after placement of internal cardioverter defibrillators (ICD) and its relationship to the extent of neuronal injury, we studied 42 patients undergoing ICD (n = 21) or pacemaker (PM) insertion (control patients, n = 21). The Mini Mental State Examination, the Trailmaking A test and the forward and backward Digit Span tests were used and P300 latencies were determined preoperatively and postoperatively. Serum neuron-specific enolase (NSE) was determined before and at the end of, as well as 2, 6, and 24 h after surgery. Preoperatively, PM patients scored worse in the Digit Span backward and the Trailmaking tests and showed prolonged P300 latencies. Postoperatively, the Digit Span backward scores declined and NSE levels increased only in the ICD group (P ≤ 0.05). The difference between preoperative and postoperative Digit Span backward scores correlated with the increase in serum NSE levels (r2 = 0.3, P ≤ 0.05). Moreover, P300 latencies increased in 13 of 17 ICD patients, but decreased in 7 of 10 PM patients (P ≤ 0.05). PM patients even improved in the Trailmaking test (P ≤ 0.05). Neuronal injury from even brief periods of global brain ischemia seems to be associated with deteriorating neurocognitive function.

A rare case of primary cardiac B cell lymphoma

Primary cardiac lymphomas represent an extremely rare entity of extranodal lymphomas and should be distinguished from secondary cardiac involvement of disseminated lymphomas belonging to the non-Hodgkin’s classification of blood cancers. Only 90 cases have been reported in literature. Presentation of cardiac lymphomas on imaging studies may not be unambiguous since they potentially mimic other cardiac neoplasms including myxomas, angiosarcoma or rhadomyomas and therefore require multimodality cardiac imaging, endomyocardial biopsy, excisional intraoperative biopsy and pericardial fluid cytological evaluation to establish final diagnosis.Herein we report the case of a 70 y/o immunocompetent Caucasian female with a rapidly progressing superior vena cava syndrome secondary to a large primary cardiac diffuse large B cell lymphoma (NHL lymphoma) almost completely obstructing the right atrium, right ventricle and affecting both mitral and tricuspid valve. The patient had no clinical evidence of disseminated disease and was successfully treated with extensive debulking during open-heart surgery on cardiopulmonary bypass and 6 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy (R-CHOP).

Impaired recovery of cardiac output and mean arterial pressure after successful defibrillation in patients with low left ventricular ejection fraction

BACKGROUND Early defibrillation clearly improves survival from malignant arrhythmia. However, in some cases the cause of death will only be altered from arrhythmic to nonarrhythmic. We evaluated the impact of left ventricular ejection fraction (LVEF) on trend and recovery profile of beat-to-beat cardiac output (CO) and mean arterial blood pressure (MAP) after successful defibrillation. METHODS We investigated 63 NYHA class I-III patients undergoing threshold testing in the course of insertion of an implantable cardioverter defibrillator (ICD) in monitored anaesthesia care. Preoperatively, LVEF was classified as either normal (>50%), moderately (30-50%) or severely impaired (<30%). CO and MAP were measured continuously throughout the implantation procedure. RESULTS Arrest time and body mass index were not different between groups. CO in patients with severely and moderately reduced LVEF dropped 21% and 13% below baseline (P<0.05), respectively. MAP also decreased by 26% and 17%, respectively. In contrast, 45% of patients with LVEF>50% showed sympathetic activation that resulted in a 12% and 2% increase in mean values for CO and MAP, respectively. In relation to patients with LVEF<50%, CO and MAP values were significantly higher after defibrillation (P<0.05). Additionally, recovery of CO was prolonged in the groups with ventricular dysfunction (P<0.05). Temporary post-shock pacing was observed in 40% of patients. CONCLUSIONS A large number of ICD patients with restricted LVEF appears to lack the ability to quickly restore CO and MAP after successful defibrillation. Organ reperfusion may thus still be compromised.

