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The aim of this study was to evaluate if there is a correlation between the use of intraoperative transesophageal echocardiography and an increased rate of extubation failure and to find other risk factors for severe upper airway obstructions after pediatric cardiac surgery.Retrospective analysis.Cardiac PICU.Patients 24 months old or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were retrospectively enrolled and divided into two groups depending on whether they received an intraoperative transesophageal echocardiography or not. We analyzed all cases of early reintubations within 12 hours after extubation due to a documented upper airway obstruction.None.From a total of 424 patients, 12 patients (2.8%) met our criteria of early reintubation due to upper airway obstruction. Ten of 207 children in the transesophageal echocardiography group had to be reintubated, whereas only two of the 217 children in the control group had to be reintubated (4.8% vs 0.9%; p = 0.018). Logistic regression analysis showed a significant correlation between use of intraoperative transesophageal echocardiography and extubation failure (odds ratio, 5.64; 95% CI, 1.18-27.05; p = 0.030). There was no significant relationship among sex (odds ratio, 4.53; 95% CI, 0.93-22.05; p = 0.061), weight (odds ratio, 1.07; 95% CI, 0.82-1.40; p = 0.601), duration of surgery (odds ratio, 1.04; 95% CI, 0.74-1.44; p = 0.834), duration of mechanical ventilation (odds ratio, 1.00; 95% CI, 0.99-1.00; p = 0.998), and occurrence of trisomy 21 (odds ratio, 3.47; 95% CI, 0.83-14.56; p = 0.089).Although the benefits of intraoperative transesophageal echocardiography during pediatric cardiac surgery are undisputed, it may be one factor which could increase the rate of severe upper airway obstruction after extubation with the need for reintubation. We suggest to take precautions before extubating high-risk patients, especially in young male children with genetic abnormalities after cardiac surgery with cardiopulmonary bypass.

The early diagnosis and treatment of right ventricular (RV) dysfunction are of critical importance in cardiac surgery patients and impact clinical outcome. Two-dimensional (2D) transesophageal echocardiography (TEE) can be used to evaluate RV function using surrogate parameters due to complex RV geometry. The aim of this study was to evaluate whether the commonly used visual evaluation of RV function and size using 2D TEE correlated with the calculated three-dimensional (3D) volumetric models of RV function.Retrospective study, single center, University Hospital.Seventy complete datasets were studied consisting of 2D 4-chamber view loops (2-3 beats) and the corresponding 4-chamber view 3D full-volume loop of the right ventricle. RV function and RV size of the 2D loops then were assessed retrospectively purely qualitatively individually by 4 clinician echocardiographers certified in perioperative TEE. Corresponding 3D volumetric models calculating RV ejection fraction and RV end-diastolic volumes then were established and compared with the 2D assessments.2D assessment of RV function correlated with 3D volumetric calculations (Spearman's rho -0.5; p0.0001). No correlation could be established between 2D estimates of RV size and actual 3D volumetric end-diastolic volumes (Spearman's rho 0.15; p = 0.25).The 2D assessment of right ventricular function based on visual estimation as frequently used in clinical practice appeared to be a reliable method of RV functional evaluation. However, 2D assessment of RV size seemed unreliable and should be used with caution.

Fig 1. The platelet count profile. The first value was obtained before coronary angiography and enoxaparin exposure (day 0). The second value was obtained on the preoperative morning before CPB (pre-CPB) 16 days after exposure to enoxaparin (day 16). The third value was obtained on admission to the ICU (post-CPB). Further values were obtained on postoperative (PO) days 1 through 7.

Background To compare the risks, implications, and outcomes of transvenous semipermanent pacing as a bridge to permanent system implantation or recovery. Methods We investigated semipermanent transvenous pacing systems consisting of one (n = 57%) or two (n = 3%) bipolar active-fixation pacing leads and an attached epicutaneous pulse generator implanted from 2000 to 2009. The study population comprised 60 patients aged 72.9 ± 10.5 years (44 [73.3%] male). Forty-two (70%) were enrolled for complete system explantation for cardiac-implanted electronic devices associated infection. Eighteen (30%) required temporary pacing in the context of a variety of mostly severe cardiac and noncardiac conditions. The semipermanent pacing systems were removed after implantation of permanent systems or recovery of a noncompromising heart rhythm, respectively. Results Transvenous semipermanent lead implantation was successful in 59 (98.3%) patients. Major and minor intraoperative complications occurred in one case (1.7%) each. The semipermanent systems were left in situ for a mean period of 14.6 ± 8.1 days). They served as a bridge to permanent system implantation in 68.3% (n = 41) and as a bridge to recovery of a noncompromising heart rhythm in 11.7% (n = 7). Four patients (8.3%) died with the semipermanent pacing system in situ, and seven (11.7%) were transferred to external hospitals with semipermanent pacing systems. Conclusions Transvenous semipermanent pacing with bipolar active-fixation leads and epicutaneous pulse generators provide an important option for prolonged temporary pacing as a bridge to permanent system implantation or recovery.

