Evaluation of fetal and uterine hemodynamics during maternal cardiopulmonary bypass

BACKGROUND

About 4% of pregnant women have concomitant cardiac disease and a few of these do not respond to medical therapy and require surgical correction during pregnancy. We report a unique case describing fetal hemodynamics and uterine blood flow before, during, and after maternal cardiopulmonary bypass, and compare them to normal reference values in the second trimester.

CASE

A woman with severe aortic regurgitation underwent aortic valve replacement at 19 weeks' gestation. A nonpulsatile cardiac pump was used for cardiopulmonary bypass, maintaining the mean arterial pressure at 77-90 mmHg, with a peak flow rate of 3.5-4.0 L/minute/m2 and core temperature of 34-35C throughout surgery. Blood velocity waveforms were recorded by Doppler ultrasound at the level of maternal main uterine artery and fetal vessels. Pulsatility index (PI) values were calculated. Preoperatively, fetal hemodynamic characteristics were within normal limits. Preoperatively, uterine artery PI was 3.9 (normal 0.5-1.5 at 20 weeks). Intraoperatively, fetal bradycardia ensued after aortic clamping (120 to 75 beats per minute), with a rise in umbilical artery PI (1.7 to 7.1) and disappearance of diastolic flow. The middle cerebral artery PI decreased (2.0 to 0.92) and the PI increased in the descending aorta (2.22 to 3.55), inferior vena cava (2.7 to 9.3), and ductus venosus (0.6 to 1.7). During bypass, after aortic clamping, nonpulsatile uterine artery flow was noted. Postoperatively, the uterine artery PI improved, to 1.0. Two days later, hydrocephalus and hydrops were observed.

CONCLUSION

Despite high peak flow rates, normal mean arterial pressure, and normothermia, fetal outcome was dismal. Nonpulsatile cardiopulmonary bypass under normothermia may not be able to meet the demands of the fetoplacental circulation.

Coronary artery bypass surgery in patients on chronic hemodialysis. A case-control study

STUDY OBJECTIVE

To determine the morbidity and mortality of cardiac catheterization and coronary artery bypass surgery in patients on chronic hemodialysis.

DESIGN

Retrospective case-control study.

SETTING

A referral-based university hospital.

PATIENTS

Sixteen consecutive patients on chronic hemodialysis who had catheterization and bypass surgery: 30 controls matched for age, sex, year of operation, severity of coronary disease, left ventricular function, hypertension, diabetes, and urgency of surgery: and 34 consecutive controls having bypass surgery.

MEASUREMENTS AND MAIN RESULTS

No major complications of catheterization occurred. Of 16 patients on dialysis, 7 had urgent surgery within 24 hours of catheterization. One patient on dialysis and 3 consecutive controls died, but none of the matched controls died. Postoperative morbidity was increased in the hemodialysis group as measured by the duration of mechanical ventilation (4.7 +/- 2.3 compared with 1.5 +/- 0.8 days in matched controls [mean +/- SE]), the duration of hemodynamic support (4.2 +/- 2.3 compared with 0.8 +/- 0.2 days), the length of stay in the intensive care unit (6.4 +/- 2.4 compared with 2.8 +/- 0.9 days), and the length of postoperative stay in the hospital (15.4 +/- 2.1 compared with 10.8 +/- 1.1 days) (all P less than 0.05). Four intraoperative myocardial infarctions occurred in patients on dialysis compared with two patients in the case-matched controls. Differences in morbidity between the two control groups were not significant.

CONCLUSIONS

Morbidity is increased in patients on hemodialysis having coronary artery bypass surgery compared with controls matched for severity of coronary disease; however, the outcome in all but one patient on dialysis was good. Bypass surgery is an acceptable treatment for patients on dialysis with advanced coronary artery disease. Because urgent surgery is often needed in these patients, earlier evaluation of the need for revascularization may improve clinical results.

3,5-Diphenyl-1H-pyrazole derivatives. I--Esters and N-substituted carbamates of 1-(2-hydroxyethyl)-3,5-diphenyl-1H-pyrazole and its 4-bromo derivative with depressant, antiarrhythmic, analgesic and other activities

The synthesis of 1-(2-hydroxyethyl)-3,5-diphenyl-1H-pyrazole (II) and its 4-bromo derivative (III) starting from chalcone epoxide, as well as of a series of esters and N-substituted carbamates derived from (II) and (III), is described. Some of these compounds showed remarkable depressant, antiarrhythmic and analgesic activities in mice and rats. Moreover, the above compounds usually exhibited moderate hypotensive, bradycardic and antiinflammatory activities in rats, infiltration anesthesia and hypoglycemic activity in mice, as well as a weak platelet antiaggregating activity in vitro.