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1/478. Fatal cardiac ischaemia associated with prolonged desflurane anaesthesia and administration of exogenous catecholamines.

    PURPOSE: Four cardiac ischaemic events are reported during and after prolonged anaesthesia with desflurane. CLINICAL FEATURES: We have evaluated desflurane in 21 consecutive patients undergoing advanced head and neck reconstructive surgery. Four deaths occurred which were associated with cardiac ischaemic syndromes either during or immediately after operation. All patients in the study received a similar anaesthetic. This comprised induction with propofol and maintenance with alfentanil and desflurane in oxygen-enriched air. Inotropic support (either dopamine or dobutamine in low dose, 5 micrograms.kg.min-1) was provided as part of the anaesthetic technique in all patients. Critical cardiovascular incidents were observed in each of the four patients during surgery. These were either sudden bradycardia or tachycardia associated with ST-segment electrocardiographic changes. The four patients who died had a documented past history of coronary heart disease and were classified American Society of Anesthesiologists (ASA) II or III. One patient (#2) did not survive anaesthesia and surgery and the three others died on the first, second and twelfth postoperative days. Enzyme increases (CK/CK-MB) were available in three patients and confirmed myocardial ischaemia. CONCLUSION: These cases represent an unexpected increase in the immediate postoperative mortality for these types of patients and this anaesthetic sequence.
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2/478. cardiomyoplasty and implantable cardioverter defibrillator: efficacy and safety of concomitant device implantation: sudden death and cardiomyoplasty.

    Sudden death represents a common event in the natural history of patients affected by chronic heart failure. Such an outcome also has been shown to characterize the follow-up of the cardiomyoplasty procedure. We report two cases of patients who had cardiomyoplasty and experienced witnessed episodes of ventricular arrhythmia at variable times after surgery (2 years and 2 months, respectively). In the first case, an implantable cardioverter defibrillator (ICD) was implanted subsequent to the arrhythmic episode, whereas the second patient had a combined cardiomyoplasty and ICD implantation procedure. In particular, this patient underwent a modified wrapping technique, herein described, because of a large left ventricular dilatation. In both cases, ventricular defibrillation did not affect the correct functioning of the implanted cardiomyostimulator. Our article confirms that ventricular arrhythmia is common in cardiomyoplasty patients. The combined use of a skeletal muscle stimulator and implantable defibrillator may therefore be effective in preventing arrhythmia-related sudden death without any concurrent effect on the correct functioning of the wrapped muscle/heart circuit, with likely benefit on long-term cardiomyoplasty patient survival.
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keywords = death
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3/478. Provision of a neuroendoscopy service. The Southampton experience.

    BACKGROUND: A series of 21 patients (aged 1 week to 80 years) underwent a total of 22 neuroendoscopic procedures in our Unit in the period July 1993 to January 1996. methods: The procedures were performed by one surgeon familiar with the technique using the Stortz rigid neuroendoscope system. The most common indication for neuroendoscopy was obstructive hydrocephalus. The most frequently performed procedure was third ventriculostomy and tumor biopsy. The intended surgical procedure was successfully performed in all but two of the cases (attempted septostomy and internal cyst drainage) were both abandoned due to unrecognisable anatomy. RESULTS: Of the 19 patients treated by fenestration or ventriculostomy to relieve hydrocephalus, 5 eventually required definitive shunting procedures. CONCLUSIONS: Complications relating directly to the neuroendoscopy occurred in 2 patients (bleeding requiring temporary external ventricular drain) and there were no surgical deaths.
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4/478. Fatal late multiple emboli after endovascular treatment of abdominal aortic aneurysm. Case report.

