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The 7-year long-term survival after Aspergillus fumigatus mediastinitis after heart transplantation, an uncommonly described condition, is herein reported. A 66-year-old male developed an infection with A. fumigatus covering the entire thoracic cavity with a fungal turf after orthotopic heart transplantation. Repeated surgical removal of infectious and necrotic tissue together with innovative topical treatment using voriconazole and chlorhexidine combined with systemic antifungal treatment, helped in controlling the infection. Definitive wound closure was achieved by standard sternal refixation and latissimus dorsi muscle flap plasty. Survival after A. fumigatus mediastinitis after heart transplantation was achieved with sequential debridement in combination with topical application of antifungal agents.

Background and objectives A knowledge of baseline serum creatinine (bSCr) is mandatory for diagnosing and staging AKI. With often missing values, bSCr is estimated by back-calculation using several equations designed for the estimation of GFR, assuming a “true” GFR of 75 ml/min per 1.73 m 2 . Using a data set from a large cardiac surgery cohort, we tested the appropriateness of such an approach and compared estimated and measured bSCr. Moreover, we designed a novel data-driven model (estimated serum creatinine [eSCr]) for estimating bSCr. Finally, we analyzed the extent of AKI and mortality rate misclassifications. Design, setting, participants, & measurements Data for 8024 patients (2833 women) in our cardiac surgery center were included from 1997 to 2008. Measured and estimated bSCr were plotted against age for men and women. Patients were classified to AKI stages defined by the Kidney Disease Improving Global Outcomes (KDIGO) group. Results were compared with data from another cardiac surgery center in Zurich, Switzerland. Results The Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration formulae describe higher estimated bSCr values in younger patients, but lower values in older patients compared with the measured bSCr values in both centers. The Pittsburgh Linear Three Variables formula correctly describes the increasing bSCr with age, however, it underestimates the overall bSCr level, being in the range of the 25% quantile of the measured values. Our eSCr model estimated measured bSCr best. AKI stage 1 classification using all formulae, including our eSCr model, was incorrect in 53%–80% of patients in Vienna and in 74%–91% in Zurich; AKI severity (according to KDIGO stages) and also mortality were overestimated. Mortality rate was higher among patients falsely classified into higher KDIGO stages by estimated bSCr. Conclusions bSCr values back-estimated using currently available eGFR formulae are inaccurate and cannot correctly classify AKI stages. Our model eSCr improves the prediction of AKI but to a still inadequate extent.

OBJECTIVE: Traditional cutoff values of serum creatinine considered to define postoperative acute renal failure have been challenged recently. In a previous investigation we demonstrated that minimal changes in serum creatinine concentration were associated with a substantial decrease in survival after cardiac surgery. In this investigation, we assessed the impact of minimal absolute increases in serum creatinine in a second institution, and we analyzed whether relative changes, as in the RIFLE classification and, partially, in Acute Kidney Injury Network (AKIN) classification, confer a different prognostic potential. DESIGN: Prospective analysis. SETTING: University hospital. PATIENTS: All consecutive patients undergoing cardiac surgery in the University Hospital of Zurich (Center USZ) over a 46-month period. INTERVENTIONS: Patients were prospectively documented. We analyzed maximal changes in serum creatinine in the first 48 hrs postoperatively (DeltaCrea) regarding death within 30 days. Results were compared with those of the University Hospital Vienna (Center AKH). Moreover, the prognostic potential of DeltaCrea within 48 hrs vs. serum creatinine elements according to RIFLE and AKIN classifications was assessed. MEASUREMENTS AND MAIN RESULTS: A total of 3,123 patients were evaluated from USZ. The majority of patients had decreased postoperative serum creatinine values (negative DeltaCrea) and the lowest mortality (1.8%). Minimal increases, [0, 0.5) mg x dL(-1), were associated with a more than doubled mortality in both centers (5%/6%). Mortality, according to RIFLE and AKIN classifications for both populations combined, was as follows: 7,023 (3.6%), 160 (29%), 43 (19%), and 15 (33%) for RIFLE Normal, Risk, Injury, and Failure; 6,644 (2.8), 463 (16.4), 3 (66.7), and 131 (1.8) for AKIN stage 0, 1, 2, and 3. CONCLUSIONS: Measuring repeat serum creatinine concentrations within 48 hrs and determining DeltaCrea were the most effective discrimination method to find patients at risk for adverse postoperative outcome after cardiac surgery, better than application of this sole criterion to the RIFLE (least discriminatory) or the AKIN classification.

