Bupivacaine-induced seizure after accidental intravenous injection, a complication of epidural anesthesia

A technique is presented to eliminate the residual gradient more completely after removing the main pulmonary band at the time of primary repair of ventricular septal defect. The band and underlying pulmonary artery are circumferentially excised, except for a small posterior part, and pulmonary artery is reanastomosed.     

Lung transplantation for primary pulmonary hypertension and giant pulmonary artery aneurysm

We report the case of an 18-year-old patient with a giant pulmonary artery aneurysm and primary pulmonary hypertension who was successfully treated with bilateral lung transplantation and complete reconstruction of the pulmonary artery.     

An intimal sarcoma of the pulmonary artery. An immunohistochemical study

Pulmonary artery intimal sarcomas tend to be presented with symptoms of pulmonary thromboembolism and grow regionally, with little capacity to metastasize. They probably originate from subendothelial cells, that become myofibroblasts. Knowledge of it is important to establish a presurgery diagnosis, with the possibility of a total resection, the only useful treatment until now. We report a case of a pulmonary artery primary sarcoma, in a 73 year old woman, admitted with hemoptysis and pleuritic chest pain, who died ten days after. Autopsy revealed an intraluminal mass at the pulmonary artery trunk, without regional nor distance involvement. Microscopic study showed a pleomorphic tumor with spindle and epithelioid cells, positive for actin, desmin and vimentin. All these data support the diagnosis of primary intimal sarcoma of the pulmonary artery. We want to emphasize the myogenic differentiation of the tumor, uncommon in previously reported cases.     

False-positive diagnosis of pulmonary hypertension by Doppler echocardiography

A 37-yr-old female presented with a history of several months of exertional dyspnoea. A diagnosis of primary pulmonary hypertension was suspected on the basis of a negative extensive cardiorespiratory work-up with a systolic pulmonary artery pressure of 41-46 mmHg calculated from repeated measurement of the maximum velocity of tricuspid regurgitation jets at 2.8-3 m x s(-1) by continuous-wave Doppler echocardiography. However, a right heart catheterization with a high-fidelity transducer-tipped catheter revealed pulmonary artery pressures of 22/8 mmHg at rest, which remained within normal limits at exercise. This case indicates a possible misleading overestimation of pulmonary artery pressures from Doppler echocardiographic studies of tricuspid regurgitation.     

Clinical results of the staged Fontan procedure in high-risk patients

BACKGROUND: For high-risk Fontan candidates, the introduction of a bidirectional Glenn shunt before total cavopulmonary connection (a two-staged strategy) may extend the indications for the Fontan procedure. The clinical results of the two-staged and one-staged Fontan procedure were thus reviewed and compared. METHODS: Between November 1991 and July 1996, the two-staged strategy was performed in 40 high-risk Fontan candidates with a mean interval of 17.2 months after introducing the bidirectional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (> or =20 mm Hg), high pulmonary vascular resistance (> or =3 Wood units), small pulmonary artery (Nakata index <200 mm2/m2), atrioventricular valve incompetence (> or = moderate), distortion of pulmonary artery, anomalous pulmonary venous return, and poor ventricular function as risk factors for the successful completion of Fontan circulation. During the same period, 68 patients underwent the modified Fontan procedure in a one-step fashion (primary group). RESULTS: In the staged group after the bidirectional Glenn shunt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demonstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality was also similar and low in both groups (1.5% in the primary group and 0% in the staged group). CONCLUSIONS: A bidirectional Glenn shunt was found to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure.     

Central venous catheter use in low-risk coronary artery bypass grafting

BACKGROUND: To assess the impact of central venous pressure catheter monitoring in low-risk coronary artery bypass grafting (CABG), we compared the hospital course of patients undergoing CABG with central venous pressure catheter monitoring with that of similar patients undergoing CABG with pulmonary artery catheter monitoring. METHODS: All isolated primary CABG procedures (n = 312) performed between April 22 and October 31, 1996, were evaluated, and 194 patients meeting six central venous pressure catheter use criteria were identified. Of these 194 patients, 133 (68%) underwent CABG with central venous pressure catheter monitoring, and 61 (32%) had pulmonary artery catheter monitoring owing to surgeon or anesthesiologist preference. RESULTS: In-hospital mortality was similar. A trend toward increased overall complications was seen in the pulmonary artery catheter group. The total volume infused in the first 12 hours, the 24-hour weight gain, and the intubation time were significantly greater in the pulmonary artery catheter group. Increases in intensive care unit length of stay and in total hospital charges trended toward statistical significance in the pulmonary artery catheter group. CONCLUSIONS: Pulmonary artery catheter use in low-risk patients undergoing CABG was associated with greater weight gain and longer intubation time and may be associated with increased morbidity and utilization of hospital resources.     

