Background: The transcatheter edge-to-edge mitral valve repair, using MitraClip, has been a safe and effective treatment for severe mitral regurgitation (SMR) in the westerners. However, the therapeutic results of the MitralClip in Taiwan remained elucidated. Methods: Patients with symptomatic SMR were evaluated by the heart team. For those with high or prohibitive surgical risks, transcatheter mitral valve repair was performed in hybrid operation room. During procedure, continuous hemodynamic monitoring was conducted. Transthoracic echocardiography (TTE), blood tests, and six-minute walk test (6MWT) were performed before and 1-month after surgery. Results: A total of 20 patients (73.4 ± 11.1 years, 85% male) with a mean Euroscore II of 13.2 ± 17.7% and a mean STS score of 8.7 ± 9.0% for mortality were enrolled. After a mean procedural time of 239 ± 95 min, an average of 1.8 ± 0.7 clips were used in each procedure. The procedural successful rate was 95% to achieve mild residual mitral regurgitation. Cardiac output was increased from 3.6 ± 0.9 to 4.6 ± 1.4 (p = 0.008) and V-wave of left atrial pressure declined from 24.4 ± 9.8 to 19.3 ± 7.1 (p = 0.030) immediately during the index procedure. There was no peri-procedural death, myocardial infarction, stroke or any events requiring emergent cardiac surgery. All patients experienced significant improvement in heart failure symptoms. The 6-min walk distance increased from 219.6 ± 118.4 m to 279.1 ± 111.6 (p = 0.04) at 1 month. The echocardiogram further showed significant improvements of mitral regurgitation, pulmonary artery systolic pressure, and the left ventricular end-diastolic volume. Conclusion: Trans-catheter edge-to-edge mitral valve repairs are safe and effective in Asians with symptomatic SMR, regarding the improvements of clinical symptoms and exercise capacities. MitraClips is also associated with reverse remodeling of pulmonary hypertension and left ventricular size in patients with SMR.
OBJECTIVE:The end-tidal concentration of inhalation anesthetics is a clinical indicator for predicting the emergence from anesthesia.This study was conducted to assess the relationship between arterial blood and end-tidal sevoflurane concentrations during emergence.METHODS: Thirty-two female American Society of Anesthesiologists physical status I-II patients receiving general anesthesia for elective gynecologic surgery were included.A fixed dose of 3.5% inspiratory sevoflurane in 6 L min -1 oxygen was maintained until the end of surgery.At 20 and 10 minutes before and 0, 5, 10, 15, and 20 minutes after discontinuing sevoflurane, as well as at the time of eye opening by verbal command, defined as awakening, 1 ml arterial blood was obtained to measure its sevoflurane concentration by gas chromatography.Simultaneous inspiratory and end-tidal concentrations of sevoflurane were detected by an infrared analyzer and tested by Bland-Altman agreement analysis. RESULTS:The arterial blood concentrations of sevoflurane were similar to the simultaneous end-tidal concentrations during emergence: 0.36% (0.10) and 0.36% (0.08) sevoflurane at awakening, respectively.The mean time from discontinuing sevoflurane to eye opening was 15.8 minutes (SD 2.9, range 10-26) and was significantly correlated with the duration of anesthesia (52-192 minutes) (P = 0.006) but not with the body mass index or total fentanyl dose.CONCLUSION: The mean awakening arterial blood concentration of sevoflurane was 0.36%.The time to awakening was prolonged in accordance with the anesthetic duration within 3 hours.With well-assisted ventilation during emergence, the sevoflurane end-tidal concentration was nearly equal to its arterial blood concentration, which could be a feasible predictor for awakening.