Ibutilide, a class III antiarrhythmic drug, has been shown to convert atrial fibrillation to sinus rhythm more rapidly than procainamide or sotalol. Our objective was to compare the efficacy and safety of ibutilide and amiodarone in patients after cardiac surgery.Prospective, randomized, double-blinded study.Intensive care unit of a university hospital.Forty adults with an onset of atrial fibrillation within 3 hrs after admission.Before the administration of antiarrhythmic drugs, a 24-hr Holter electrocardiograph was attached. Patients in the ibutilide group received ibutilide 0.008 mg/kg body weight over 10 mins; treatment was repeated if atrial fibrillation or flutter persisted. If sinus rhythm was not achieved within 4 hrs, amiodarone 5 mg/kg was administered over 30 mins, followed by amiodarone 15 mg/kg over 24 hrs. Patients in the amiodarone group received amiodarone 5 mg/kg over 30 mins, followed by amiodarone 15 mg/kg over 24 hrs if atrial fibrillation or flutter continued.Within the first 4 hrs, atrial fibrillation was converted in nine of 20 patients (45%) in group ibutilide and in ten of 20 patients (50%) in group amiodarone (not significant). Mean time for conversion overall was 385 mins in group ibutilide and 495 mins in group amiodarone (not significant). In group amiodarone, the protocol was discontinued in two patients because of severe arterial hypotension. Atrial fibrillation recurred in 11 of 20 patients (55%) in group ibutilide and in seven of 20 patients (35%) in group amiodarone (not significant). Ventricular arrhythmia did not occur during the first 24 hrs of the protocol.Ibutilide has no significant advantage over amiodarone for the conversion of atrial fibrillation to sinus rhythm in either time to conversion or conversion overall, but severe hypotension was not seen with ibutilide.

Preoperative renal insufficiency is an important predictor of mortality after cardiac surgery. This retrospective cohort study was designed to identify the optimal cut-off for baseline serum creatinine (bSCr) and estimated glomerular filtration rate (eGFR) to predict survival. Furthermore, we investigated the potential confounding effect of other perioperative risk indicators on short- and long-term survival.Data of 9490 cardiac surgical patients were prospectively collected between 1997 and 2008 (follow up to 2010) at the Medical University Vienna. We identified bSCr cut-off values and calculated uni- and multivariate hazard models for short- and long-term survival and compared the results with a validation set from Zurich. The estimated survival curves defined a distinct period of increased mortality until 150 days.Cut-off values of115 µmol litre(-1) for bSCr and ≤50 ml min(-1) for eGFR were identified. Increased bSCr, associated with higher mortality [hazard ratio (HR) 2.61, 95% confidence interval (CI) 2.43-2.80, P0.0001], was present in 19.5% of patients and remained predictive for short- (HR 1.59, 95% CI 1.38-1.83, P=0.0027) and long-term survival (HR 1.46, 95% CI 1.32-1.62, P0.0001) in the multivariate hazard models. A cut-off of120 µmol litre(-1) for bSCr was determined for the validation set. Decreased eGFR was present in 23.6% (HR 2.86, 95% CI 2.67-3.06, P0.0001).In our patients, increased bSCr was an independent predictor of mortality, which may critically influence risk evaluation and perioperative treatment guidance.