Introduction: Use of extracorporeal life support (ECLS) has significantly increased in critically ill patients refractory to medical management. ECLS requires systemic anticoagulation to avoid thromboembolic complications and superimposed coagulopathies are common. Transesophageal echocardiography (TEE) is frequently employed to assess cannula position and cardiac function during extracorporeal therapy. The goal of this study was to assess whether TEE probe insertion and removal in systemically anticoagulated ECLS patients was safe compared to patients without ECLS and normal coagulation studies. Methods: Eighty-seven separate TEE examinations in 53 adult ECLS patients were analyzed. Detailed complication profiles were logged for each patient from initiation through discontinuation of ECLS. Routine coagulation testing was recorded within two hours prior to the TEE exams. Controls consisted of age- and gender-matched patients undergoing perioperative TEE without ECLS and normal coagulation (N=87). Results: Overall TEE-associated morbidity in ECLS patients was 2.3% and consisted of minor oropharyngeal bleeding (2/87 TEE exams) exclusively. The patients presenting with oropharyngeal bleeding received heparin for anticoagulation and had two or more abnormal coagulation studies at the time of TEE. Seventy-nine percent of ECLS patients received intravenous heparin infusions, 6.8% argatroban and 3.4% epoprostenol. Ten-point-eight percent of patients were not anticoagulated at the time of TEE because of pre-existing bleeding complications and/or deranged plasmatic coagulation profiles. No major complications (e.g., esophageal perforation, gastrointestinal bleeding, accidental extubation) were recorded in either group. Conclusions: TEE remained safe in critically ill patients under ECLS, despite systemic anticoagulation, during probe insertion, manipulation and removal. TEE-related complications pertained solely to oropharyngeal bleeding amenable to conservative management.

Extracorporeal circulation (ECC) is an essential tool for the execution of cardiac operations. However, ECC is also associated with undesirable side effects. These include the induction of a systemic inflammatory response associated with leukocyte activation and cytokine release as well as potentially life-threatening complications. The volatile anesthetic sevoflurane has been reported to exert anti-ischemic and anti-inflammatory effects. We therefore investigated whether sevoflurane modulates the ECC-triggered inflammatory response. Heparinized human blood was circulated for 90 min in a normothermic (37°C) ex vivo ECC circuit. An air-oxygen mixture was administered via an oxygenator in controls (n=5). Sevoflurane (2 vol.%) was added to the gas mixture in a second group (n=5). At baseline and after 30, 60 and 90 min of ECC, blood samples were taken. In each sample whole blood counts were determined. Expression of the activation-indicating Mac-1 receptor on granulocytes and monocytes as well as leukocyte-platelet aggregate formation was measured in flow cytometry. Levels of the granulocyte activation marker PMN-elastase and of the cytokines IL-1β, IL-8 and TNF-α were analyzed using ELISA. ECC induced significant increases in Mac-1 expression on granulocytes (p

Seit der Einfuhrung der intraoperativen Echokardiographie in die Klinik Mitte der 1970er Jahre sind deren Anwendung und Nutzen im perioperativen Bereich stetig gewachsen. Die intraoperative Echokardiographie spielt vor allem bei herzchirurgischen Patienten eine bedeutende Rolle. Hier stehen dem Untersucher mit der transosophagealen Echokardiographie (TEE) und der epiaortalen Sonographie (EUS) zwei wichtige diagnostische Untersuchungstechniken zur Verfugung. Mit der intraoperativen TEE konnen Befunde erhobenen werden, die Einfluss auf das chirurgische Management haben und somit das Outcome eines Patienten beeinflussen konnen. Aber auch bei nichtkardiochirurgischen Patienten kann der Einsatz der TEE sinnvoll sein und zu einer Verbesserung des intraoperativen Managements bei Hochrisikopatienten beitragen. Zudem kann die TEE bei Patienten, die intraoperativ hamodynamisch instabil werden oder kardiopulmonal reanimiert werden mussen, zur Klarung der Ursache beitragen. Durch den in der TEE erhobenen Befund kann so moglicherweise eine weiterfuhrende Therapie veranlasst werden. Ein Vorteil der TEE ist hierbei, dass diese ohne Unterbrechung der chirurgischen Versorgung des Patienten durchgefuhrt werden kann.

We report a 67-yr-old male after multiple surgical procedures for treatment of arterial occlusive disease who suffered an anaphylactic reaction after administration of aprotinin (Trasylol) prior to urgent coronary artery bypass surgery. The patient had been treated with aprotinin-containing fibrin sealant in 2004 and in 2007, 2 wk before coronary artery bypass surgery. The postoperative serologic screening revealed positive results for qualitative aprotinin-specific IgG, highly elevated quantitative aprotinin-specific IgG and moderately elevated aprotinin-specific IgE antibodies.

