Christopher J. Plambeck

Sudden cardiac death resulting from acute coronary artery aneurysm occlusion: successful resuscitation and treatment of an adolescent boy with previously unrecognized Kawasaki disease.

Kawasaki disease (mucocutaneous lymph node syndrome) is an inflammatory vasculitis of unknown etiology that is the most common cause of acquired coronary artery disease in children between 6 months and 5 years of age. Kawasaki disease is also the leading cause of acquired pediatric heart disease in the United States, exceeding rheumatic heart disease. Originally described and most common in Japan, Kawasaki disease is more prevalent in children of Asian or Pacific Island extraction compared with those of African-American or White decent. The disease affects boys more frequently than girls, occurs before the age of 5 years in more than three-quarters of affected children, and carries an overall mortality rate of approximately 0.17%.

Changing the Laryngoscope Blade and Its Effect on Laryngeal Visualization

To the Editor: Amour and colleagues compared single-use with reusable metal laryngoscope blades and found better laryngeal exposure and more successful intubation with the former. Laryngeal visualization and subsequent tracheal intubation are dependent, however, on many other factors besides the blade type. Upper airway anatomy, experience of the laryngoscopist, adequate relaxation, patient’s head and neck position, external laryngeal manipulation, blade size, and the laryngoscope lifting force are all factors that can dramatically affect the ability to visualize the larynx. Therefore, to separate out the effect of one factor on laryngeal visualization, all of the other factors will have to be standardized. The authors should be applauded for trying to control most of the factors. Two important factors, however, were not addressed: the use of external laryngeal manipulation and the laryngoscope lifting force. There was no mention in the study of whether external laryngeal manipulation was used in some patients, all patients, or none; whether it was used during the first attempt, second attempt, both, or neither; and most importantly, whether the documented laryngoscopic grade was the one before or after its application, if it was applied. The use of external laryngeal manipulation can improve visualization by a whole grade and, in some patients, can be the factor that makes the difference between intubation failure and success. Similarly, there was no mention of whether any attempt was made to standardize the laryngoscope lifting force. Increasing the force can be accompanied by a change in the resultant view, and this increase can occur in response to a poor view without the laryngoscopist even being aware of it. The forces applied during laryngoscopy can be measured, and thus controlled, by a device that can be used for both clinical research and patient care purposes. There is no doubt that the metal single-use blade provided better illumination, but was the difference in the results solely caused by the light factor or also influenced by the effect of the other factors that were not addressed? The results could have been more informative if these two factors were also standardized, especially because, as the authors themselves mentioned, it is extremely difficult to keep such a study blinded.

A Small Circular Structure in the Right Atrium: A Cause for Right Atrial and Ventricular Dilatation?

From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI; and †Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. Address reprint requests to Paul S. Pagel, MD, PhD, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 West National Avenue, Milwaukee, WI 53295. E-mail: pspagel@ mcw.edu

Feeling the pressure? Anterior mitral leaflet immobility in a patient with bicuspid aortic valve disease.

t s l t p t A 32-YEAR-OLD, 87-kg, 173-cm man with a past medical history of a congenital bicuspid aortic valve was admitted o the authors’ hospital for evaluation of dyspnea on exertion. he patient had been a frequent participant in strenuous athletic ctivities including full-court basketball. He reported that his tamina during these activities had declined substantially in ecent months. The patient also described unusual episodes of atigue while performing his job as a biomedical engineer. He enied a history of angina pectoris, syncope, palpitations, orhopnea, paroxysmal nocturnal dyspnea, and peripheral edema. he physical examination was notable for a grade III of VI olodiastolic murmur heard best along the left sternal border. n Austin Flint murmur1 was not appreciated. The remainder of the physical examination was noncontributory. Noninvasive measurements of arterial blood pressure indicated the presence of a widened pulse pressure (75-80 mmHg). A plasma brain natriuretic peptide concentration was normal. Transesophageal echocardiography (TEE) was performed as part of the evaluation and confirmed the presence of a bicuspid aortic valve with thickened anterior-lateral (left and right coronary cusp fusion;