Transoesophageal echocardiography (TOE) has gained widespread acceptance among cardiac anaesthetists as a tool to facilitate peri‐operative decision‐making. This observational study analyses the impact of TOE and its inter‐observer variability on intra‐operative patient management during cardiac and major vascular surgery. From June 1996 to December 1998, standardized reports were obtained from 11 anaesthetists in 1891 adult cardiac and vascular surgery patients undergoing routine biplane or multiplane TOE. Inter‐observer variability and the difference between variables of interest were tested using the chi‐squared test or factorial analysis of variance as appropriate. TOE examinations were performed before and after the operation; 1673 (88.5%) patients underwent cardiopulmonary bypass (CPB), and 218 (11.5%) patients had surgery without CPB, including 42 (2.2%) coronary revascularizations. In 923 patients (49%), TOE provided additional information that influenced the patient's therapy. In 968 patients (51%), TOE had only minor or no impact on clinical decision‐making. In two patients (0.10%) the scheduled operation was not performed, and in another two patients the TOE examination led to major complications. Observer‐dependent variables were: implications of TOE for intra‐operative decision‐making (P

UNLABELLED Inhaled nitric oxide (iNO) is superior to i.v. vasodilators for treatment of pulmonary hypertension (PH) after cardiac surgery, but iNO is a potentially toxic gas, and patient subsets who benefit from iNO are not yet clearly defined. We administered iNO 40 ppm, prostaglandin E1 (PGE1) 0.1 microg x kg(-1) min(-1), and nitroglycerin (NTG) 3 to 5 microg x kg(-1) min(-1), in a randomized crossover study to 14 adult patients with severe PH after cardiac surgery. iNO, PGE1, and NTG were of similar efficacy in reducing pulmonary vascular resistance (P = 0.003). iNO induced selective pulmonary vasodilation, while PGE1 and NTG had significant concomitant systemic vasodilatory effects. iNO led to an increase in cardiac index (CI) (P = 0.012), and PGE1 increased CI (P = 0.006) and right ventricular (RV) ejection fraction (P = 0.015), while NTG had no effect on CI and RV performance. After study completion, patients continued with PGE1 administration with favorable in-hospital outcome. We conclude that PH per se, even if severe, does not necessarily imply postoperative RV dysfunction, and selective pulmonary vasodilation with iNO may not be superior to PGE1 with regard to CI and RV performance. IMPLICATIONS In a prospective, randomized crossover study of inhaled nitric oxide (iNO) versus IV vasodilators, performed in adult patients with severe pulmonary hypertension but preserved right ventricular function after cardiac surgery, iNO was not superior to IV prostaglandin E1 with regard to cardiac index and right ventricular performance. Considering the potential toxicity of iNO, better definition of patient subsets with a positive benefit/risk ratio is warranted.

Background . Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events. Methods . Twenty-two patients, mean age 68 ± 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 ± 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed. Results . There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta. Conclusions . For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.

BACKGROUND: Aortic valve replacement is one of the most common cardiac surgical procedures, especially in elderly patients. Whether or not there is a net life gain over a long period of time is a matter for debate. OBJECTIVE: To compare survival of patients with that of the age, sex, and follow-up year-matched normal population (relative survival). DESIGN: Single-centre, prospectively collected data. SETTING: Tertiary care centre, Vienna, Austria. PATIENTS: We enrolled 1848 patients undergoing elective aortic valve replacement between 1997 and the end of 2008. INTERVENTIONS: None. MAIN OUTCOME MEASUREMENT: Relative survival at the end of 2011 as determined by relative Cox regression analysis. RESULTS: Sixty-nine patients (3.7%) died within the first 30 days. Another 70 patients (3.8%) died within the first year and 429 (23.2%) died during the remaining follow-up period. The longest follow-up period was 14 years (median, 5.8; interquartile range, 3.2 to 8.9). Medical risk indicators for relative survival were diabetes mellitus [hazard ratio 1.69, 95% confidence interval, CI 1.37 to 2.07, P

peak EA to peak creatinine changes (R1⁄40.41; p1⁄40.004). At T0, no significant difference in EA levels was observed between patients who did or did not develop AKI [0.47 (0.04–0.78) vs. 0.43 (0.15–0.79); p 1⁄4 0.74]. However, the AKI group was characterized by a continuous increase in EA from T0 to T3, becoming statistically significant at T3 [T0 1⁄4 0.6 (0.32–1.0) vs. T3 1⁄4 0.47 (0.04–0.78); p 1⁄4 0.004]. In contrast, the non-AKI group did not show any differences in EA [T0 1⁄4 0.47 (0.16– 0.6) vs. T3 1⁄4 0.43 (0.15–0.79); NS]. Table 2 reports all EA values among AKI and non-AKI groups.

