Background: Microcirculatory disturbances are typically most severe during cardiopulmonary bypass (CPB), which occurs during cardiac surgeries. If microvascular reactivity compensates for microcirculatory disturbances during CPB, tissue hypoxemia can be minimized. The primary aim of this study was to assess whether microvascular reactivity during CPB could predict major adverse events (MAE) after cardiac surgery. Methods: This prospective observational study included 115 patients who underwent elective on-pump cardiac surgeries. A vascular occlusion test (VOT) with near-infrared spectroscopy was performed five times for each patient: before the induction of general anesthesia, 30 min after the induction of general anesthesia, 30 min after applying CPB, 10 min after protamine injection, and post-sternal closure. The postoperative MAE was recorded. The area under the receiver operating characteristic (AUROC) curve analysis was performed for the prediction of MAE using the recovery slope. Results: Of the 109 patients, MAE occurred in 32 (29.4%). The AUROC curve for the recovery slope during CPB was 0.701 (P < 0.001; 95% CI [0.606, 0.785]). If the recovery slope during CPB was < 1.08%/s, MAE were predicted with a sensitivity of 62.5% and specificity of 72.7%. Conclusions Our study demonstrated that the recovery slope of the VOT during CPB could predict MAE after cardiac surgery. These results support the idea that disturbances in microcirculation induced by CPB can predict the development of poor clinical outcomes, thereby demonstrating the potential role of microvascular reactivity as an early predictor of MAE after cardiac surgery.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared. METHODS: Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h. RESULTS: EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group. CONCLUSIONS: Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.
Administration, Intravenous ; Analgesia ; Analgesia, Epidural ; Analgesia, Patient-Controlled ; Analgesics ; Anesthesia, Epidural ; Humans ; Injections, Epidural ; Laparoscopes ; Laparoscopy ; Methods ; Morphine ; Nefopam ; Oxycodone ; Pain Measurement ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis ; Patient Satisfaction ; Pica ; Prostatectomy ; Thoracic Vertebrae

Anesthetic experience in frontotemporal dementia (FTD) with severe hypotension associated autonomic dysfunction has not yet been reported. Here in case, we report on the case of treatment with vasopressin to refractory hypotension in FTD patient. A 54-year-old male presented with a ten-year history of FTD with frequent syncope. The patient was scheduled to undergo subtotal gastrectomy for resection of stomach cancer. During the operation, sudden hypotension occurred and it was refractory to fluid and 1 unit of blood resuscitation and did not respond to catecholamine. Transesophageal echocardiography showed normal heart with adequate volume state. After intravenous administration of arginine vasopressin, the patient's vital signs returned to baseline values. Arginine vasopressin might be considered as a valuable alternative for treatment of severe refractory hypotension in autonomic dysfunction patients with FTD.
Administration, Intravenous ; Arginine Vasopressin ; Echocardiography, Transesophageal ; Frontotemporal Dementia* ; Gastrectomy ; Heart ; Humans ; Hypotension ; Male ; Middle Aged ; Resuscitation ; Stomach Neoplasms ; Syncope ; Vasopressins ; Vital Signs

The leading cause of morbidity and mortality in patients with acromegaly is cardiovascular complications. Myocardial exposure to excessive growth hormone can cause ventricular hypertrophy, hypertension, arrhythmia, and diastolic dysfunction. However, congestive heart failure as a result of systolic dysfunction is observed only rarely in patients with acromegaly. Most cases of acromegaly exhibit high levels of serum insulin-like growth factor-1 (IGF-1). Acromegaly with normal IGF-1 levels is rare and difficult to diagnose. Here, we report a rare case of an acromegalic patient whose first clinical manifestation was severe congestive heart failure, despite normal IGF-1 levels. We diagnosed acromegaly using a glucose-loading growth hormone suppression test. Cardiac function and myocardial hypertrophy improved 6 months after transsphenoidal resection of a pituitary adenoma.
Acromegaly* ; Arrhythmias, Cardiac ; Estrogens, Conjugated (USP)* ; Growth Hormone ; Heart Failure* ; Humans ; Hypertension ; Hypertrophy ; Insulin-Like Growth Factor I ; Mortality ; Pituitary Neoplasms

BACKGROUND: The purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort. METHODS: DSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 microg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a > or = 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group]. RESULTS: There were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 +/- 3.4% vs. -21.0 +/- 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%). CONCLUSION: Assessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.
Constriction, Pathologic ; Coronary Angiography ; Coronary Artery Disease ; Coronary Stenosis ; Dobutamine ; Echocardiography ; Echocardiography, Stress* ; Humans ; Myocardial Stunning ; Sensitivity and Specificity ; Thorax