Determinants of the pulmonary artery pressure rise in left ventricular dysfunction

Pulmonary artery hypertension in patients with left ventricular dysfunction is related to poor outcome but the role of cardiac functional abnormalities in the genesis of pulmonary hypertension remains unknown. The aim of this prospective study was to identify the determinants of pulmonary hypertension in 102 consecutive patients with primary left ventricular dysfunction (ejection fraction < 50%). Systolic pulmonary artery pressure was measured by continuous wave Doppler. Left ventricular systolic and diastolic function, severity of functional mitral regurgitation, cardiac output, and left atrial volume were assessed using Doppler echocardiography. In patients with left ventricular dysfunction, systolic pulmonary artery pressure was increased (51 +/- 14 mmHg, range 23 to 87 mmHg). Mitral deceleration time (r = -0.61; p = 0.0001) and mitral effective regurgitant orifice (r = 0.50; p = 0.0001) were the strongest parameters related to systolic pulmonary artery pressure. Multivariate analysis identified these two variables as the strongest predictors of systolic pulmonary artery pressure in association with the mitral E/A ratio (p = 0.006) and age (p = 0.005). In conclusion, pulmonary hypertension is common and variable in patients with left ventricular dysfunction. It is closely related to diastolic dysfunction and severity of functional mitral regurgitation but not independently to the degree of left ventricular systolic dysfunction. These findings underline the importance of assessing diastolic function and quantifying mitral regurgitation in patients with left ventricular dysfunction.     

Characteristics of pulmonary artery pressure waveform for differential diagnosis of chronic pulmonary thromboembolism and primary pulmonary hypertension

OBJECTIVES: The accurate diagnosis of chronic pulmonary thromboembolism (CPTE) is a prerequisite for life-saving surgical interventions. To help in the differential diagnosis of CPTE and primary pulmonary hypertension (PPH), we characterized the configuration of the pulmonary artery pressure waveform. BACKGROUND: Because CPTE predominantly involves the proximal arteries, whereas PPH involves the peripheral arteries, we hypothesized that patients with CPTE would have stiff or high resistance proximal arteries, whereas those affected by PPH would have high resistance peripheral arteries. These differences in the primary lesions would make arterial pulsatility relative to mean pressure larger in CPTE than in PPH. METHODS: In 34 patients with either CPTE (n = 22) or PPH (n = 12) whose pulmonary systolic pressure was > or = 50 mm Hg, we measured pulmonary artery pressure using a fluid-filled system that included a balloon-tipped flow-directed catheter. RESULTS: To quantify the magnitude of pulsatility relative to mean pressure, we normalized pulse pressure by mean pressure, hereinafter referred to as fractional pulse pressure (PPf). PPf was markedly higher in CPTE than in PPH (mean [+/-SD] 1.41 +/- 0.20 and 0.80 +/- 0.18, respectively, p < 0.001) and was diagnostic in separating the two groups without overlap. Similarly, the coefficient of variation of pulmonary artery pressure also separated the two groups without overlap (0.45 +/- 0.06 and 0.25 +/- 0.06, respectively, p < 0.001). Fractional time to half the area under the pressure curve separated the two groups reasonably well (0.35 +/- 0.02 and 0.43 +/- 0.03, respectively, p < 0.001). CONCLUSIONS: The analysis of pulsatility of pulmonary artery pressure is useful in the differential diagnosis of CPTE and PPH.     

Differential diagnosis of various forms of primary aldosteronism

The blood pressure was investigated in the common left carotid artery (LC), in the left atrium (LA), in the pulmonary artery (PA) and in the right atrium (RA). After adrenaline injection the blood pressure rised rapid and simulatneously in all four regions. After vasopressin injection the blood pressures rised sequence in LC, in LA and PA. The blood pressure in RA in this time was unchanged. These results indicate that primary causes of the lung oedema after adrenaline or vasopressin are different.     

Digital clubbing associated with pulmonary artery sarcoma

A case of digital clubbing in a patient with pulmonary artery sarcoma and severe pulmonary hypertension is presented. The differential diagnosis of clubbing and clinical features of pulmonary artery sarcoma are reviewed with emphasis on the possible association of clubbing with pulmonary artery sarcoma.     

Variation in the size and distensibility of the pulmonary arteries in d-transposition of the great arteries

The relative size of the main pulmonary artery was determined from cineangiograms of 117 patients with d-transposition of the great arteries by calculating the ration between the diameters of the main pulmonary artery and aorta. The pulmonary artery was largest in patients with ventricular septal defect or patent ductus arteriosus, or both, because of increased pulmonary arterial pressure and flow. In patients with an intact ventricular septum or with left ventricular outflow tract obstruction, or both, the main pulmonary artery was approximately the size of the aorta. Two cases of d-transposition and gross dilatation of the main pulmonary artery and hypoplastic first branch pulmonary arteries are presented. In these cases the ratio between the diameters of the main pulmonary artery and aorta was greater than in any of the other 117 cases studied...     