Summary The aim of this study was to compare the accuracy of pulse dye densitometry with that of bolus thermodilution cardiac output measurement in patients before and after elective coronary artery bypass grafting. Twenty-eight patients were studied. Agreement between mean thermodilution and pulse dye densitometry cardiac output values was assessed by Bland-Altman analysis. Preoperative median [range] cardiac output was 3.87 [2.37-6.0] l.min(-1) by thermodilution, and 3.11 [1.7-5.45] l.min(-1) by pulse dye densitometry using indocyanine green 5 mg. Pulse dye densitometry underestimated cardiac output (mean bias - 0.42 l.min(-1)); the limits of agreement were +/- 1.91 l.min(-1), and mean error was 50.3%, indicating low precision. Preoperative median [range] cardiac output was 3.85 [2.2-6.0] l.min(-1) for bolus thermodilution cardiac output and 4.2 [2.0-7.2] l.min(-1) for pulse dye densitometry using indocyanine green 20 mg. Mean bias was + 0.566 l.min(-1), the limits of agreement were +/- 2.51 l.min(-1) and mean error was 60.9%. Postoperative cardiac output data were not analysed because pulse dye densitometry signals were low or absent in > 50% of the patients. We conclude that pulse dye densitometry using indocyanine green 5 mg or 20 mg is inaccurate in anaesthetised patients before coronary artery bypass surgery and cannot be used after surgery because of a high incidence of low pulse dye densitometry signal amplitudes.

Acute renal failure increases risk of death after cardiac surgery. However, it is not known whether more subtle changes in renal function might have an impact on outcome. Thus, the association between small serum creatinine changes after surgery and mortality, independent of other established perioperative risk indicators, was analyzed. In a prospective cohort study in 4118 patients who underwent cardiac and thoracic aortic surgery, the effect of changes in serum creatinine within 48 h postoperatively on 30-d mortality was analyzed. Cox regression was used to correct for various established demographic preoperative risk indicators, intraoperative parameters, and postoperative complications. In the 2441 patients in whom serum creatinine decreased, early mortality was 2.6% in contrast to 8.9% in patients with increased postoperative serum creatinine values. Patients with large decreases (DeltaCrea-0.3 mg/dl) showed a progressively increasing 30-d mortality (16 of 199 [8%]). Mortality was lowest (47 of 2195 [2.1%]) in patients in whom serum creatinine decreased to a maximum of -0.3 mg/dl; mortality increased to 6% in patients in whom serum creatinine remained unchanged or increased up to 0.5 mg/dl. Mortality (65 of 200 [32.5%]) was highest in patients in whom creatinine increasedor =0.5 mg/dl. For all groups, increases in mortality remained significant in multivariate analyses, including postoperative renal replacement therapy. After cardiac and thoracic aortic surgery, 30-d mortality was lowest in patients with a slight postoperative decrease in serum creatinine. Any even minimal increase or profound decrease of serum creatinine was associated with a substantial decrease in survival.

Transesophageal echocardiography (TEE) is a monitoring and diagnostic tool for the care of children undergoing cardiac surgery. We analyzed reports from 865 routine TEE examinations performed between January 1994 and March 2002 in patients younger than 17-yr-old who were undergoing surgery for congenital heart disease. Patients' median age was 36 mo (range, 1 day-16 yr). The primary end-point of the study was the incidence of surgical and medical management decisions changed as a result of TEE findings; secondary end-points were diagnostic impact (diagnostic exclusions and new diagnoses) and surgical outcome. Fifty percent of the examinations were performed by anesthesiologists with an advanced level of training in perioperative TEE; all of the examiners had an experience ofor=500 TEE examinations. Supervision by an anesthesiologist with an advanced level of training was requested in 36.7% of cases; supervision by a cardiologist was requested in 3.8%. Surgical alterations of management were reported in 12.7% of cases and included the need for a repeat bypass run in 7.3%; medical alterations of management were required in 19.4% of cases. We observed a diagnostic impact of TEE in 18.5% of cases and a suboptimal but acceptable surgical outcome in 27.6%; TEE findings predicted postoperative difficulties in 4.0%. Our results confirm the utility of routine TEE to assess repair of congenital heart defects. Furthermore, this service was competently performed by a regular team of cardiac anesthesiologists appropriately trained in TEE.Transesophageal echocardiography (TEE) is an essential monitoring and diagnostic device for the care of children undergoing cardiac surgery. The surgical and medical impact of TEE is demonstrated in a large series of patients. This service can be performed by appropriately trained cardiac anesthesiologists.

