Laser surgery in a patient with Romano-Ward (long QT) syndrome and an automatic implantable cardioverter defibrillator

A 48-year-old woman with Romano-Ward syndrome (a hereditary long QT syndrome), asthma and an automatic implantable cardioverter defibrillator presented for laser surgery for debulking of a massive nasopharyngeal tumour prior to radiotherapy. Automatic implantable cardioverter defibrillators have only relatively recently been used to treat patients with the long QT syndrome and are indicated for the high-risk individual when conventional treatment has failed or when beta-blockers are contraindicated. If surgery requires the use of surgical diathermy, a cardiac technician must be present to deactivate the defibrillator and external pacing electrodes are sited on the chest until the defibrillator can be reactivated. Radiotherapy requires both deactivation and shielding of the device.     

A Medically Staffed Emergency Ambulance Service. Report of a 5-year Prospective Study

The results of a prospective 5-year study of a medically staffed ambulance service are presented. There was a total of 558 turn-outs distributed among a mixed patient material. In 192 cases, resuscitation was attempted and this proved primarily successful in 59 patients. A total of 23 of these resuscitated patients could be discharged, 19 without cerebral sequelae, two with slight brain damage and two with severe brain damage. In 44 further cases, other relevant forms of emergency treatment were administered. It is concluded that prehospital treatment at the scene of accident seems beneficial to patients with life-threatening conditions.     

Anaesthetic management of a patient with an automatic implantable cardioverter defibrillator in situ

The automatic implantable cardioverter defibrillator (AICD) is becoming used more frequently in patients with refractory malignant ventricular arrhythmias. The anaesthetic implications of patients with an AICD in situ presenting for surgery are discussed.      

Continuing experience with the automatic implantable cardioverter defibrillator.

The automatic implantable cardioverter defibrillator (AICD) is now used commonly in the management of malignant ventricular arrhythmias. Its use may obviate the need for antiarrhythmic drugs or endocardial resection. We reviewed our continuing experience with the AICD to determine its safety and efficacy. Since June 1987, 102 patients (mean age: 63 years) who survived out-of-hospital ventricular fibrillation or hemodynamically unstable ventricular tachycardia not associated with acute myocardial infarction underwent implantation of an AICD. There were three operative deaths and nine complications. Eighty-nine patients are alive. No patient has experienced sudden cardiac death. Forty-two patients (43%) have had 1 or more AICD discharges associated with symptoms of cardiac arrest. During AICD implantation, it appears preferable to configure lead placement by individual patient characteristics rather than by a rigid protocol. The relative safety and efficacy of the AICD support its use as an alternative to toxic medications or more dangerous endocardial resection in suboptimal candidates.     

Experience with an external valve in small volume tissue expanders

Tissue expansion has been a reconstructive technique for nearly 10 years. All published work has described serial expansion by percutaneous injection into a buried reservoir. This paper reviews a small series of patients who had tissue expansion using small volume expanders with an external valve. The complications with small expanders are discussed. The external valve is shown to be satisfactory and free from infection in this series.     

Right mini-thoracotomy: an adjunct to left subcostal automatic implantable cardioverter defibrillator implantation

High defibrillation thresholds are encountered in some patients during implantation of the automatic implantable cardioverter defibrillator (AICD). In a consecutive series of 52 patients with AICD implants, 46 had allepicardial implants by left subcostal thoracotomy, and 8 of these patients had thresholds greater than 30 J. Placement of an apicolateral large left ventricular patch and an extrapericardial large right atrial patch electrode through a limited right thoracotomy produced substantial reduction in their thresholds. Especially in patients who have had previous intrapericardial operations, this technique provides a simple solution to the problem of high thresholds.     

Experience with the use of an external fixator in patients with multiple injuries

The authors report on experiences with fixateur extern according to Raoul Hoffmann in 110 open fractures of second-degree and third-degree severity. The patient material comprised 90 patients, of which a total of 71 (79 per cent) had polytraumas. It was shown that good results can be expected if fixateur extern is applied immediately. The advantages of good positioning and care of soft parts are emphasized. A detailed discussion is devoted to the specific problems of polytraumatized patients with second-degree and third-degree open fractures.     

Treatment of malignant ventricular arrhythmias with the automatic implantable cardioverter defibrillator.