    BACKGROUND: The short term experience of endovascular treatment of abdominal aortic aneurysms (AAA) seems promising but long term randomised data are lacking. Consequently, cases treated by endovascular procedures need to be closely followed for potential risks and benefits. CASE REPORT: A 70 year-old mildly hypertensive male without previous or present arteriosclerotic, pulmonary, or urological manifestations was subjected to endovascular treatment after his mass-screening diagnosed abdominal aortic aneurysm had expanded to above 5 cm in diameter, the aneurysm having been found by CT-scanning and arteriography to be endovascularly treatable. A Vanguard bifurcated aortic stent graft was implanted under epidural/spinal anaesthesia and covered by cephalosporine and heparin (8000 IE) protection. Apart from treatment of a groin haematoma and stenosis of the left superficial femoral artery, the postoperative period presented no problems. A few days before the monthly follow-up visit, the patient developed uraemia, gangrene of one foot and dyspnoea. blood glucose and LDH was elevated. Deterioration led to death a month and a half after stent implantation. autopsy showed extraordinary large, extensive soft, brown vegetations in the lower part of the thoracic aorta above the properly infrarenally-placed stent. Microscopic examination revealed multiple microemboli in the liver, spleen, pancreas, intestines, testes, and especially the kidneys. DISCUSSION: Early death from microemboli after aortic stent implantation has been reported. However, the present case developed fatal multiple microemboli so late that they could not have originated from the excluded mural thrombus. The sudden death of an otherwise healthy man of extensive microemboli is difficult to explain. The stent application may have altered the proximal flow and wall movements disposing to microemboli in the case of vegetations.
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5/478. Fungal endocarditis in critically ill children.

    All cases of infective endocarditis occurring from January 1990 to December 1996 at our institution were reviewed, with a special focus on fungal endocarditis. Five critically ill children with fungal endocarditis and eleven children with bacterial endocarditis were recorded. The proportion of fungal endocarditis in our series was 5/16 (31%) and candida albicans (4/5) was the most common fungal pathogen. Only one patient required heart surgery because of a loose patch but all the others were treated only by medical management for cure. The hospital survival rate was 80% (4/5) and the overall long-term survival rate was 60% (3/5) with only one death directly related to fungal infection. CONCLUSION: Despite the small number of cases, a sole medical approach including amphotericin b and long-term fluconazole prophylaxis for the treatment of fungal endocarditis in critically ill children seems to offer an alternative to surgical treatment which may be kept for failure of medical treatment.
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6/478. Ogilvie's syndrome after lower extremity arthroplasty.

    OBJECTIVE: To alert surgeons who perform arthroplasty to the possibility of acute colonic pseudo-obstruction (Ogilvie's syndrome) after elective orthopedic procedures. To identify possible risk factors and emphasize the need for prompt recognition, careful monitoring and appropriate management so as to reduce morbidity and mortality. DESIGN: A case series. SETTING: A university-affiliated hospital that is a major referral centre for orthopedic surgery. patients: Four patients who had Ogilvie's syndrome after lower extremity arthroplasty. Of this group, 2 had primary hip arthroplasty, 1 had primary knee arthroplasty and 1 had revision hip arthroplasty. MAIN OUTCOME MEASURES: morbidity and mortality. RESULTS: In all 4 patients Ogilvie's syndrome was recognized late and required surgical intervention. Two patients died as a result of postoperative complications. CONCLUSIONS: Our case series identified increasing age, immobility and patient-controlled narcotic analgesia as potential risk factors for Ogilvie's syndrome in the postoperative orthopedic patient. Prompt recognition and early consultation with frequent clinical and radiographic monitoring are necessary to avoid colonic perforation and its significant associated death rate.
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7/478. Three cases of severe subfulminant hepatitis in heart-transplanted patients after nosocomial transmission of a mutant hepatitis b virus.

