Pulmonary Hypertension Crisis in Patient with Tetralogy of Fallot and Mixed Total Anomalous Pulmonary Vein Connection after the Primary Correction:A Rare Case Report

Tetralogy of Fallot(TOF)with total anomalous pulmonary vein connections(TAPVC)is a rare type of complex congenital heart disease among all TOF cases.Co-presentation of major aortopulmonary collateral arteries(MAPCAs)compensates for the lack of central pulmonary bloodflow and decreases the severity of right-to-left shunting in TOF.We present a case of a 2-year-old child with complex diagnoses of TOF,TAPVC,a large secun-dum atrial septal defect(ASD),and intraoperatively identified MAPCAs.She underwent surgery to repair the TAPVC,valve-sparing reconstruction of the right ventricular outflow tract,interventricular defect closure,and the creation of patent foramen ovale(PFO).After the operation,hemodynamic instability happened along with sudden blood pressure drop,desaturation,and increased central venous pressure,which subsided after adminis-tering inhalational nitric oxide(NO).A postoperative pulmonary hypertension crisis was suggested when the patient experienced recurrent symptoms after the termination of NO.Echocardiographicfindings of a D-shaped left ventricle(LV),right-to-left PFO shunt and high tricuspid valve gradientfirmly established the diagnosis.It was subsequently managed with continuous NO inhalation and sildenafil,which rendered a satisfactory outcome.Repaired TOF and TAPVC could be at particular risk of developing pulmonary hypertension crisis,especially in the presence of MAPCAs due to possible remodeling of the pulmonary vasculature.Furthermore,a relatively non-compliant LV function and small left atrial size may exacerbate the risk of developing postcapillary pulmonary hypertension after TAPVC repair.A successful postoperative outcome calls for a meticulous preoperative analysis of the anatomical lesions,as well as careful monitoring.

Changes of TXA_2 and PGI_2 during Postoperative Hypertensive Crisis in Patients with Hypertensive Intracerebral Hemorrhage

In order to explore the changes and the roles of TXA2 and PGI2 during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage, 31 cases subject to craniotomy were divided into three groups： group A, 9 patients with postoperative hypertensive crisis; group B, 13 patients without postoperative hypertensive crisis; and group C, 9 patients without history of hypertension and hypertensive intracerebral hemorrhage. TXA2, TXB2, 6-keto-PGF1α and PGI2 were measured after operation in the three groups respectively. The postoperative blood pressure in group A, including SBP and DBP, was elevated more obviously than that in the other two groups. TXA2 and PGI2 in group A were significantly higher than those in other two groups （P〈0.01）. Moreover, the ratio of TXB2 to 6-keto-PGF1α in group A was significantly higher than that in other two groups （P〈0.05）. The increase of TXA2 and the relative inadequacy of prostacyclin, especially 6-keto-PGF1α, may play roles in the postoperative hypertensive crisis. And the increased value of TXB2 to 6-keto-PGF1α could provide the basis for diagnosis of postoperative hypertensive crisis.

The Treatment of Peripheral Vestibular Dysfunction Using Caloric Vestibular Stimulation in Patients with Cerebral Hypertensive Crisis

Background: To verify the efficacy of caloric vestibular stimulation in patients with peripheral vestibular dysfunction after cerebral hypertensive crisis. Methods: Enrolled in the study were 60 patients with peripheral vestibular dysfunction caused by a cerebral hypertensive crisis, docu-mented by vestibulometry. Thirty patients underwent standard treatment plus caloric vestibular stimulation, and 30 control group patients received standard treatment alone. Results: After the two-week treatment course, the sensation of vertigo was observed in 40.0% ± 8.9% of treatment group patients compared with 80.0% ± 7.3% of control group patients (t = 3.46;p < 0.001). Spontaneous vestibular somatic reactions were found in 46.7% ± 9.1% of the study treatment group in contrast to 86.7% ± 6.2% of the control group (t = 3.63;p < 0.001). Spontaneous nystagmus was seen in 40.0% ± 8.9% of treatment group patients compared with 93.3% ± 4.6% of control subjects (t = 5.31;p < 0.001). Spontaneous vestibular vegetative reactions were observed in 33.3% ± 8.6% of patients receiving study treatment in contrast to 93.3% ± 4.6% of control group patients (t = 6.16;p < 0.001). Also, 53.3% ± 9.1% of study treatment group patients showed asymmetry of labyrinths compared with 86.7% ± 6.2% of patients from the control group (t = 3.03;p < 0.001). Conclusion: Caloric vestibular stimulation was shown to be an effective treatment for peripheral vestibular dysfunction in patients with cerebral hypertensive crisis. During the 14-day treatment of cerebral hypertensive crisis, complete labyrinthine function recovery occurred in 46.7% of treatment group patients who underwent caloric vestibular stimulation as opposed to 13.3% of control group patients who received standard treatment alone.

