Utility of transesophageal echocardiography and pulmonary artery catheterization during laparoscopic assisted abdominal aortic aneurysm repair

BACKGROUND: Advanced laparoscopic procedures are more commonly performed in elderly patients with cardiac disease. There has been limited data on the use of pulmonary artery catheters (PAC) and transesophageal echocardiography (TEE) to monitor hemodynamic changes. METHODS: We prospectively studied eight patients undergoing laparoscopic assisted abdominal aortic aneurysm repair. All patients had a PAC and all but one had an intraoperative TEE. Data included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex) and was obtained prior to induction, during insufflation, after desufflation, during aortic cross-clamp, and at the end of the procedure. End diastolic area (EDA), a reflection of volume status, was measured on TEE. ANOVA was used for data analysis. RESULTS: No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. PAD and CVP were greater during insufflation compared with baseline and aortic cross-clamp without associated changes in EDA. MAP was higher at baseline compared with all other times during the procedure. CONCLUSIONS: Insufflation increased PAD and CVP. However, volume status as suggested by EDA and PCWP did not change. These data question the reliability of hemodynamic measurements obtained from the PAC during pneumoperitoneum and suggest that TEE may be sufficient for evaluation of volume status along with the added benefit of timely detection of ventricular wall motion abnormalities.     

A new operative technique for pulmonary artery banding: adjustment of pulmonary artery bands by mitral valve flow velocity

We developed a new technique to adjust the pulmonary artery band at surgery by monitoring the mitral valve flow velocity, which is indirectly indicative of the pulmonary flow. We employed this technique for 10 consecutive patients aged from 5 days to 5 months (mean, 1 months) weighing from 2.7 to 4.4 kg (mean, 3.3 kg). Underlying disease was aortic coarctation or interrupted+ventricular septal defect in 7 patients, single ventricule in 1 patients and miscellaneous defects in 2 patients. The pulmonary artery was exposed through a left lateral thoracotomy and a 3 mm wide Teflon tape was placed around the main pulmonary artery. The transducer of the Doppler echocardiography was placed along the left sternal border. The band was tightened gradually until the maximum velocity of the mitral valve flow decreased to around 70% of the previous level. During banding procedure, arterial oxygen saturation, heart rate and left ventricular contractility were monitored continuously. If bradycardia, unacceptable hypoxemia or ventricular dysfunction occurred, the band was released. The mitral valve flow velocity decreased rapidly by just a little additional tightness of the band between the range of 50% to 80% of the previous level. This technique enabled a very fine adjustment (less than 0.5 mm plication) and postoperative management has become very easy. Although there is a limitation of this technique that monitoring of the mitral valve flow velocity cannot be applied to the patients with significant interatrial shunt or mitral regurgitation, we conclude that this technique is simple and useful to obtain the optimum constriction of the pulmonary artery with excessive pulmonary blood flow.     

Giant coronary artery pseudoaneurysm causing pulmonary artery obstruction: a rare complication of coronary bypass surgery--a case report

The authors report the diagnosis and successful management of a 57-year-old man with right ventricular outflow tract obstruction from a large pseudoaneurysm of the left anterior descending coronary artery 5 years after he had undergone redo coronary artery bypass grafting.     

A multicenter evaluation of a new continuous cardiac output pulmonary artery catheter system

OBJECTIVE: To validate a new system of continuous cardiac output monitoring. DESIGN: Multicenter, prospective, nonrandomized clinical study. SETTING: Four university hospitals. PATIENTS: Forty-seven adult intensive care unit patients. INTERVENTIONS: Pulmonary artery catheterization. MEASUREMENTS AND MAIN RESULTS: Continuous and bolus cardiac output measurements were obtained over 72 hrs. The 327 continuous cardiac output measurements compared favorably with bolus cardiac output measurements (bias = 0.12 L/min, precision = +/-0.84). The continuous cardiac measurement was not adversely affected by temperatures of <37 degrees C or >38 degrees C, high (>7.5 L/min) or low (<4.5 L/min) cardiac output values, or duration (72 hrs) of the study. CONCLUSIONS: This continuous cardiac output system provides a reliable estimate of cardiac output for clinical use if applied in conditions similar to this study. The combination of a continuous measure of cardiac output with other continuous physiologic monitoring (arterial and mixed venous oxygen saturation, oxygen consumption, etc.) may provide important information that no single parameter could achieve.     