Arrhythmias are a recognized complication of cardiac operations. However, little is known about the incidence, treatment, and risk factors for early postoperative arrhythmias in children after cardiac operations.Diagnosis and treatment of early postoperative arrhythmias were prospectively analyzed in an intensive care unit in 100 consecutive children with a median age of 17 months (range, 1 day to 191 months) who had undergone cardiac operation. Patients were grouped in three different categories of surgical complexity.During a median postoperative time of 1 day (range, 0 to 15 days), 64 critical arrhythmias occurred in 48 patients. Arrhythmias consisted of sinus bradycardia in 30, atrioventricular block II to III in 7, supraventricular tachyarrhythmias in 14, and premature complexes in 13 instances. Treatment of 52 arrhythmias was successful and included pacing in 41, intravenous amiodarone in 8, body cooling in 5, overdrive pacing in 3, and electrolyte correction in 2 cases, with more than one treatment modality in 8 cases. Risk factors for arrhythmias were lower body weight (p0.05), longer cardiopulmonary bypass duration (p0.05), and a category of higher surgical complexity (p0.001).Early postoperative arrhythmias occur frequently after cardiac operations in children. Sinus bradycardia, atrioventricular block II to III, and supraventricular tachyarrhythmias are the most frequent arrhythmias, which, however, can be treated effectively by means of temporary pacing, cooling, and antiarrhythmic drug therapy. Lower body weight, longer cardiopulmonary bypass duration, and a higher surgical complexity are risk factors for early postoperative arrhythmias.

To compare the effect of combined intrathecal morphine and sufentanil with low-dose iv sufentanil during propofol anesthesia for fast-track cardiac surgery.Twenty-four consecutive patients with normal cardiopulmonary function who were scheduled for elective cardiac surgery were randomized to receive either a continuous iv infusion of sufentanil 0.9 to 1.8 microg x kg(-1) x min(-1) (13 patients), or a single lumbar intrathecal dose of sufentanil 50 micro g and morphine 500 micro g (11 patients). We prospectively studied perioperative analgesia, time to extubation and early postoperative maximal inspiratory capacity in the two groups. In the intensive care unit, the medical and nursing staff were blinded to the analgesic technique.Intrathecal sufentanil morphine allowed a shorter duration of intubation (104 +/- 56.5 min vs 213 +/- 104 min; P = 0.01), reduced the need for postoperative analgesia with nicomorphine (equipotent to morphine) (0.7 +/- 0.4 mg x hr(-1) vs 1.2 +/- 0.4 mg x hr(-1); P = 0.008) and improved postoperative maximal inspiratory capacity (53.4 +/- 16.1 vs 38.4 +/- 12.5% of the norm; P = 0.05).In low-risk patients undergoing coronary artery bypass graft or valve surgery, combined intrathecal sufentanil and morphine with a target-controlled infusion of propofol satisfies the goals of fast-track cardiac surgery.