Clinical results after en block double lung transplantation with direct bronchial revascularization. The first three and a half years' experience in Denmark

En-bloc double lung transplantation with tracheal anastomosis and direct revascularization of the bronchial arteries to the left internal mammary artery has been carried out in Denmark since June 1992. Forty-seven patients (32 with alfa-1 antitrypsin deficiency, 11 with chronic obstructive pulmonary disease, two with cystic fibrosis and two with primary pulmonary hypertension), 25 men and 22 women, average age 39 years (17-64 years), have received their first double-lung transplant with bronchial artery revascularization. Arteriography of the internal mammary artery and bronchial arteries was performed in 42 (89%) of the patients from 1-150 days after the operation. Successful bronchial artery revascularization was demonstrated arteriographically in 40 patients, in two patients the arteriography failed to show bronchial artery revascularization. Arteriography was not performed in five patients due to early complications and death. Bronchoscopy showed rapid, uncomplicated airway healing in 42 patients. Mucosal necrosis under the tracheal anastomosis was found in three patients, and severe obstructive endobronchial growth of the fungus Aspergillus fumigatus was diagnosed in the last two patients. The one- and two-year survival is 83% (Kaplan-Meier). Eleven patients are dead, five due to pulmonary causes and six due to extra-pulmonary causes. Pulmonary function became normal in nearly all surviving patients between three to six months after the transplantation. In conclusion, en-bloc double-lung transplantation with bronchial artery vascularization has shown good short-term results, and the one- and two-year survival gives hope that a successful bronchial artery revascularization will improve the long-term survival following lung transplantation.     

Radiographic signs of cor pulmonale (author's transl)

The pulmonary artery pressure of 47 patients was compared with radiological criteria of pulmonary hypertension: in rest and exercise. The diameter of the truncus intermediul is the only measurable criterium. A diameter larger than or equal to 18 mm is an indication for latent or manifest cor pulmonale. If the diameter is less than or equal to 15 mm a pulmonary hypertension is improbably. Additional findings (primary pulmonary disease, diameter of the truncus pulmonalis, loss of lung vessel structure in the periphery, marked reduction in vessel caliber--graded 0-3) leads to the diagnosis of manifest cor pulmonale on the basis of routine x-ray of the chest. The differentiation between manifest and latent cor pulmonale ist possible in most cases. An overestimation of the primary lung disease, particularly by fibrosis, may mistead from the correct diagnosis.     

Protein fold irregularities that hinder sequence analysis

Cicletanine, a furopyridine-derivative drug, was shown to enhance the production of endogenous prostacyclin. The potent vasodilating properties of prostacyclin are used to treat severe primary pulmonary hypertension. Prostacyclin has a short half-life and can be administered only as an i.v. infusion. The aim of this study was to evaluate the effects of cicletanine on pulmonary artery hypertension (PAH) resulting from chronic obstructive lung disease (COLD). In a double-blind controlled study, we evaluated the effects of short- and long-term administration of cicletanine (50 mg daily, orally) on hemodynamics and blood gases of patients with PAH resulting from COLD. The initial dose of 50 mg of cicletanine had no effect. A significant decrease in the mean pulmonary artery pressure (15%) and in total pulmonary resistance (20%) was observed after 3 or 12 months of treatment in the cicletanine group (11 patients), when compared with placebo (12 patients). PaO2 decreased slightly in the cicletanine group, but the difference from the control group was not significant. These results suggest that long-term treatment with cicletanine can induce effective pulmonary vasodilation in patients with PAH caused by COLD and that this is probably responsible for a small venous admixture.     

Device to limit inflation of a pulmonary artery catheter balloon

OBJECTIVE: The most serious complication seen with pulmonary artery catheters is rupture of the pulmonary artery. The effectiveness of an external safety balloon added to the pulmonary artery balloon inflation port was tested. DESIGN: The external balloon is designed to inflate and absorb excess volume from the inflation syringe after the internal balloon contacts the vessel wall. When the catheter tip is in a small pulmonary artery, expansion of the external balloon indicates that the catheter tip is in a noncompliant or small vessel. SETTING: The external balloon was tested in a bench simulation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The pulmonary artery balloon was slowly inflated inside 2.6-, 3.0-, 4.7-, 8.6-, and 11.6-mm internal diameter polyvinyl chloride tubes, with and without the external safety device in place. Without the external balloon, the average balloon pressure was 1647 +/- 145 (SD) mm Hg in the 2.6-mm vessel. With the external balloon in use, the maximum pulmonary artery balloon pressure was 473 +/- 7.2 mm Hg in the 2.6-mm vessel. CONCLUSIONS: The external balloon can limit balloon pressures within the pulmonary artery and identify when excessive volumes are being forced into the pulmonary artery balloon.     