Inadvertent catheterization of the hepatic artery during placement of transjugular intrahepatic portosystemic shunts

Inadvertent catheterization of the hepatic artery may occur during placement of transjugular intrahepatic portosystemic shunts (TIPS). The authors treated this complication in three patients (one man, aged 60 years; two women, aged 50 and 52 years) by embolizing the transparenchymal tract leading to the hepatic artery and performing hepatic angiography after completion of TIPS placement. No sequelae were noted at follow-up of any of these patients.     

Coronary artery dissection - a complication of cardiac catheterization without sequelae: case report and review of the literature

This report describes an acute right coronary artery dissection occurring during diagnostic cardiac catheterization. Following catheter manipulation in the vicinity of the aortic valve, the patient complained of mild chest discomfort and had transient electrocardiographic evidence of acute inferior wall myocardial infarction with runs of 2:1 atrioventricular block. Within 5 min, the EKG reverted to precatheterization appearance, and the patient was asymptomatic. Coronary angiography revealed a dissection of the proximal vessel without obstruction. The patient had no clinical sequelae while monitored in the intensive care unit. The patient underwent elective aortic and mitral valve replacement. The area of the dissection was directly visualized, and no abnormality was noted. We review the literature of spontaneous and iatrogenic coronary artery dissections with regard to pathology, diagnosis, and prognosis, and make recommendations for therapy.     

Flow-dependent pulmonary vasodilation during acute unilateral pulmonary artery occlusion in Jungle Fowl

Giant Jungle Fowl previously were shown to be highly resistant to the onset of pulmonary hypertension syndrome (PHS, ascites) under conditions that induce a substantial incidence of PHS in broiler chickens. In the present study, lightly anesthetized, clinically healthy 12- to 13-wk-old male Giant Jungle Fowl maintained a lower respiratory rate, a similar hematocrit, and superior arterial blood gas values when compared with 6-wk-old male broilers. Giant Jungle Fowl weighed less than broilers (1,860 +/- 19 vs 2,788 +/- 63 g, respectively) and had equivalent absolute values for pulmonary arterial pressure, cardiac output, and pulmonary vascular resistance. Acute unilateral pulmonary artery occlusion in Giant Jungle Fowl doubled the pulmonary vascular resistance and forced the right ventricle to propel a sustained 60% increase in blood flow through the vasculature of the unoccluded lung. A transient increase in pulmonary arterial pressure initially was required to overcome the vascular resistance of the unoccluded lung; however, flow-dependent vasodilation gradually reduced the pulmonary vascular resistance and permitted pulmonary arterial pressure to return toward control levels. Unilateral pulmonary artery occlusion also triggered an immediate reduction in the partial pressure of oxygen in arterial blood, and the gradual return of pulmonary arterial pressure toward control levels did not eliminate this ventilation-perfusion mismatch, which has been attributed to blood flowing too rapidly through the unoccluded lung to permit diffusive gas equilibration. The inherent capacity for flow-dependent pulmonary vasodilation may reduce the susceptibility of Giant Jungle Fowl to PHS by reducing the increment in pulmonary arterial pressure required to propel an elevated blood flow through the lungs.     

Neonatal bladder rupture: an unusual complication of umbilical catheterization

Bladder injury in the neonatal period is an exceedingly rare phenomenon that is usually iatrogenic. Bladder rupture as a complication of umbilical catheterization in a newborn with urinary ascites, respiratory distress and hematuria is presented and discussed.     

Left main coronary artery compression during primary pulmonary hypertension

Primary pulmonary hypertension (PPH) is often associated with angina-like chest pain, the mechanism of which is controversial. A 37-year-old woman with severe PPH and angina had transient ischemic ECG changes and reversible anterior perfusion defect on 201thallium scintigraphy. Coronary angiography revealed severe stenosis of the left main coronary artery (LMCA) and otherwise normal vessels. After heart-lung transplantation, examination of the explanted heart showed normal coronary arteries. Compression of the LMCA by the dilated pulmonary artery trunk was responsible for myocardial ischemia. This mechanism should be considered in patients with PPH and angina and might contribute to the high sudden death rate.     