Water ingestion induces a sympathetically mediated increase in blood pressure in dysautonomic patients and the elderly, but not consistently in young healthy subjects. The aim of study was to determine the extent of the pressor response and changes of sympathetic activity biomarker salivary alpha-amylase (sAA) after water ingestion in young healthy subjects. Compared with ingestion of 50 mL of water, the blood pressure, total peripheral resistance and sAA significantly increased and the plasma osmolality decreased 25 min after drinking 500 mL of water. The results confirm the osmopressor response in young subjects and suggest that sAA may be used as a non-invasive marker of sympathetic activity in future studies.
OBJECTIVES: Under a constant inspired concentration, the uptake of a volatile anesthetic into the arterial blood should mainly be governed by alveolar ventilation, according to the assumption that the patient's cardiac output remains stable during anesthesia.We investigated whether ventilation volume affects the rate of desflurane uptake by examining arterial blood concentrations.METHOD: Thirty female patients were randomly allocated into the following three groups: hyperventilation, normal ventilation and hypoventilation.Hemodynamic variables were measured using a Finometer, inspiratory and end-tidal concentrations of desflurane were measured by infrared analysis, and the desflurane concentration in the arterial blood (Ades) was analyzed by gas chromatography. RESULTS:During the first 10 minutes after the administration of desflurane, the Ades was highest in the hyperventilation group, and this value was significantly different from those obtained for the normal and hypoventilation groups.In addition, hyperventilation significantly increased the slope of Ades-over-time during the first 5 minutes compared with patients experiencing normal ventilation and hypoventilation, but there were no differences in these slopes during the periods from 5-10, 10-20 and 20-40 minutes after the administration of desflurane.This finding indicates that there were no differences in desflurane uptake between the three groups after the first 5 minutes within desflurane administration.CONCLUSIONS: Hyperventilation accelerated the rate of the rise in Ades following desflurane administration, which was time-dependent with respect to different alveolar ventilations levels.
We investigated the effect of the inspired isoflurane concentration (C<sub>I</sub>iso) on body uptake by comparing the isoflurane concentration in the pulmonary artery blood (PAiso) and that in the arterial blood (Aiso) in 16 patients undergoing coronary artery bypass grafting surgery during the 1st, hour of isoflurane anesthesia. The patients received standardized anesthetics consisting of fentanyl and thiopental and were then allocated to receive either 1% or 2% C<sub>I</sub>iso (n = 8 in each group). C<sub>I</sub>iso and end-tidal isoflurane concentration (C<sub>E</sub>iso) were measured by infrared analysis, and Aiso and PAiso were analyzed by gas chromatography. The cardiac output was measured by thermodilution by use of a pulmonary artery catheter. The body tissue could be represented by the gradient C<sub>I</sub>iso–C<sub>E</sub>iso or Aiso–PAiso over time, respectively. The 2% inspired isoflurane group had twice the gradients (either C<sub>I</sub>iso–C<sub>E</sub>iso or Aiso-PAiso) than the 1% inspired isoflurance group. Additionally, both C<sub>I</sub>iso–C<sub>E</sub>iso and Aiso–PAiso were nearly constant over the hour of the study. The inspired concentration-dependent and near- constant uptake of isoflurane over time has important implications <i>which enable us to apply the uptake pattern of isoflurane to clinical practice.</i>
The aim of the study was to evaluate the effects of high-dose nitroglycerine administered during cardiopulmonary bypass on the intraoperative cerebral saturation and postoperative serum creatinine concentration in cardiac surgery.In a retrospective cohort study, a total of 239 patients undergoing cardiac surgery with cardiopulmonary bypass at a tertiary medical center were included. General anesthesia consisted of volatile anesthetic and either intravenous loading of high-dose nitroglycerin (infusion rate 10 to 20 mg·h with a total dose of ≥0.5 mg·kg) starting from rewarming of cardiopulmonary bypass throughout the end of the surgery (NTG group; N = 96) or without high-dose nitroglycerin (control group; N = 143). Data for intraoperative cerebral saturation and serum creatinine concentrations before and after cardiac surgery were collected. Propensity score method was used to adjust for potential confounders.Patients receiving high-dose nitroglycerin had significantly lower mean arterial pressure and hematocrit levels during and after cardiopulmonary bypass. The risk of intraoperative cerebral desaturation was left-sided 23.9% versus 38.5% (p = 0.023), right-sided 28.1% versus 35.7% in the NTG and control groups, respectively. The risk of new-onset stroke and postoperative dialysis was 2.1% versus 6.3% and 1.0% versus 3.5% in the NTG and control groups, respectively.An infusion of high-dose nitroglycerin initiating at rewarming of cardiopulmonary bypass and throughout the postbypass interval may induce hypotension and hemodilution in cardiac surgical patients. Cerebral saturation and renal function were well maintained without increasing the risk of stroke and renal replacement therapy after cardiac surgery with cardiopulmonary bypass.