To evaluate the feasibility, efficacy, safety and side effects of routinely performed continuous venovenous hemofiltration (CVVH) with regional citrate anticoagulation using a citrate-containing substitution solution as compared with conventional systemic low-dose unfractionated heparin-anticoagulation in postoperative cardiac surgery patients.Database review of all patients on CVVH during a three-year period at a cardiovascular intensive care unit of a tertiary referring university hospital.Patients who had undergone cardiac surgery with acute or chronic renal failure were studied. Thirty-seven citrate CVVH courses in 31 patients (January to November 2000) and 59 heparin CVVH courses in 50 patients (1998 and 1999) had been undertaken postoperatively. Indications for hemofiltration were acute renal failure in 24 and chronic renal failure in 7 of the citrate patients, and acute renal failure in 44 and chronic renal failure in 6 of the heparin patients.CVVH with either regional citrate anticoagulation using a custom-made citrate-based substitution solution or unfractionated heparin anticoagulation.The following parameters were measured: median filtration time, hemofilters used per day, differences in creatinine and blood urea levels as opposed to baseline, blood loss within the first 24 h of hemofiltration, incidence of bleeding-related resternotomies, acidosis, and alkalosis.No significant differences in any of the measured parameters were registered. No serious electrolyte imbalance was observed in either group. Furthermore, the two groups did not differ in terms of mortality, duration of stay in the intensive care unit or in hospital, and restoration rate of normal renal function.We conclude that citrate-based regional anticoagulation is effective, safe and easy to use in CVVH following cardiac surgery and might become the first choice for anticoagulation in patients in whom the application of systemic heparin is contraindicated.

The aim of this study was to validate measurements of intraoperative left ventricular (LV) area by transoesophageal echocardiography against simultaneous measurements of LV volume by conductance catheter (CC) in cardiac surgical patients with normal systolic LV function. Echo area was compared with CC volume during steady state and during acute changes of pre‐ and afterload by partial clamping of the inferior vena cava and the ascending aorta in eight patients scheduled for coronary artery bypass grafting. At steady state, Bland-Altman analysis of 32 recordings revealed a bias (sd) of 0.6% (2.5%) between echo area and CC volume, related to the initial values of end‐diastolic area (100% area) and volume (100% volume), respectively. During loading interventions, bias between the two methods, as assessed by 112 measurement sequences, was 0.5% (3.7%) during aortic occlusion and -3.9% (4.4%) during cava occlusion at end‐systole (P

A 36-yr-old pregnant woman with a history of hypertension presented at term for elective Caesarean section because of breech position. At preoperative examination, a diastolic murmur was found and transoesophageal echocardiography (TOE) revealed a large, 8.1-cm diameter ascending aortic aneurysm with severe aortic regurgitation and moderate pericardial effusion. Surgical repair was not considered to be urgently required. The patient was delivered electively by Caesarean section under epidural anaesthesia using invasive arterial pressure monitoring. TOE performed 6 h post-partum showed progressing pericardial effusion, for which emergency replacement of the aortic valve and ascending aorta were indicated. The epidural catheter was removed 4 h before starting the cardiopulmonary bypass procedure. Arterial pressure was controlled by a titrated infusion of esmolol and clonidine. To improve uterine tone, the patient received an i.v. infusion of oxytocin throughout surgery. After implantation of an aortic composite graft and weaning from cardiopulmonary bypass, the patient was transferred to the intensive care unit. Awake and receptive to neurological evaluation, her trachea was extubated 4 h after surgery. Mother and baby made an uneventful recovery.

Changes in transesophageal echocardiography (TEE)-derived Doppler flow velocities through the mitral valve and pulmonary veins occur after cardiopulmonary bypass and are believed to reflect left ventricular (LV) diastolic functional impairment. The aim of this study was to determine the time-coincidence between these Doppler flow velocity parameters, LV two-dimensional (2D) short-axis area measurements, and hemodynamic parameters in patients after coronary artery bypass grafting.Prospective clinical study.University hospital.Twenty patients with normal ejection fraction undergoing elective cardiac surgery.At multiple intervals during surgery and 6 hours postoperatively, mitral inflow velocity and pulmonary venous flow velocity were measured with pulsed Doppler TEE. LV short-axis area by echocardiography and cardiac output by thermodilution were simultaneously obtained.Time-coincidence was found in the immediate postbypass period between a decreased E/A ratio from 1.16 (95% confidence interval, 1.0 to 1.31) to 0.64 (95% confidence interval, 0.47 to 0.81, p0.01), a decreased E-wave deceleration time, and a significantly increased heart rate (HR) and cardiac index. End-diastolic area (EDA) and stroke volume index (SVI) decreased after sternal closure. HR, E-wave deceleration time, and SVI remained altered until 6 hours postoperatively. No change was found in pulmonary venous flow velocity parameters and systolic LV function.In patients with normal systolic ventricular function and no inotropic support, Doppler flow velocity patterns alone did not sufficiently reflect hemodynamic changes, whereas 2D LV area, especially EDA measurements, provided useful information about hemodynamically significant LV filling impairment.