Aortic aneurysm developing after umbilical artery catheterization

A variety of complications of umbilical vessel catheterization in the newborn have been reported by earlier investigators. This paper describes a case in which umbilical artery catheterization probably gave rise to an aortic aneurysm. The histological findings suggested that the hypoxic changes in the aortic wall as well as the mechanical effect of the catheter were involved in the origin of the aneurysm.     

Anomalous left pulmonary artery without pulmonary artery sling

Although most news surrounding the declining dollar has concentrated on its impact on Canadian shoppers, economists say it is bound to affect the financially strapped health care system too. They point out that many of the good purchased by Canadian hospitals come from the US, and the weak loonie means their price will rise.     

Intraoperative transesophageal and contrast echocardiographic detection of an unusual complication associated with a misplaced pulmonary artery catheter

The penetration of four radioiodinated materials-Tyr-MIF-1, DAMGO, tyrosine, and albumin-into the periventricular tissue after ICV injection was studied in rats by film autoradiography. Rates of disappearance from the CNS for the injected compounds were also determined by computer-assisted image analysis of the autoradiographic images. The four materials showed distinct patterns of dispersion from the ventricular system, with Tyr-MIF-1 moving farthest into the parenchyma of the brain and albumin primarily restricted to the ventricular space. The other two compounds, tyrosine and DAMGO, had intermediate values. Tyr-MIF-1 also displayed the fastest rate of removal from the brain, which may represent the ability of the peptide to gain access to sites of saturable transport. By contrast, the exit from the brain of DAMGO was minimal, whereas the efflux of albumin and tyrosine was intermediate. These results show the utility of these methods in the simultaneous measurement of both the patterns of distribution within the CNS and the rates of removal from the CNS of compounds injected into the brain.     

Ruptured pseudoaneurysm of the splenic artery. A complication of chronic pancreatitis

HISTORY AND FINDINGS: A pale looking 33-year-old man with a history of perforated gastric ulcer and pancreatitis with surgically drained pseudocyst was admitted because of painless anal bleeding. Heart rate was 100/min, blood pressure 90/60 mm Hg. INVESTIGATIONS: Haemoglobin concentration (6.3 g/dl) and RBC count (2.4 mill./microliters) indicated anaemia due to bleeding. Sonography and computed tomography demonstrated chronic calcifying pancreatitis and thrombosis of splenic and mesenteric veins. There were grade 1 oesophageal varices on endoscopy. The source of bleeding was found by coloscopy to be a submucous pulsating tumour in the region of the left flexure, which on angiography was an aneurysm of the splenic artery. TREATMENT AND COURSE: The pseudoaneurysm of the splenic artery, which had perforated into the colon, was resected together with a partial pancreas excision and splenectomy. There were no complications and the patient was discharged symptom-free after 15 days, and there had been no further bleeding 6 months later. CONCLUSION: Pseudoaneurysm of a visceral artery is a rare, but life-threatening, complication of pancreatitis. Treatment options are operation and/or interventional catheter embolisation.     

Anterior spinal artery syndrome after thoraco-abdominal esophagus resection. A rare complication

We report a case of postoperative paraplegia resembling an anterior spinal artery syndrome after curative esophagectomy in a patient with carcinoma of esophagus and clinical stage III (UICC). Neurologic deficit was characterized by loss of sensibility at the level of T12/L1 together with paraparesis of both lower extremities. Furthermore, dissociated sensorimotor depletion at C6/C7 (right-sided) and at T5 (left-sided) was noted. This severe complication was most probably caused by peeling of an arteriosclerotic plaque of the thoracic aorta due to preexisting advanced arteriosclerosis, leading to a partial occlusion of the great radicular artery of Adamkiewicz. Even though anterior spinal artery syndrome is a well-known problem in the operative management of thoracic aortic aneurysms, this complication has not previously been reported after esophagectomy.