Introduction Intraaortic balloon pump counterpulsation (IABP) is often used in patients with acute coronary syndrome for its favourable effects on left ventricular (LV) systolic function and coronary perfusion. However, the effects of IABP on LV diastolic function have not been comprehensively investigated. Acute diastolic dysfunction has been linked to increased morbidity and mortality. The aim of this study was to examine the influence of IABP on LV diastolic dysfunction using standard TEE derived parameters. Methods Intraoperative TEE was performed in 10 patients (mean age 65 ± 11 yrs) undergoing urgent coronary artery bypass graft surgery (CABG), who had received an IABP preoperatively. TEE derived measures of diastolic dysfunction included early to late transmitral Doppler inflow velocity ratio (E/A), deceleration time (Dt), pulmonary venous systolic to diastolic Doppler velocity ratio (S/D), transmitral propagation velocity (Vp), and the ratio of early to late mitral annular tissue Doppler velocities (e’/a’). Statistical analyses included the Wilcoxon Sign-Rank test, and a p

To determine whether closed elastic-stable intramedullary nailing (ESIN) of radial neck fractures in children is accepted as standard procedure with satisfactory results, a prospective multicenter case collection study was conducted. Sixty-six cases from 12 departments were analyzed during 2 years. Thirty-six fractures of Judet 1 or 2 grade (54.5%) were treated without reduction; all of these fractures showed good to excellent results. Thirty fractures of grade 3 or 4 needed a closed (25 [37.9%]) or open reduction (5 [7.6%]), and 74% of them had good to excellent results. Osteosynthesis was carried out in 26 of the reduced fractures (23 ESIN, 3 Kirschner wire fixation). Using ESIN, 78% of the results were good to excellent. Seven children developed significant restrictions of pronation/supination, including three of the five open reduced fractures. ESIN has found wide acceptance, and the results are satisfactory. Restricted use of open interventions may be the key to improving results.

Summary Background The muscle-relaxing effects of succinylcholine are terminated via hydrolysis by plasma cholinesterase. There are multiple genetic variants of this enzyme and clinical circumstances that might influence the activity of plasma cholinesterase and eventually lead to prolonged neuromuscular blockade following succinylcholine application. Case Report Here, we report a parturient woman with atonic bleeding who suffered significant blood loss (hemoglobin 6.0 g·dL−1). For surgical curettage, general anesthesia was performed by using short-acting succinylcholine. By the end of the 105-minute procedure, the patient’s trachea was extubated. After extubation she showed signs of the prolonged neuromuscular blocking action of succinylcholine. At this time, the patient received an AB0-compatible red blood cell transfusion and recovered instantly from neuromuscular blockade. The plasma cholinesterase (3.200 U·L−1) was below the normal range (4.900–12.000 U·L−1). Patient’s blood DNA analysis revealed heterozygously the genetic K variant of plasma cholinesterase. After red blood cell transfusion, serum potassium was elevated (5.7 mmol·L−1; 4.4 mmol·L−1 prior to transfusion). Conclusions Pregnancy, blood loss and genetic variation contributed to impairment of plasma cholinesterase. Due to high-speed red blood cell transfusion, hemolytic release of erythrocyte cholinesterase might have terminated the neuromuscular blocking succinylcholine effect.

Background Increasing application of cardiac resynchronization therapy is accompanied by an increase in patients requiring removal of coronary sinus (CS) leads. The aim of this study was to determine outcomes of closed chest CS lead extraction using intravascular dissection devices. Methods Between 2000 and 2011, 41 patients (80.5% men; aged 64.2 ± 13.8 years) underwent transvenous CS lead extraction procedures. Reasons for lead extraction were infection in 9, CS lead dislodgement in 15, lead malfunction, including manufacturer-initiated product recall in 6, phrenic nerve stimulation in 5, combinations of causes in 5, and elective extraction concomitant with generator replacement for battery depletion in 1. Results In addition to 24 isolated CS lead extractions, we performed 17 multiple lead extractions (2 to 4 leads) after a mean of 30.6 ± 32.5 months. The time elapsed from implantation was 4.6 ± 9.1 months for isolated CS and 42.6 ± 32.4 months for multiple lead extractions. Extraction by direct manual traction was feasible in 13 patients by locking stylets in 6. Escalation to mechanical sheaths was required in 17 patients and to electrosurgical sheaths in 5. More aggressive methods were associated with longer implantation times and positive infection status. No deaths or major periprocedural complications occurred. Six minor postprocedural complications, of which three were surgically related, occurred in 5 patients. Conclusions Closed chest CS lead extraction can be safely performed with excellent results. We recommend an escalating approach from isolated manual traction over locking stylets to mechanical sheaths and, eventually, electrosurgical dissection devices. The application in mainly high-risk patients demands an interdisciplinary approach to enhance safety and limit morbidity and death.