Position dependent right ventricular dysfunction caused by a giant right coronary artery aneurysm

ZusammenfassungWir berichten über einen 79 jährigen Patienten mit einem Riesenaneurysma der rechten Kranzarterie und einem kleineren Aneurysma der Arteria circumflexa sowie ungewöhnlicher Symptomatologie. Riesenaneurysmen (Durchmesser >2 cm) finden sich selten, ihre Prävalenz wird mit 0,02 % angegeben. Sie sind entweder angeborenen Malformationen oder arteriosklerotischen Ursprungs. Obgleich Spontanrupturen von Riesenaneurysmen beschrieben wurden, bleiben sie meist klinisch inapparent oder aber sie führen zu myokardialer Minderperfusion. Der Patient klagte allerdings nicht über typische Angina pectoris Symptome sondern über transiente, positionsabhängige Prä-Synkopen. Die weiterführende kardiologische Diagnostik wie auch die intraoperativen Überlegungen hinsichtlich der Führung des Patienten werden beschrieben. Die chirurgische Manipulation des Riesenaneurysmas war begleitet von einer deutlichen Einschränkung der Rechtsventrikelfunktion und echocardiographisch ebenfalls nachweisbaren regionalen Myokardhypokinesien. Von einer Kanülierung des rechten Vorhofes wurde deshalb Abstand genommen und die venöse Kanüle für die extrakorporale Zirkulation über die Vena femoralis eingebracht. Die folgende Dissektion sowie die chirurgische Sanierung waren unauffällig und die Erholung des älteren Patienten verlief komplikationslos. Dieser Fallbericht unterstreicht dass nach Diagnosestellung, Riesenaneurysmen bei adäquatem perioperativen Management auch noch bei Patienten im höheren Alter chirurgisch versorgt werden können.SummaryWe describe an instructive case of a 79-year-old patient with a giant coronary aneurysm and a second smaller aneurysm with an uncommon symptomatology. Giant coronary artery aneurysms (>2 cm diameter) are rare pathologic entities with a prevalence of 0.02%. They either can be congenital malformations or are atherosclerotic in origin. Although spontaneous rupture of giant coronary artery aneurysms has been reported, they generally remain silent or induce myocardial ischemia. Our patient, however, showed no signs of myocardial malperfusion but transient position-dependent pre-syncope. The cardiologic work-up and the intraoperative considerations regarding patient management are described. During surgery, manipulation of the giant coronary artery aneurysm caused impairment of right ventricular function and regional wall hypokinesia, as assessed by transesophageal echocardiography. Venous cannulation of the right atrium was thus abandoned and extracorporeal circulation was established via the femoral vein. Subsequent dissection and surgical repair were uneventful and further recovery of the elderly patient was uncomplicated. This case underlines that once the diagnosis is established, proper perioperative management enables successful surgical treatment even of patients of advanced age.

Comparison of two new generation pulse oximeters during emergency ambulance transportation.

Objectives We wanted to test whether there is a difference between the total number and duration of malfunctions and a correlation between the oxygen saturation and pulse rate values of two new generation pulse oximeters (Masimo ‘Radical 7’ and Nellcor ‘N 600’) during emergency ambulance transportation. Methods Patients were monitored with two pulse oximeters (‘Radical 7’ and ‘N 600’) on different randomly selected fingers of the same hand during transportation. Data of both devices were recorded continuously by a laptop computer. Results Fifty-two patients with signs of peripheral vasoconstriction (including 22 patients with a blood pressure ≤100/60) were included. There were 0.21 ± 0.72 (0–4) malfunctions per patient lasting for a mean 113.55 ± 272.55 s in the ‘Radical 7’ and 0.13 ± 0.49 (0–3) malfunctions per patient with a mean duration of 301.0 ± 426.58 s in the ‘N 600’. Oxygen saturation and pulse rate values correlated significantly [r2 = 0.9608 (SpO2), r2 = 0.9608 (pulse rate)] between the devices and showed a bias of −0.177770 (SpO2) and 0.310883 (pulse rate) with a standard deviation of 1.68367 (SpO2) and 4.46532 (pulse rate) in a Bland–Altman test. Conclusion Although number and duration of malfunctions did not differ significantly between the devices, they showed a very low number of malfunctions even in hypotensive patients with peripheral vasoconstriction. Oxygen saturation correlated significantly in the two devices investigated at 49.409 time points. In addition, pulse rate also correlated significantly.