The aim of this study was to evaluate the relationship between coronary artery calcium score (CACS) assessed by multidetector computed tomography (MDCT) and plaque components assessed by virtual histology-intravascular ultrasound (VH-IVUS) in 172 coronary artery disease (CAD) patients with 250 coronary lesions. CACS was assessed according to Agatston scoring method by MDCT and patients were divided into four groups: Group I (CACS = 0 [n = 52]); Group II (CACS = 1-100 [n = 99]); Group III (CACS = 101-400 [n = 84]); and Group IV (CACS > 400 [n = 15]). Total atheroma volume was greatest in Group IV (152 +/- 132 microL vs 171 +/- 114 microL vs 195 +/- 149 microL vs 321+/-182 microL, P < 0.001). The absolute dense calcium (DC) and necrotic core (NC) volumes were greatest, and relative DC volume was greatest in Group IV (5.5 +/- 6.6 microL vs 11.0 +/- 10.3 microL vs 15.6 +/- 13.6 microL vs 36.6 +/- 18.2 microL, P < 0.001, and 14.8 +/- 18.2 microL vs 19.5 +/- 18.9 microL vs 22.5 +/- 19.1 microL vs 41.7 +/- 27.9 microL, P < 0.001, and 6.4 +/- 5.3% vs 11.0 +/- 6.2% vs 14.0 +/- 6.5% vs 20.0 +/- 7.8%, P < 0.001, respectively). The absolute plaque and DC and NC volumes and the relative DC volume correlated positively with calcium score. CAD patients with high calcium score have more vulnerable plaque components (greater DC and NC-containing plaques) than those with low calcium score.
Adult ; Aged ; Calcinosis/*diagnosis/radiography/ultrasonography ; Calcium/*analysis ; Coronary Angiography ; Coronary Artery Disease/*diagnosis/radiography/ultrasonography ; Coronary Vessels/pathology ; Female ; Humans ; Male ; Middle Aged ; *Multidetector Computed Tomography ; Necrosis ; Plaque, Atherosclerotic/*pathology ; *Ultrasonography, Interventional

BACKGROUND AND OBJECTIVES: Endothelial dysfunction and increased vascular inflammation may be associated with variant angina (VA). However, their exact roles remain to be clarified. The aim of the presents study is to investigate whether the level of inflammation markers and the flow-mediated dilation (FMD) are related to VA. SUBJECTS AND METHODS: The study included 46 patients (VA group: 53.9+/-12.0 years, 20 males) with positive spasm provocation tests and they were without significant coronary stenosis, and 14 patients (control group: 46.6+/-13.5 years, 7 males) with negative spasm provocation tests and they were without significant coronary stenosis. The clinical characteristics and inflammatory markers, including the high sensitive C-reactive protein (hsCRP) level, the monocyte count and the von Willebrand factor (vWF) level, and the FMD were compared between the two groups. The FMD and inflammatory markers were measured in the morning before performing the ergonovine provocation coronary angiogram. RESULTS: The level of vWF was significantly higher in the VA group than in the control group (166.5+/-41.9% vs. 118.0+/-65.3%, respectively, p=0.029). The FMD was significantly decreased in the VA group compared with the control group (9.2+/-4.3% vs. 12.4+/-4.2%, respectively, p=0.021). Nitrate-mediated dilation did not differ between the two groups. The levels of the monocyte count, hs-CRP and homocysteine were higher in the VA group than in the control group (554.7+/-261.0/mm3 vs. 440.7+/-136.0/mm3, respectively, p=0.039; 0.3+/-0.4 mg/dL vs. 0.1+/-0.1 mg/dL, respectively, p=0.029; 7.54+/-4.0micronmol/L vs. 5.92+/-1.6micronmol/L, respectively, p=0.033). CONCLUSION: The results of this study suggested that increased inflammatory markers and endothelial dysfunction may be associated with variant angina.
Angina Pectoris ; C-Reactive Protein ; Coronary Stenosis ; Endothelium ; Ergonovine ; Homocysteine ; Humans ; Inflammation ; Monocytes ; Spasm ; von Willebrand Factor

OBJECTIVE: The purpose of our study is to compare the outcome of the modified transvaginal cerclage (MTVC) in patients who had not undergone a previous TVC with the outcome of patients treated with the transvagianl cerclage (TVC). METHOD: Incompetent cervix patients in the Obstetric/Gynecology department of Hanyang University Hospital post January, 1996 were selected as subjects for this study. 94 patients who received the TVC and 44 patients who received the MTVC using fibrin sealant were compared. The success of the operation was determined in the 34th week of pregnancy, and duration of pregnancy. RESULTS: Clinical characteristics of the TVC group and the MTVC group are showing no significant statistical difference between the two groups. The average gestational age of delivery was 36.0 and 37.0 week and the average weight was 2,797 g and 2,828 g respectively, also showing no significant (p=0.06) statistical difference. However, the duration of pregnancy between surgery and birth was 19.5 and 21.5 weeks showing significant (p=0.013) statistical difference, when the success rates of the treatments of incompetent cervix were observed according to the 34th week standard, TVC showed a 74% (71/96) rate of success and MTVC with fibrin sealant showed a 90.9% (40/44) rate of success, showing a significant statistical difference (Chi(2)=4.503, p<0.05). CONCLUSION:The success rate of MTVC using fibrin sealant showed to be significantly higher than the success rate of TVC. The reason for the difference in success rates is suspected to be because the fibrin sealant injected between the two TVC bands blocked the possibility of infection originating in the vagina. In the future, further research should focus on cultures of vaginal and amniotic fluids.
Pregnancy ; Female ; Humans