The objectives of this study were to determine whether minimal low-flow isoflurane-based anesthesia could be a feasible technique for patients undergoing coronary artery bypass graft surgery. It is hypothesized that isoflurane-based anesthesia facilitates an agreeable recovery from surgery is mediated through preventing hyperglycemia and metabolic disturbance associated with cardiopulmonary bypass.107 consecutive patients were randomly assigned to two groups, i.e., isoflurane-based anesthesia group (n = 54) and fentanyl-based anesthesia group (control group, n = 53). In isoflurane-based anesthesia group, patients received isoflurane from induction up till departure from operating room to intensive care unit (ICU). In the control group, fentanyl (66.4 +/- 3.2 micrograms/kg) and midazolam (320 +/- 20 micrograms/kg) were administered to anesthetize the patients during the operation.Patients with isoflurane-based anesthesia required less dopamine (0.6 +/- 0.2 vs. 4.2 +/- 0.4 micrograms/min) and dobutamine (0.4 +/- 0.2 vs. 4.1 +/- 0.5 micrograms/min); they could be extubated earlier (7.9 +/- 1.0 vs. 35.1 +/- 2.9 h), and had a shorter stay at ICU (2.2 +/- 0.2 vs. 4.8 +/- 0.4 days). In addition, occurrence of hyperglycemia (167 +/- 7.7 vs. 243 +/- 9.5 mg/dl) and bicarbonate requirement (128 +/- 7.0 vs. 313 +/- 22.0 mEq) were less in patients with isoflurane-based anesthesia as compared with those in fentanyl group.These results demonstrate that isoflurane, not fentanyl, benefits patients undergoing coronary artery bypass grafting surgery. This benefit perhaps is mediated through maintaining hemodynamic stability and metabolic homeostasis and preventing hyperglycemia.
Studies in patients with an impaired efferent baroreflex led us to discover that ingesting water induces a robust increase in blood pressure and vascular resistance. This response was also present in healthy subjects with intact baroreflexes, described as osmopressor response. This study was to discover the physiology of the osmopressor response by determining functional activation of the aquaporin-1 water channel receptor on red blood cell membranes in young healthy subjects. In a randomized, controlled, crossover fashion, 22 young healthy subjects (age, 19-27 years) ingested either 500 or 50 mL of water. Heart rate, blood pressure, cardiac index, and total peripheral vascular resistance were measured using a Finometer hemodynamic monitor. Blood sampling was performed at 5 minutes before and at 25 and 50 minutes after either the water ingestion or control session. Immunoblotting for aquaporin-1 tyrosine phosphorylation was performed before and after subjects ingested either 500 or 50 mL of water. At 25 minutes after the ingestion of 500 mL of water, total peripheral resistance increased significantly, and plasma osmolality decreased. Functional expression of aquaporin-1 tyrosine phosphorylation on red blood cell membranes increased significantly at 25 and 50 minutes after subjects ingested 500 mL of water compared with that before water ingestion. This study concludes that water ingestion produces upregulation of aquaporin-1 tyrosine phosphorylation on red blood cell, which presents as a novel biological marker that occurs simultaneously with the osmopressor response.
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