To compare the risks, implications, and outcomes of transvenous semipermanent pacing as a bridge to permanent system implantation or recovery.We investigated semipermanent transvenous pacing systems consisting of one (n = 57%) or two (n = 3%) bipolar active-fixation pacing leads and an attached epicutaneous pulse generator implanted from 2000 to 2009. The study population comprised 60 patients aged 72.9 ± 10.5 years (44 [73.3%] male). Forty-two (70%) were enrolled for complete system explantation for cardiac-implanted electronic devices associated infection. Eighteen (30%) required temporary pacing in the context of a variety of mostly severe cardiac and noncardiac conditions. The semipermanent pacing systems were removed after implantation of permanent systems or recovery of a noncompromising heart rhythm, respectively.Transvenous semipermanent lead implantation was successful in 59 (98.3%) patients. Major and minor intraoperative complications occurred in one case (1.7%) each. The semipermanent systems were left in situ for a mean period of 14.6 ± 8.1 days). They served as a bridge to permanent system implantation in 68.3% (n = 41) and as a bridge to recovery of a noncompromising heart rhythm in 11.7% (n = 7). Four patients (8.3%) died with the semipermanent pacing system in situ, and seven (11.7%) were transferred to external hospitals with semipermanent pacing systems.Transvenous semipermanent pacing with bipolar active-fixation leads and epicutaneous pulse generators provide an important option for prolonged temporary pacing as a bridge to permanent system implantation or recovery.

Background In unstable metaphyseal and diaphyseal forearm fractures the treatment of choice is percutaneous Kirschner wire (K-wire) fixation or elastic stable intramedullary nailing (ESIN), respectively. The optimal treatment for the diametaphyseal transition zone is still a matter of debate. Methods The diametaphyseal transition zone was defined as the square over the "physis of distal radius and ulna" minus the square of "physis of distal radius alone". Transepiphyseal intramedullary K-wire fixation was performed in unstable fractures affecting this transitional area. The operative, postoperative and functional outcomes were assessed and compared to previously treated patients who were treated using other techniques (plate, external fixator or ESIN). Results 10 patients received transepiphyseal intramedullary K-wire fixation. Additionally the ulna was stabilized by antegrade ESIN in 5 cases. Cast immobilization was performed for 39, sports restriction for 43 and metal removal was done after 50 days. No complications, bone malalignment, or functional deficits occurred (mean follow-up: 17 months). 13 patients were treated using alternative options. 3 patients had plates with cast immobilization for 26 days, sports restriction for 63 and metal removal after 287 days. 5 patients were treated by external fixation for 54 days. Their sports restriction was 73 days. The remaining 5 patients had ESIN. In 1 of these cases additional cast immobilization was necessary. Their sports restriction was 51 days and metal removal was done after 88 days. In 4 cases a malalignment >10° of the radius was documented, and 1 patient had a functional deficit of forearm pro-/supination. Conclusion Transepiphyseal intramedullary K-wire fixation in unstable diametaphyseal forearm fractures is a minimally invasive, quick and technically easy treatment option but requires additional immobilization. Our data suggest that this technique offers advantages compared to alternative treatment options.

Objective: Cardiac surgery employing cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) can induce coagulation disturbancesand bleedingcomplications thatmay beespecially severeininfants. A better understanding of thecoagulopathyanda quickmethod for its evaluation would be helpful in the management of patients exposed to CPB and DHCA. This study aimed to monitor coagulation defects in congenital heart surgery using rotational thromboelastometry (ROTEM W ), standard coagulation tests and platelet flow cytometry. Methods: The study comprised 10 infants undergoing surgery for congenital heart disease on CPB and DHCA. Blood was sampled at skin incision, after heparinisation during CPB (directly pre- and directly post-DHCA) and after protamine administration post-CPB. ROTEM W using different reagents including a heparinase-containing assay to evaluate coagulation during heparinisation, APTTand INR, and flow cytometry to evaluate platelet activation were performed. Results: During CPB, the ROTEM W indicated CPB-induced clotting factor depletion and platelet dysfunction that persisted after CPB and heparin neutralisation. ROTEM W results were available within 15 min and therefore much faster than standard tests. ROTEM W -guided specific blood product treatment resulted in satisfactory coagulatory function. The highest degree of platelet activation was found directly after DHCA. Conclusions: A major benefit of ROTEM W is the quick detection of a developing coagulopathy already during CPB. ROTEM W guides quick and specific blood product treatment after CPB, which may decrease bleeding complications in cardiac surgery. The finding of maximal platelet activation directly after DHCA suggests that not only CPB but also hypothermia activates platelets in vivo, thereby contributing to platelet dysfunction. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.