OBJECTIVE: We aim to analyze each variable of FHR in high risk pregnancies, namely intrauterine growth restriction (IUGR) and pregnancy-induced hypertension (PIH) including chronic hypertensive vascular disease (CHVD), mild and severe preeclampsia to build an objective decision basis using correlation analysis. METHODS: The patients were divided into two groups (500 normal pregnancies and 500 high risk pregnancies related to IUGR, CHVD, mild and severe preeclampsia), and then subdivided into intrauterine pregnancy before 24 weeks, 25-39 weeks, and after 40 weeks. We compared the canonical correlation between each group using variables of FHR after nonstress test (NST). RESULTS: In high risk pregnancies, the linearity was 0.6-0.8 in intrauterine pregnancy before 24 weeks, 0.53-0.68 in 25-29 weeks, 0.50-0.60 in 30-34 weeks, 0.38-0.45 in 35-39 weeks and 0.42-0.55 in after 40 weeks. In normal pregnancies, the linearity was 0.44-0.52 in intrauterine pregnancy before 24 weeks, 0.38-0.45 in 25- 39 weeks which was stable, and there was no specific change in after 40 weeks. Before 32 weeks, canonical variates of FHR_D and FHR_I revealed highest (0.36, 0.47 respectively) in high risk pregnancy and fetal movement and signal loss was the most valuable factors in normal pregnancy. In between 33 to 37 weeks, fetal movement (0.40) and signal loss (0.48) were related most closely in high risk pregnancies and 0.34 and 0.49 respectively in normal pregnancies which show similar pattern. In contrast, FHR_D was most highly related to the duration of pregnancy and FHR_I to fetal movement (0.38) in high risk pregnancy. In normal pregnancies, fetal movement (0.40) and signal loss (0.52) showed the highest linearity. CONCLUSION: The pregnancy with intrauterine growth restriction and pregnancy induced hypertension has more linear relation and less complexity in each variable of FHR than the normal pregnancy group. The formal, functional underdevelopment of fetus may results in the increasement of the linear depedent relation in each variable of FHR in these type of high risk pregnancies.
Female ; Fetal Development* ; Fetal Growth Retardation ; Fetal Heart* ; Fetal Movement ; Fetus ; Heart Rate, Fetal* ; Humans ; Hypertension, Pregnancy-Induced* ; Pre-Eclampsia ; Pregnancy ; Pregnancy* ; Pregnancy, High-Risk ; Vascular Diseases

OBJECTIVE: The purpose of this study was to investigate the effectiveness of further successful pregnancies and prognosis after delivery where the band was not removed from a transabdominal cervicoisthmic cerclage (TCIC) after a first successful pregnancy. The candidates of TCIC were those who were diagnosed with incompetent internal os of cervix (IIOC) and either had failed to maintain pregnancy after undergoing transvaginal cerclage (TVC) or could not undergo TVC due to cervical abnormalities. METHODS: During the period from May of 1991 until November of 2002, there were total 20 cases in which the band was not removed after previous TCIC, followed by a first successful pregnancy. RESULTS: In the 20 patients who had undergone TCIC, the average age, average gestational age at the time of operation, average number of previous pregnancy, average number of surviving fetus, average number of preterm delivery, and average number of fetal death were 32 years old, 12.8 weeks, 5.4, 0.2, 2 and 2.2, respectively. Cesarean section was performed at an average gestational age of 37.1 weeks in which the average birth weight was 2903 g in the first born child among 19 patients. In the following pregnancies, the average age of the patients were 34 years old in which there were 17 successful deliveries out of 20 cases where the average gestational period was 35.4 weeks and an average weight of 2661 g. There was an average of 22.5 months between the time of the first and second delivery. CONCLUSION: When the location and tension of the band had been confirmed after the first delivery in a total of 20 patients, there was a high successful delivery rate of 85% (17/20) in the next pregnancy. In this study, there was no evidence to support the complications reported in previous studies of difficulty in removal of trophoblastic tissue after abortion, dysmenorrhea, and increase in infertility associated with non removal of bands.
Adult ; Birth Weight ; Cervix Uteri* ; Cesarean Section ; Child ; Dysmenorrhea ; Female ; Fetal Death ; Fetus ; Gestational Age ; Humans ; Infertility ; Pregnancy* ; Prognosis ; Trophoblasts