Effect of Preload Alterations on Left Ventricular Systolic Parameters Including Speckle-Tracking Echocardiography Radial Strain During General Anesthesia

OBJECTIVES Frequently used parameters for evaluation of left ventricular systolic function are load-sensitive. However, the impact of preload alterations on speckle-tracking echocardiographic parameters during anesthesia has not been validated. Therefore, two-dimensional (2D) speckle-tracking echocardiography radial strain (RS) was assessed during general anesthesia, simulating 3 different preload conditions. DESIGN Single-center prospective observational study. SETTING University hospital. PARTICIPANTS Thirty-three patients with normal left ventricular systolic function undergoing major surgery. INTERVENTIONS Transgastric views of the midpapillary level of the left ventricle were acquired at 3 different positions. MEASUREMENTS AND MAIN RESULTS Fractional shortening (FS), fractional area change (FAC), and 2D speckle-tracking echocardiography RS were analyzed in the transgastric midpapillary view. Considerable correlation above 0.5 was found for FAC and FS in the zero and Trendelenburg positions (r = 0.629, r = 0.587), and for RS and FAC in the anti-Trendelenburg position (r = 0.518). In the repeated-measures analysis, significant differences among the values measured at the 3 positions were found for FAC and FS. For FAC, there were differences up to 2.8 percentage points between the anti-Trendelenburg position and the other 2 positions. For FS, only the difference between position zero and anti-Trendelenburg was significant, with an observed change of 1.66. Two-dimensional RS was not significantly different at all positions, with observed changes below 1 percentage point. CONCLUSIONS Alterations in preload did not result in clinically relevant changes of RS, FS, or FAC. Observed changes for RS were smallest; however, the variation of RS was larger than that of FS or FAC.

Accuracy of Continuous Cardiac Output Measurement With the LiDCOplus System During Intra-Aortic Counterpulsation After Cardiac Surgery

OBJECTIVE To evaluate the effect of intra-aortic counterpulsation on precision, accuracy, and concordance of continuous pulse contour cardiac output determined using LiDCOplus (LiDCO Group, London). DESIGN Prospective trial. SETTING University hospital critical care unit. PARTICIPANTS Patients with intra-aortic balloon pump support in the 1:1 mode after elective or urgent cardiac surgery. INTERVENTIONS Lithium dilution calibrated pulse contour cardiac output was compared with pulmonary artery bolus thermodilution cardiac output during hemodynamically stable conditions in the course of standardized postoperative management. MEASUREMENTS AND MAIN RESULTS Fifty-one paired measurements demonstrated good correlation between the 2 methods (r = 0.88, p<0.001). Mean bias was -0.14±0.81 L/min, limits of agreement 1.48 to -1.77 L/min, and percentage error 28%. Concordance between the 2 techniques regarding directional changes>±10% cardiac output was 100% (p = 0.008). Trending ability was moderate when paired cardiac output changes were assessed using linear regression, 4-quadrant table, and polar plots. When changes <±10% of the reference cardiac output were excluded, 90% of the data pairs still lay within the 30° radial limits. Optimal timing of the balloon pump was indispensable for proper determination of pulse contour cardiac output. CONCLUSIONS Because of the LiDCOplus-specific algorithm in determining stroke volume from the arterial pulse waveform, which differs from other devices, accuracy and precision of continuous pulse contour cardiac output only are affected insignificantly by intra-aortic counterpulsation. The authors nevertheless caution that the device should be recalibrated after major hemodynamic alterations or otherwise inexplicable changes of the pulse contour cardiac output to improve trending.

Hyperglycaemia worsens neurocognitive function after implantation of an internal cardioverter/defibrillator (ICD): P-77

Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, University Hospital, Vienna, Austria Introduction: Hyperglycaemia has a negative impact on neurologic outcome after cerebral ischaemia [1]. ICD implantation requires repetitive brief induction of ventricular fibrillation with global hypoperfusion [2]. We evaluated whether diabetes mellitus (DM) also affects neurocognitive function after these iatrogenically induced cardiac arrests. Method: We investigated 25 patients (18 without DM and 7 with DM) scheduled for elective ICD insertion in monitored anaesthesia care. Immediately prior to induction of each ventricular fibrillation 0.1 mg/kg etomidate was administered as the sole anaesthetic. The Digit Span forward (DSTf) and backward test (DSTb) as well as the Mini Mental State Exam (MMSE) were performed preand three days postoperatively. The maximum scores that can be obtained in these tests are 60, 50 and 30 points, respectively. These tests have already been used in the postoperative setting after cardiac surgery [3]. Results: On average, two shocks were applied per patient without group differences. Preoperative blood glucose was 5.6 0.7 vs. 8.5 2.5 mmol/L (P 0.008, t-test) in No DM and DM patients, respectively. Neurocognitive test results (median with 25 and 75 percentiles) are given below: