In Response: We thank Dr. Spahn for his comments regarding our recent article. As he points out, there were several errors in the units of doses. We would like to correct the mistakes and also provide additional information concerning the study protocol. Prostaglandin E, and nitroglycerin were infused IV at a rate of 0.3 [micro sign]g [center dot] kg-1 [center dot] min-1 and 5 [micro sign]g [center dot] kg-1 [center dot] min-1, respectively. Anesthesia was induced by an IV dose of 30 [micro sign]g/kg of fentanyl, 0.2 mg/kg of midazolam and 0.2 mg/kg of vecuronium. Vecuronium was supplemented at a rate of 0.1 mg [center dot] kg-1 [center dot] 30 min-1 by the end of operation. The study reported in this article was completed within 1 h after the induction. No other drug was given in this study. The administration protocol of the anesthetics and the muscular relaxant was exactly the same for each group. Considering the hemodynamic stability of the patients, their anesthesia status was thought to be stable and sufficient for the stimulus in this study. Before the operation, the patients in this study had been under the same preoperative medication protocol at least for 1 wk. That pro-tocol was oral administration of 20 mg/d isosorbide dinitrate and 10 mg/d nitrendipine. Because the body weights of the patients were within the 40-60 kg range, the dose was not modified according to the body weight. Yuji Kadoi, MD Department of Anesthesiology and Reanimatology; Gunma University School of Medicine; Maebashi 371, Japan
The purpose of this study was to examine the effects of rewarming rate on internal jugular venous oxygen hemoglobin saturation (Sjvo2) during the rewarming period, and long-term cognitive outcome in diabetic patients. We studied 30 diabetic patients scheduled for elective coronary artery bypass graft surgery. As a control, 30 age-matched nondiabetic patients were identified. The diabetic patients were randomly divided into two groups: the Slow Rewarming group (n = 15) (mean rewarming speed: 0.22° ± 0.07°C/min, mean ± sd) or the Standard Rewarming group (Standard group) (n = 15) (mean rewarming speed: 0.46° ± 0.09°C/min, mean ± sd). After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor Sjvo2 continuously. Hemodynamic variables and arterial and jugular venous blood gases were measured at nine time points. All patients underwent a battery of neurologic and neuropsychologic tests on the day before the operation and at 4 mo after surgery. The Sjvo2 values in the Standard group were decreased during the rewarming period compared with at the induction of anesthesia (P < 0.05). There was a significant difference in the Sjvo2 value in the Control group between standard rewarming and slow rewarming during rewarming periods (Standard Control group: 51% ± 8%, Slow Control groups: 58% ± 5%) (P < 0.05). However, there was no difference in the Sjvo2 value in diabetic patients between standard rewarming and slow rewarming during the rewarming period. The rewarming rates (odds ratio: 0.8; 95% confidence interval: 0.5–1.3;P = 0.6) had no correlation with cognitive impairment at 4 mo after the surgery. Diabetes (odds ratio: 1.6; 95% confidence interval: 0.9–2.6;P = 0.04) was a factor in relation to cognitive impairment at 4 mo after the surgery. We concluded that a slow rewarming rate had no effects on the reduction in Sjvo2 value and long-term cognitive outcome in diabetic patients.
A 70-year-old man was scheduled for tricuspid valvuloplasty for severe tricuspid regurgitation (TR). Preoperative 2D transthoracic echocardiography revealed severe TR resulting from tricuspid annular dilation with a thickened anterior tricuspid leaflet (AL). Intraoperative transesophageal echocardiography (TEE) was performed using a 3D echocardiographic matrix-array probe (X7-2t Transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a dilated right ventricle (RV), dilated tricuspid annular dimension of 44 mm at end diastole, and discontinuity in the AL (Fig. 1A and the first part of Video 1, Supplemental Digital Content, https://links.lww.com/AA/B42). Color-flow Doppler (CFD) analysis revealed a central, broad-based jet of TR (second part of Video 1, Supplemental Digital Content, https://links.lww.com/AA/B42). The ME RV inflow view with the multiplane angle at 70 degrees demonstrated a thickened and divided tricuspid AL, with each bundle of chordae from the anterior papillary muscle (Fig. 1B and the third part of Video 1, Supplemental Digital Content, https://links.lww.com/AA/B42). CFD revealed severe TR (fourth part of Video 1, Supplemental Digital Content, https://links.lww.com/AA/B42). The transgastric RV basal short-axis view demonstrated a notch at the center of the AL (Fig. 1C and the first part of Video 2, Supplemental Digital Content, https://links.lww.com/AA/B43), and CFD analysis revealed the location of the TR (second part of Video 2, Supplemental Digital Content, https://links.lww.com/AA/B43). Next, a 3D echocardiographic view was scanned for additional morphological evaluations. A 3D zoom image was obtained from an ME view of the tricuspid valve at 100 degrees and manipulated to provide en face views of the tricuspid valve from the right atrium (RA) with the septal leaflet located in the 6 o’clock position, which confirms the spatial relationship of the AL to surrounding tissues such as the aortic valve and anterior mitral leaflet1 (Fig. 2A, and the first part of Video 3, Supplemental Digital Content, https://links.lww.com/AA/B44). This view revealed that the notch in the tricuspid AL did not extend to the annulus. To facilitate analysis and understanding of the 2D ME views in Figure 1, A and B, 2 lines were depicted on the 3D view obtained with a 90-degree clockwise rotation from the RA view in Figure 2, A and B. Three-dimensional morphological and CFD analysis from the RV side demonstrated the location and extent of the notch and the site of the regurgitation (second and third parts of Video 3, Supplemental Digital Content, https://links.lww.com/AA/B44). Surgical inspection was consistent with the 3D view from the RA perspective at mid-diastole (Fig. 3, A and B) and confirmed that the defect was not a cleft but a notch. Although echo dropout was present in the 3D view, the notch could be identified and correlated with 2D imaging (Fig. 3B).Figure 1: Two-dimensional transesophageal echocardiographic analysis of the tricuspid valve using midesophageal (ME) and transgastric views. A, The ME 4-chamber (ME 4ch) view revealed a thickened anterior tricuspid leaflet (AL) and discontinuity (red arrow) in it during ventricular systole. B, The ME right ventricular (RV) inflow view demonstrated a thickened and divided AL (red arrow), with a bundle of chordae extending from the anterior papillary muscle (APM) to each part of the divided AL. C, An abnormal notch (red arrow) on the tricuspid AL at ventricular mid-diastole was visualized with the transgastric (TG) RV basal short-axis (SAX) view. The pulmonary artery catheter (PAC) is indicated by a circle. The triangles indicate the echo dropout resulting from PAC. LA = left atrium; RA = right atrium; AV = aortic valve; A = anterior tricuspid leaflet; S = septal tricuspid leaflet; P = posterior tricuspid leaflet.Figure 2: Three-dimensional transesophageal echocardiographic analysis of the tricuspid valve. A, The abnormal notch on the anterior tricuspid leaflet as seen from the right atrial perspective (red arrow). This view demonstrated that the notch did not extend to the annulus, and that the annulus was dilated laterally. B, Right atrial view with clockwise rotation by 90 degrees from A. This view facilitated the 2D midesophageal (ME) views in Figure 1, A and B. The scan lines of the ME 4-chamber and right ventricular inflow view correspond to a and b, respectively. The scan line of b is orthogonal to the notch compared with a. The notch on the divided leaflet was clearly scanned in the ME right ventricular inflow view. AV = aortic valve; MV = mitral valve; RVOT = right ventricular outflow tract; A = anterior tricuspid leaflet; S = septal tricuspid leaflet; P = posterior tricuspid leaflet.Figure 3: Surgical inspection and 3D echocardiographic views of the anterior leaflet of the tricuspid valve. A, Surgical inspection showed extension of the fissure, which was as deep as the commissure, to the transition area between the rough and clear zones. B, Three-dimensional views from the right atrial perspective were consistent with the findings of surgical inspection. The red arrows in A and B indicate the notch on the anterior tricuspid leaflet. The blue triangle indicates echo dropout at the clear zone of the anterior leaflet. Ao = ascending aorta; PAC = pulmonary artery catheter; IVC = inferior vena cava; A-S = commissure of the anterior and septal leaflets; A-P = commissure of the anterior and posterior leaflets; AV = aortic valve; MV = mitral valve; RVOT = right ventricular outflow tract.The notch was sutured, and an annuloplasty ring was implanted for correction of the dilated annulus. Only trivial residual TR was observed on TEE after weaning off cardiopulmonary bypass. The postoperative course of the patient was uneventful. DISCUSSION Isolated congenital TR is very rare, and one of its typical causes includes a cleft tricuspid valve.2 A review of 28,091 echocardiograms in the general population during a period of 7 years reported an incidence of cleft tricuspid valve of 0.018%, whereas Eichhorn et al.3 found a higher incidence of this anomaly in 0.6% of patients with associated congenital diseases. Generally, a cleft leaflet is defined as a discontinuity in the leaflet that extends to the annulus, whereas a notch is a discontinuity that does not extend to the annulus.1 Tricuspid notches are commonly noted during surgical inspection or pathologic examination although they are less frequently recognized by echocardiography. Silver et al.4 found that many notches, of variable depth and width, were observed in the free edge of the tricuspid AL, close to the anteroseptal commissure in 47 of 50 leaflets, whereas another notch was seen at the apex of the AL in 6 of 50 hearts, which, although not as deep as a commissure, subdivided the leaflet, and rough zone chordae were always inserted into them. The notch in our patient would be consistent with the latter. Unlike leaflet clefts, it is unclear how frequently notches contribute to TR. The use of 2D and 3D TEE for assessment of mitral valve leaflet clefts has been reported5,6; we applied a similar technique to evaluate the tricuspid valve. The 2D transgastric RV basal short-axis view enables visualization of en face views of the tricuspid valve, but it is neither always able to scan the precise location and range of extension of the abnormal notch nor can it display the regurgitant orifice with CFD because the imaging plane interrogates the leaflets obliquely and because there might be echo dropout due to annular calcification or the presence of a pulmonary artery catheter, especially in the tricuspid valve area. However, 3D echocardiographic analysis from the RA side enables scanning of the precise morphology of the notched leaflet. Ultrasound insertion into the whole tricuspid leaflet and annulus from above, together with volume scanning, allows demonstration of the entire structure of the leaflet notch and depicts the precise location and extension to the annulus although the quality of the scan may not be equal to that of the mitral valve because the tricuspid valve is more distant from the TEE transducer, and there could be echo dropout because of the thinner leaflet. In our case, 3D analysis enabled visualization of true en face views of the tricuspid valve leaflet and annulus and confirmed that the notch did not extend to the annulus, but was as deep as a commissure, leading to the diagnosis of a notch rather than a cleft on the AL. The ME RV inflow view allowed orthogonal scanning of the notched AL and the major axis of the regurgitant jet with CFD, indicating the location of the TR and its cause, which was consistent with 3D CFD analysis. Furthermore, the pathophysiology of TR in this case included coaptation failure because of complex mechanisms of thickened anterior leaflet tips at the notch and a laterally dilated annulus. Thickening of the AL compared with the septal and posterior leaflets was more clearly and precisely depicted in 2D analysis of the ME 4-chamber and RV inflow views in this case. However, 3D analysis with en face views of the tricuspid valve was useful for evaluating the location and extent of the notch, the precise location of the regurgitant orifice, and morphologic images of the laterally dilated annulus. This information enabled planning of the surgical procedure of tricuspid valvuloplasty. In conclusion, detailed 2D and 3D TEE analysis complement each other in analyzing the morphological features of tricuspid valve notches and the pathophysiology of TR. CFD analysis with both 2D and 3D TEE is useful for diagnosing the precise origin of TR. Clinician’s Key Teaching Points By J. Skubas, MD, Roman M. Sniecinski, MD, and Martin J. London, MD Isolated congenital tricuspid valve (TV) regurgitation, although rare, is often the result of a cleft in 1 of the 3 leaflets. A cleft is defined as an anatomic discontinuity that extends through the body of the leaflet (“clear zone”) to the annulus. A more limited form of discontinuity, often called a “notch,” does not extend all the way to the annulus. Two-dimensional transesophageal echocardiography (TEE) imaging in the midesophageal (ME) 4-chamber or right ventricular inflow–outflow views usually allows assessment of the mobility and quality of the TV leaflets but often fails to distinguish between clefts and notches. Three-dimensional TEE imaging, by providing a true en face view, facilitates more precise identification and localization of leaflet discontinuities. In this case of isolated severe tricuspid regurgitation, 2D TEE imaging revealed a dilated tricuspid annulus and a thickened and divided anterior TV leaflet. Using 3D TEE datasets, acquired from a modified ME bicaval view and rotated to match the 2D ME orientation from the right atrial and right ventricular perspectives, the extent of the anterior leaflet discontinuity was correctly diagnosed as a notch. Two-dimensional TEE oblique echocardiographic planes do not always permit the correct diagnosis of a TV leaflet anatomic lesion or the precise location of tricuspid regurgitation jets. This may be important in cases of concurrent mitral valve regurgitation, when the TV pathology should be considered when planning for surgery. Three-dimensional TEE greatly facilitates identification of subtle leaflet discontinuities such as TV clefts and notches. DISCLOSURES Name: Masataka Kuroda, MD, PhD. Contribution: This author helped design the study, conduct the study, data collection, data analysis, and manuscript preparation. Attestation: Masataka Kuroda approved the final manuscript. Name: Joe Ohta, MD. Contribution: This author helped prepare the manuscript. Attestation: Joe Ohta approved the final manuscript. Name: Norikatsu Mita, MD. Contribution: This author helped prepare the manuscript. Attestation: Norikatsu Mita approved the final manuscript. Name: Sohtaro Miyoshi, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Sohtaro Miyoshi approved the final manuscript. Name: Yuji Kadoi, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Yuji Kadoi approved the final manuscript. Name: Shigeru Saito, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Shigeru Saito approved the final manuscript. This manuscript was handled by: Martin J. London, MD.
Using transesophageal echocardiography (TEE) we assessed left ventricular end-systolic elastance (Ees) during the pre- and post-cardiopulmonary bypass (CPB) periods in 10 patients undergoing an elective coronary artery bypass graft surgery. The end systolic volume of the left ventricle was obtained by TEE, and the end systolic pressure was obtained by the femoral artery pressure wave form. LVSWI decreased at post-CPB compared to the value at pre-CPB. There were no significant differences in cardiac output, ejection fraction and Ees between pre-CPB and post-CPB period. Intraoperative end-systolic pressure-volume relationship may be clinically useful to assess left ventricular function and also useful to confirm anesthetic management in patients who has undergone an coronary artery bypass graft surgery.
In three patients, EEG, jugular venous oxygen saturation (Sjvo2) and near infrared spectroscopy (NIRS) were monitored to detect cerebral ischemia during carotid endarterectomy. In all cases, no changes in Sjvo2 and NIRS were observed during carotid artery occlusion, but in two patients EEG showed changes when carotid artery was clamped. It is important to know the precise mechanism of cerebral monitors to assess the cerebral ischemia in patients with preexisting neurological disorder during carotid endarterectomy.
This study was conducted to (1) compare the recovery times from rocuronium-induced muscle relaxation after reversal with sugammadex between young and elderly patients undergoing electroconvulsive therapy (ECT), and (2) to examine the existence of a correlation between cardiac index and reversibility of rocuronium-induced neuromuscular block with sugammadex after ECT.Seventeen patients (young group, 50 years or younger, n = 8; elderly group, 70 years or older, n = 9) who were scheduled to undergo ECT were studied. Anesthesia was induced using propofol (1.0 mg/kg) followed by rocuronium (0.6 mg/kg). Assisted mask ventilation was initiated with 100% oxygen. Cardiac index was monitored noninvasively throughout the procedure. After the first twitch of the train of four (TOF) was assessed as being zero by neuromuscular monitoring, an electroshock stimulus was applied bilaterally. Immediately after the seizure stopped, patients were given 8-mg/kg sugammadex intravenously to reverse the muscle relaxation. Neuromuscular monitoring was continued until recovery of the TOF ratio to 0.9 at the tibial nerve in the leg. The time to recovery of the TOF to 0.1 and 0.9 was compared in both groups.Although no significant difference in return to a TOF of 0.1 was found between the groups, there were significant differences in both recovery to a TOF of 0.9 and the time interval to the first spontaneous breath between groups (time to recovery to a TOF of 0.9, young group, 403 ± 37 seconds; elderly group, 443 ± 36 seconds; P < 0.05). In contrast, there was no relationship between cardiac index after ECT and recovery time to TOF of 0.9.Although recovery time to TOF of 0.9 after the administration of 8.0-mg/kg sugammadex was longer in the elderly patients than in the young patients, it had no relationship with cardiac output after ECT.
We evaluated the effects of anesthetic drugs and temperature on brain stem and mid-latency evoked potentials (BAEP and MLAEP) in 20-patients who were scheduled for elective cardiac operation using cardiopulmonary bypass with moderate hypothermia. At esophageal temperature of 36 degrees C, the latency of MLAEP was slightly prolonged by the increase of fentanyl dose, which suggested that the latency prolongation of MLAEP could not block the oscillation of auditory stimulation. At esophageal temperature of 27 degrees C, the latency of MLAEP nearly disappeared, and the latency of MLAEP gradually returned with the recovery of the esophageal temperature. The latency of BAEP was markedly prolonged at 27 degrees C and returned to the normal latency at 36 degrees C. The latency of MLAEP retained by high dose fentanyl suggests that patients may be aware during cardiopulmonary bypass at normothermia, and BAEP may be one of the useful brain function monitors during cardiopulmonary bypass.
Diabetes mellitus is an increasingly common disease that affects people of all ages, resulting in significant morbidity and mortality. Diabetic patients require more frequent hospitalization, have greater lengths of stay, and cost more to manage than non-diabetics. The major risk factors for diabetics undergoing surgery are the end-organ diseases associated with diabetes: cardiovascular disease, autonomic neuropathy and immune deficiency. Physicians should pay extra attention to preoperative and preprocedure evaluation and treatment of these diseases to ensure optimal perioperative management. Furthermore, these patients unexpectedly develop hemodynamic instability in response to vasopressor or vasodilator administration during anesthesia, this being of particular importance in patients with concurrent ischemic heart disease in whom it may have a direct effect on mortality. Recent studies have shown that tight glycemic control in diabetic patients undergoing major surgery has been shown to improve perioperative morbidity and mortality. Keywords: Diabetes mellitus, Tight glycemic control, Preoperative management, Diabetic retinopathy
In Brief In this study, we evaluated the time course of changes in inducible nitric oxide synthase (iNOS) in the brain by using the rat model of sepsis induced by cecal ligation and puncture (CLP) and examined whether selective iNOS inhibition can prevent the hemodynamic and neurological changes induced by sepsis. Male Wistar rats were randomly divided into four groups: control, sham, CLP, and CLP + the selective iNOS inhibitor l-N 6-(1-iminoethyl)-lysine (l-NIL). Septic shock was induced in the rats by CLP under pentobarbital anesthesia, and then we measured hemodynamic variables, neurological indicators, blood gases, plasma levels of nitrate/nitrite (an indicator of the biosynthesis of NO), and brain iNOS activity and nitrotyrosine levels after 1, 6, 12, and 24 h. Plasma nitrite was increased at 12 and 24 h in the CLP group. The activity of iNOS in the brain was increased at 12 and 24 h after CLP (at 12 h: control, 0.3 ± 0.05; sham, 0.3 ± 0.1; CLP, 1.3 ± 0.08*; CLP + l-NIL, 0.33 ± 0.1 fmol · mg−1 · min−1; at 24 h: control, 0.27 ± 0.08; sham, 0.31 ± 0.1; CLP, 1.0 ± 0.3*; CLP + l-NIL, 0.34 ± 0.1 fmol · mg−1 · min−1; mean ± sd; *P < 0.05). Brain nitrotyrosine was increased at 24 h after CLP (at 24 h: control, 6.7 ± 0.4; sham, 6.7 ± 0.5; CLP, 11.2 ± 2.8*; CLP + l-NIL, 7.52 ± 0.5 densitometric units; means ± sd; *P < 0.01). In contrast, in both the CLP and CLP + l-NIL groups, the consciousness reflex was significantly decreased at 24 h after CLP. Selective iNOS inhibition restored the hemodynamic changes induced by sepsis but could not improve neurological dysfunction. IMPLICATIONS: We examined whether selective inducible nitric oxide synthase inhibition can prevent the neurological changes induced by sepsis and found that it could not improve neurological dysfunction.