Pulmonary hypertension: newer concepts in diagnosis and management

Pulmonary hypertension comprises a family of disorders occurring as a primary disease or as a complication of a large number of respiratory and cardiac diseases. Pulmonary hypertension is present when pulmonary artery pressure or mean pressure exceeds 30 mmHg or 20 mmHg, respectively. Underlying the hemodynamic changes that result in pulmonary hypertension, whether from hypoxia, acidosis, increased pulmonary blood flow, increased shear stress, or idiopathic causes, is a dysfunctional vascular endothelium. In this review, the role of the history and physical examination in the initial assessment is emphasized. Newer diagnostic modalities, such as subselective pulmonary angiography and ultrafast computed tomography scanning, are reviewed. Low-flow oxygen, anticoagulation, and calcium-channel blockade are presented as accepted therapeutic modalities. Inhaled nitric oxide and prostacyclin infusion are presented as newer therapies that may be useful given the limited availability of donor organs for hear-lung transplantation. Future therapeutic strategies are likely to develop from advances in vascular biology.     

Altitude-related illnesses

Altitude-related illnesses are a frequent cause of morbidity and occasional mortality in travelers to high altitudes in the United States and throughout the world. The primary altitude illnesses are acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema. The pathogenesis of these syndromes remains unclear despite considerable research. Altitude also has potential deleterious effects on common medical conditions including coronary artery disease, pulmonary disease, hemoglobinopathies, and pregnancy. Most of these problems are primarily preventable with appropriate information before travel. Education should include information about rate of ascent, diet, alcohol intake, physical activity, and preventive medications, including acetazolamide, nifedipine, and dexamethasone in selected circumstances.     

Effect of consecutive administration of obsidan and novodrin on pulmonary circulation in anesthesized dogs

It was established in experiments on mongrel anesthesized dogs that the beta-blocking agent obsidan (propranolol) in a dose of 0.5-1.0 mg/kg causes an increase in total pulmonary and pulmono-arteriole resistance, which correlates with the decrease in volume blood flow in the pulmonary arteries. The pressure in the pulmonary artery and the left atrium does not change substantially. Injection of 0.25-0.5 mg of novodrin increases the volume blood flow, causes no effect on pressure in the left atrium, and reduces total pulmonary resistance. The changes occurring in pulmonary circulation under the effect of beta-adrenergic agents depend on their primary action on cardiac activity whereas the increase in total pulmonary and pulmono-arteriole resistance depends on the secondary spasm of the pulmonary vessels.     

Pulmonary artery catheterisation

The introduction of balloon-tipped pulmonary artery flotation catheters revolutionised monitoring of the cardiovascular system and the management of seriously ill patients. Advances in design allow direct measurement of cardiac output and continuous mixed venous oxygen saturation, while intracardiac electrocardiogram monitoring and passage of pacing wires is now possible. The technique of insertion must be meticulous as must the method of obtaining central venous, pulmonary artery, pulmonary artery wedge and pulmonary capillary wedge pressures. Sources of error are highlighted as are methods to avoid and detect them. Correct interpretation of the data is essential for proper patient management and must be taken in light of information obtained by other methods. Complications of insertion are numerous and potentially serious or even lethal. It is mandatory that the information obtained by insertion of a pulmonary artery catheter be used to optimize patient management.     

Lipopolysaccharide and interleukin 1 augment the effects of hypoxia and inflammation in human pulmonary arterial tissue

The combined effects of hypoxia and interleukin 1, lipopolysaccharide, or tumor necrosis factor alpha on the expression of genes encoding endothelial constitutive and inducible nitric oxide synthases, endothelin 1, interleukin 6, and interleukin 8 were investigated in human primary pulmonary endothelial cells and whole pulmonary artery organoid cultures. Hypoxia decreased the expression of constitutive endothelial nitric oxide synthase (NOS-3) mRNA and NOS-3 protein as compared with normoxic conditions. The inhibition of expression of NOS-3 corresponded with a reduced production of NO. A combination of hypoxia with bacterial lipopolysaccharide, interleukin 1 beta, or tumor necrosis factor alpha augmented both effects. In contrast, the combination of hypoxia and the inflammatory mediators superinduced the expression of endothelin 1, interleukin 6, and interleukin 8. Here, we have shown that inflammatory mediators aggravate the effect of hypoxia on the down-regulation of NOS-3 and increase the expression of proinflammatory cytokines in human pulmonary endothelial cells and whole pulmonary artery organoid cultures.