Objective: To evaluate the accuracy and precision of continuous thermodilution (CCO) by using a validated bolus thermodilution (BCO) reference technique as criterion standard. Design: Under circulatory steady state conditions, a CCO system (Vigilance, software versions 4.35 and 4.39) was validated with regard to CCO as well as iced and room temperature BCO. Setting: Intensive care unit at a university hospital. Patients: Method comparison was conducted in 56 cardiac surgical patients, 28 patients being allocated to one of the two software versions, and 14 within each group to either iced or room temperature BCO. Measurements and results: CCO readings were registered in duplicate before and after three to five bolus injections conducted with both the Vigilance and reference systems. Iced BCO showed excellent agreement between the Vigilance and reference systems, yielding SDs of bias of 0.41 and 0.37 l/min and linear correlation coefficients (r) of 0.97 and 0.96. With room temperature BCO, agreement was significantly less. CCO, irrespective of software version, showed higher SDs of bias (0.90 and 0.84 l/min) and lower r values (0.84 and 0.81) than iced BCO (p < 0.0001). CCO measurements with software version 4.39 yielded a similar SD of bias to that with room temperature BCO. Conclusion: Decreased precision of CCO as compared to iced BCO may, in clinical settings, be outweighed by the advantages of automated and continuous monitoring. Under research conditions, however, iced BCO remains the method of choice.

A 58 year old man underwent mitral valve repair for prolapse of the anterior valve leaflet and consecutive severe mitral regurgitation. After weaning from cardiopulmonary bypass, transoesophageal echocardiography showed a successfully reconstructed mitral valve, but a large mass within or behind the left atrium that …

Congenitally corrected transposition of the great arteries (i.e., discordant atrioventricular connections associated with discordant ventriculoarterial connections) is frequently combined with anomalies of the tricuspid valve.1 Most often, these malformations resemble a form of Ebstein's anomaly, whereas a stenosis or hypoplasia of the tricuspid valve is rare, and a supravalvular ring represents an exceptional event.1,2 Other malformations associated with congenitally corrected transposition consist of ventricular septal defects followed by abnormalities of the pulmonary outflow tract.1

Objective: Transesophageal echocardiography (TEE) has gained widespread acceptance among intensivists as a tool to facilitate decision-making in the management of critically ill patients. This observational study analyzes the indications and impact of TEE and the outcome in patients following cardiac surgery. Design: Standardized reports containing indication, main diagnosis, and impact on patient management were completed during TEE. Setting: Intensive care unit in a university hospital. Patients: Postoperative cardiac surgery patients requiring TEE. Intervention: TEE in sedated and mechanically ventilated patients. Measurements and Results: Reports were obtained in 301 adult patients between June 1996 and June 2000. Indications were postoperative control of left ventricular function in 102 (34%) cases; unexplained, sudden hemodynamic deterioration in 89 (29%); suspicion of pericardial tamponade in 41 (14%); cardiac ischemia in 26 (9%); and other in 43 (14%). In 136 patients (45%), a new diagnosis was established or an important pathology was excluded. Pericardial tamponade was diagnosed in 34 cases (11%) and excluded in 36 cases (12%). Other diagnoses included severe left ventricular failure, large pleural effusion, and others. Therapeutic impact was found in 220 cases (73%): change of pharmacologic treatment and/or fluid therapy in 118 cases (40%), resternotomy in 43 (14%), no reoperation necessary in 39 (13%), and various in 20 (7%). No impact was found in 81 cases (27%). In a subgroup of patients in whom preoperative risk scores were evaluated, the indication for a postoperative TEE was significantly associated with a prolonged stay in the intensive care unit: 7 (5.6, 8.4) days vs. 1 (0.8, 1.2) day (median, [95% confidence interval]) (p