Twenty-eight patients with malignant ventricular arrhythmias were treated with the automatic implantable cardioverter-defibrillator (AICD) in a 14-month period. Thirteen patients were resuscitated from a ventricular fibrillation (VF) episode. Fifteen patients presented with ventricular tachycardia (VT) refractory to medical therapy. The etiology was coronary artery disease in 23 of 28 patients (82%), dilated cardiomyopathy in 2 of 28 patients (7%), sarcoidosis in 2 of 28 patients, and 1 patient in 28 had lupus erythmatosis. The mean left ventricular ejection fraction was 29%. A total of 27 of 28 patients (96%) patients had inducible ventricular tachycardia using programmed stimulation. The patients considered for AICD implant failed a mean of 3.6 antiarrhythmic drugs. Rate counting and defibrillating leads were inserted through a lateral thoracotomy in 17 patients and a mediansternotomy incision in 11 patients in conjunction with another cardiac procedure in 10 patients. The generators were positioned in a subcutaneous pocket beneath the left costal margin. There were no operative deaths. The mean follow-up was 6.7 months (range 1 to 14) with no VT/VF deaths in patients with defibrillators. The study demonstrated that AICD is an effective device for prevention of sudden cardiac death.     

Early experience with the automatic implantable cardioverter defibrillator in sudden death survivors

Medical management of life-threatening ventricular arrhythmias is difficult because of the toxicity and limited efficacy of antiarrhythmic drugs. The automatic implantable cardioverter defibrillator (AICD) offers protection against malignant ventricular arrhythmias and allows some patients to be managed without antiarrhythmic drugs. We reviewed our experience with the AICD to determine its safety and efficacy. Since June 1987, 24 patients (mean age 63 years) who survived out-of-hospital ventricular fibrillation or hemodynamically unstable ventricular tachycardia not associated with acute myocardial infarction had implantation of an AICD. None had inducible monomorphic ventricular tachycardia associated with ventricular aneurysm. Twenty-three had abnormal left ventricular function (mean ejection fraction 0.32). There were no operative deaths and three complications. At last follow-up (mean 8.9 months) 23 patients were alive. Eight patients had one or more AICD discharges associated with symptomatic or monitored cardiac arrest. AICD implantation can be performed with low risk and appears to be an effective alternative to antiarrhythmic therapy with toxic drugs.     

Ventricular fibrillation in an ex‐premature neonate following reperfusion of ischemic gut incarcerated within an inguinal hernia

We describe the case of a neonate who underwent surgery for bowel obstruction. The child was born at 25 weeks postconception, and at the time of surgery, he had a postconceptual age of 44 weeks. He had undergone two previous laparotomy procedures for necrotizing enterocolitis. At laparotomy, there was unexpected extensive compromise to gut perfusion. The child developed ventricular fibrillation following the reperfusion of a segment of ischemic gut found incarcerated in an inguinal hernial orifice. We discuss the pathophysiology of intestinal ischemia–reperfusion (I‐R) injury. We have reviewed the interventions that may be employed to minimize the systemic impact of I‐R.     

General anesthesia for patients with automatic implantable cardioverter defibrillator in place--a case report

Automatic implantable cardioverter defibrillator (AICD) was commercially available for use in patients with malignant ventricular tachycardia and ventricular fibrillation since its meeting with FDA approval in 1985. The number of AICD implantation has increased year by year worldwide. It was allowed to be used in clinical setting in Taiwan by the Department of Health in April 1997. Physicians may come across patients with an implanted AICD undergoing surgery unrelated to cardiac issues more frequently. It is also a new challenge to anesthesiologists who must make pre-operative evaluation, maintenance during operative period and post-operative re-evaluation of the AICD function. We bring forward here for discussion a 72-year-old male patient who underwent non-cardiac surgery with AICD implantation under general anesthesia. The anesthetic precautions of patients with the device are also touched.     

Electrocautery does not interfere with the function of the automatic implantable cardioverter defibrillator

The automatic implantable cardioverter defibrillator (AICD) manufactured by Cardiac Pacemakers, Inc, contains an automatic sensitivity adjustment. We tested whether this feature would prevent sensing of signals generated by electrocautery by implanting three different models of the AICD in 4 mongrel dogs. Unipolar electrocautery was applied at maximum output to a site close to the rate-sensing leads. The devices were monitored with an AICD-check probe and by auditory monitoring of QRS synchronous tones. No sensing of the electrocautery by the device occurred. Three patients with two different AICD models (1550 and 1520) underwent five surgical procedures in which electrocautery was used. No sensing of electrocautery signals, device charging, or other device malfunction occurred.