    Fulminant and severe viral hepatitis are frequently associated with mutant hepatitis b virus (HBV) strains. In this study, the genetic background of a viral strain causing severe subfulminant outcome in heart-transplanted patients was studied and compared with viral hepatitis B strains that were not linked to severe liver disease in the same setting. A total of 46 patients infected nosocomially with HBV genotype A were studied. Five different viral strains were detected, infecting 3, 9, 5, 24, and 5 patients, respectively. Only one viral strain was found to be associated with the subfulminant outcome and 3 patient deaths as a consequence of severe liver disease. The remaining 43 patients with posttransplantation HBV infection did not show this fatal outcome. Instead, symptoms of hepatitis were generally mild or clinically undiagnosed. Comparison of this virus genome with the four other strains showed an accumulation of mutations in the basic core promoter, a region that influences viral replication, but also in hepatitis B X protein (HBX) (7 mutant motifs), core (10 mutant motifs), the preS1 region (5 mutant motifs), and the HBpolymerase open reading frame (17 motifs). Some of these variations, such as those in the core region, were located on the tip of the protruding spike of the viral capsid (codons 60 to 90), also known in part as an important HLA class II-restricted epitope region. These mutations might therefore influence the immune-mediated response. The viral strain causing subfulminant hepatitis was, in addition, the only strain with a preCore stop codon mutation and, thus, hepatitis B e antigen (HBeAg) expression was never observed. The combination of these specific viral factors is thought to be responsible for the fatal outcome in these immune-suppressed heart-transplant recipients.
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8/478. Percutaneous revascularization modalities in heart transplant recipients.

    Accelerated allograft vasculopathy significantly limits the survival of heart transplant recipients. The prevalence of allograft coronary artery disease is as high as 18% by 1 year and 50% by 5 years following heart transplant. heart failure and sudden cardiac death are the two most common clinical presentations. In heart transplant recipients with severe, discrete focal allograft vascular disease, percutaneous balloon angioplasty is a viable palliative option. However, its application is limited by a significant restenosis rate and progression of allograft disease in nontreated segments. Diffuse disease with tapering of vessels may be approached by debulking devices. Emerging revascularization modalities for focal stenoses and some of the diffuse tapering vessels include coronary stents, rotational atherectomy, various wavelength lasers, and, to a lesser extent, directional atherectomy. Conceivably, stents will reduce restenosis rates related to focal, discrete plaques; yet it is unknown whether they will be efficacious in short- and long-term treatment of diffusely diseased segments affected by allograft disease. Accurate assessment of clinical outcomes and long-term evaluation is imperative prior to acceptance of these devices as fundamental interventional tools for treatment of allograft coronary artery disease.
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ranking = 1
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9/478. Use of postoperative chest x-ray after elective adult tracheotomy.

    Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. postoperative hemorrhage was the most common complication (3.6%). pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax.
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10/478. Glutaraldehyde-fixed heterologous pericardium for vena cava grafting following hepatectomy.

    BACKGROUND/AIMS: Glutaraldehyde-fixed heterologous pericardium has been widely used for grafts in cardiac surgery. We applied it for inferior vena cava (IVC) patch grafting following combined resection of the liver and the IVC. METHODOLOGY: IVC grafting using a glutaraldehyde-fixed horse pericardium following combined resection of the liver and the IVC was performed in 2 patients--one with hepatocellular carcinoma and the other with hepatic metastasis following rectal cancer. The retrohepatic vena cava defect was closed with a 10 x 5 cm patch in one patient and a 7 x 4 cm patch in the other. RESULTS: Hepatic vascular exclusion was avoided in both patients. The IVC exclusion period was 40 min for the first patient and 25 min for the second. One patient required a veno-venous bypass with an active centrifugal pump of 153 min. There was no complication and no graft infection. The microscopic extension to the IVC was evident in one patient, and fibrous adhesive was evident in the IVC wall of the other. One patient died of hepatic failure 3 years and 6 months after surgery, and the other died of hepatic recurrence 7 months after surgery. Both grafts were patent, without calcification and stricture, until the patients' death. CONCLUSIONS: Glutaraldehyde-fixed heterologous pericardium is an option for IVC grafting.
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