[Acute myocardial infarction as an incidental finding: reflections on the preanesthesia evaluation]

A preoperative electrocardiogram in a 16-year-old boy scheduled for surgery for a fractured radius and mandibular condyle after a motorcycle accident showed signs of myocardial ischemia as an incidental finding. Coronary arteriography revealed complete occlusion of the anterior descending artery, confirming a diagnosis of acute coronary syndrome with ST elevation, with no myocardial viability. As the patient's general condition was acceptable, to prevent severe functional sequelae, surgery was rescheduled for 17 days later. An axillary block was well tolerated at that time. While indiscriminate ordering of preoperative tests is not recommended in the literature, such testing continues to be practiced in many hospitals, possibly for reasons of organization and legal cover. In our case, the electrocardiogram made it possible to diagnose a severe lesion and adjust the anesthetic technique to suit this situation, thereby possibly preventing devastating consequences. We recommend performing an electrocardiogram on all patients with suspected blunt chest trauma, regardless of the severity of the lesions, particularly in patients scheduled for surgery.

[Total intravenous anesthesia for repositioning an implantable defibrillator in a patient with long QT syndrome]

We report the case of a 27-year-old woman with congenital long QT syndrome (LQTS) who was scheduled for surgery to reposition an implantable defibrillator. Given the risk of sudden death due to fatal ventricular arrhythmia, the woman required implantation of a defibrillator with pacemaker capability. Combined anesthesia-analgesia was used in order to minimize the risk of ventricular arrhythmia caused by increased serum concentrations of catecholamines. When cardioversion, defibrillation and anti-tachycardia functions had been deactivated, anesthesia was induced with propofol, fentanyl and rocuronium. Anesthesia was maintained with an infusion of propofol and remifentanil. We describe the pathophysiology and treatment of LQTS and discuss anesthetic management for repositioning a defibrillator in a patient with congenital LQTS.

[Spinal anesthesia in a patient with congenital complete atrioventricular block]

Congenital complete atrioventricular block is a rare cardiac conduction abnormality that predisposes to arrhythmias and cardiac arrest. Recommendations for the anesthetic management of patients with this condition are based on the few case reports that have been published. We describe the successful use of spinal anesthesia for ankle osteosynthesis in a patient with asymptomatic congenital complete atrioventricular block detected during preoperative assessment.

[Aortopulmonary fistula complicating aortic arch aneurysm]

Aortopulmonary fistulas secondary to thoracic aneurysms are difficult to diagnose and few cases are reported in the literature. We describe the case of a patient first admitted to another hospital with a diagnosis of right upper lobe pneumonia. After the patient had been a week in hospital without improving, a computed tomography scan of the chest revealed a saccular aneurysm of the aortic arch measuring 9 cm at its widest diameter. Hemodynamics and respiratory signs deteriorated a few hours after transfer to our hospital. Physical examination revealed a systolic murmur and poor peripheral perfusion. The patient was intubated and inotropic support was provided. Upon insertion of a Swan-Ganz catheter, given suspicion of septic shock, progressive elevation of mixed venous oxygen saturation was observed. Measurement of venous oxygen saturation was 74% in the right atrium and 93% in the pulmonary artery. Left-right shunt was diagnosed and an emergency aortography revealed the aortopulmonary fistula. Emergency surgery was performed with the patient in deep hypothermia and cardiocirculatory arrest. There were no adverse events, and postoperative recovery and clinical course were good.