Different intraoperative decisions for undiagnosed paraganglioma:Two case reports

BACKGROUND Paragangliomas may be preoperatively misdiagnosed as non-functioning retroperitoneal tumors and are sometimes suspected only at the time of intraoperative manipulation.Without preoperative alpha blockade preparation,a hypertensive crisis during tumor manipulation and hypotension after tumor removal may result in critical consequences.Therefore,primary consideration should be given to the continuation or discontinuation of surgery on the basis of the possibility of gentle surgical manipulation and hemodynamic stabilization.We report two cases of paragangliomas detected intraoperatively.CASE SUMMARY A 65-year-woman underwent laparoscopic small-bowel wedge resection.A hypertensive crisis occurred during manipulation of the mass,and an unrecognized catecholamine-producing paraganglioma was suspected.The surgeon and anesthesiologists believed that tumor excision could be performed with minimal manipulation of the tumor because the tumor was in a favorable location.Serious hemodynamic instability did not occur with aggressive use of vasoactive drugs.A week later,a 54-year-man underwent open resection of a 3-cm-sized retroperitoneal mass and showed the same findings during mass manipulation.For this patient,continuous manipulation of the mass seemed inevitable due to adhesion between the right adrenal gland and the mass in a narrow surgical field.The surgeon and anesthesiologists decided to cancel the surgical procedure and planned to perform a reoperation after alpha blockade therapy.Two weeks later,the tumor was uneventfully removed with small doses of vasoactive drugs.CONCLUSION When an undiagnosed paraganglioma is suspected intraoperatively,reoperation after adequate preparation should be considered as an option to avoid fatal outcomes.

Changes of vasoactive polypeptides during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage

Background Hypertensive crisis could be found after operation in patients with hypertensive intracerebral hemorrhage （HICH）. The aim of this study was to explore the changes and th; roles of some vasoactive polypeptides during postoperative hypertensive crisis in patients with HICH. Methods A total of 31 patients, who were admitted for craniotomy, were enrolled into this study. After the operation, the patients were divided into three groups. Group I consisted of 9 patients with postoperative hypertensive crisis, and group Ⅱ was composed of 13 patients without postoperative hypertensive crisis. Nine patients, who denied history of hypertension or HICH, were set as group Ⅲ. The levels of some vasoactivators in the three groups were measured before and after the operation. The differences in the results among the groups were analyzed using the ANOVA. The data collected before and after the operation in the group Ⅰ was compared by Wilcoxon test. Results The concentration of endothelin in group Ⅰ was significantly higher than that in group Ⅲ （P〈0.05）. The level of thromboxane A2 and the ratio of thromboxane B2 to 6-keto-PGF1α in group Ⅰ were significantly higher than those in the other two groups （P〈0.05）. In group Ⅰ, the levels of plasma renin activity, angiotensin Ⅱ, aldosterone, catecholamine, and endothelin before the operation were significantly higher than those determined after the operation （P〉0.05）. Conclusions Postoperative hypertensive crisis may be due to the increased thromboxane A2 and relatively inadequate prostacyclin, especially 6-keto-PGF1α. The increased level of endothelin and intraoperative stimulation also play a certain role in the development of postoperative hypertensive crisis.