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Pregnancy exacerbates heart diseases. The aim of this clinical report is to review the different anesthesiological management of emergent cesarean section in 2 patients with heart failure. The pathophysiology of heart failure is described according to the primary cause of disease, as well as the impact of 2 different anesthetic techniques. Two case reports of a university referral hospital are presented. Both patients left the hospital in good general conditions. Case 1: a pregnant patient with severe aortic regurgitation who received epidural anesthesia. Case 2: a pregnant patient with peripartum cardiomyopathy who was given general anesthesia. Medical and surgical therapies for aortic regurgitation and peripartum dilated cardiomyopathy are evolving. Adequate knowledge of anesthesiology is required to appropriately manage these cases. We tailored the anesthetic technique to the specific characteristics of our 2 patients. The beneficial effects of sympathectomy were observed in the postoperative period of case 1; the use of high doses opiates minimised dangerous cardiovascular changes in case 2, but rapid resuscitation of the baby should be available. Selection of the anesthetic technique in obstetrics is the most challenging issue for the anesthesiologist: extensive knowledge of the pathophysiology of heart disease is required for an optimal choice.

The natural history of patients with coronary artery disease and diastolic dysfunction who underwent coronary artery bypass grafting (CABG) is not well known. The aims of our study were to evaluate the incidence of diastolic dysfunction, its evolution after CABG and its possible correlation with adverse in-ICU prognosis. We studied 88 consecutive patients scheduled for CABG with not severely depressed left ventricular function (ejection fraction > 35%) and multivessels disease. Buckberg cardioplegia was used for myocardial protection. Diastolic function was investigated by recording mitral and venous pulmonary flow by transesophageal Doppler echocardiography (TEE). TEE examination was performed in operative room pre and post-bypass, at ICU arrival and after three months. Diastolic dysfunction was defined as mild, moderate and severe. Adverse in ICU events were defined as: use of inotropic drugs or ventricular mechanical support, an ICU stay > 24 hours, perioperative myocardial infarction and death. The study group was compared with a control group. T-Student test was used; a p < 0.05 was considered significant. A reduced diastolic function was present in 77% of patients at baseline examination. Diastolic dysfunction did not worsen significantly after hypothermic cardiac arrest and reperfusion. It persisted during ICU stay and normalized after three months from CABG in the majority of patients (85%). Diastolic failure was not associated with an adverse ICU prognosis (adverse events: 18 versus 13%; p = ns).

Background: The purpose of this study was to investigate whether the combined positive inotropic and vasodilating properties of enoximone have a short-term benefit when used in patients who underwent open heart surgery., Methods: From 7/1994 to 1/1995 twenty-six patients with severe myocardial dysfunction (ejection fraction < 35%) were enrolled into a prospective trial before undergoing coronary artery bypass graft. They were randomly selected into two study groups: the first treated with enoximone (group E) and the other one with dopamine (group D). Anaesthesia was the same for both groups using high-dose fentanyl. Buckberg cardioplegia was used. All patients were followed by: conventional monitoring, Swan-Ganz catheter and transesophageal echocardiography. measurements (hemodynamic parameters, end-systolic and diastolic area and left ventricular wall motion) were recorded: after induction of anesthesia, after loading-dose and an intensive care unit. Enoximone- and dopamine infusions were started during weaning from cardiopulmonary bypass and tailored to hemodynamic parameters (cardiac index > 2.8 l/min, wedge pressure < 16 mmHg, mixed venous blood saturation > 65%). Major events were defined as: endotracheal intubation > 36 h, using intraortic balloon pump or centrifugal pump, intensive care timer > 48 h, in hospital cardiac death. Prices, were established by DRG-tables (diagnosis related groups). Statistical analysis were performed by X and "t" Student tests., Results: Cardiac index increased more significantly in group E (CI 1.9-->3.9 vs 2.3-->3.3; p 0.05) thanks to a higher reduction of vascular systemic (SVRI 2889-->1447 vs 2536 -->1565; p 0.005) and pulmonary resistances (PVRI 271-->193 vs 288-->218; p 0.05). Fewer major cumulative events and intensive care costs were observed in group E rather than group D., Conclusions: Enoximone administer immediately after open heart surgery had more beneficial hemodynamic and clinical effects than dopamine in patients with severe left ventricular dysfunction.

The effects of propofol on cardiovascular dynamics were studied, by means of SO2 Swan-Ganz catheter, in 12 patients scheduled for elective pulmonary resection and in 10 patients undergoing closed heart mitral valve commissurotomy. Myocardial contractility was also investigated in 10 patients (5 pulmonary and 5 mitral valve patients) by means of transthoracic echocardiography. The patients were premedicated with morphine (0.1 mg/kg i.m.), scopolamine (0.005 mg/kg i.m.) and diazepam (0.1 mg/kg p.o.). Anaesthesia was induced with propofol (2 mg/kg i.v.) and fentanyl (0.005 mg/kg i.v.) and maintained with propofol (6 mg/kg/h) plus fentanyl (0.005 mg/kg/h) infusion. Muscle relaxation was assured by pancuronium bromide (0.1 mg/kg). Ventilation (O2-N2O 50%) was controlled to maintain ETCO2 between 30 and 40 mmHg. All the patients undergoing pulmonary resection were intubated with double lumen endotracheal tube. Measurements were performed with the patients awake, after induction, during steady state anaesthesia, before and after thoracotomy. Propofol together with fentanyl significantly decreased arterial pressure (more than 35%) and cardiac index (more than 40%) in both groups of patients; heart rate showed no significant changes even after intubation. Right atrial pressure didn't change meanwhile wedge pressure showed a reduction, with statistical significance only in pulmonary patients. Total systemic resistances didn't show any variation in both groups of patients. The echocardiographic data revealed an important impairment of myocardial contractility after bolus of propofol, mainly in cardiac patients, as evidenced by decrease of ejection fraction values (20%) and by increase of left ventricle end systolic volume index (10%) from baseline. SVO2 and DO2/VO2 ratio values were stable, according with deep anaesthesia level and adequate metabolic balance. In pulmonary patients, during one lung ventilation, the intrapulmonary shunt values did not differed either during or without propofol infusion, thus suggesting that propofol doesn't interfere with pulmonary hypoxic vasoconstrictor response. In conclusion an aware use of propofol and a careful haemodynamic monitoring would be advisable primarily in patients with a well known or supposed cardiovascular disease.