Postoperative atrial fibrillation is a commonly encountered issue that places patients at risk for morbidity and mortality and significantly increases the cost of care. In this chapter, we review the epidemiology and pathophysiology of postoperative atrial fibrillation, current strategies for primary prevention, and up-to-date recommendations for its treatment and management.

A 36-yr-old man with a medical history significant for anabolic steroid abuse initially presented to the operating room with aortic valve endocarditis with a focal perforation of the anterior leaflet of the mitral valve secondary to a prolapsing aortic valve vegetation. The patient underwent uneventful aortic valve replacement with a 25 mm On-X (MCRI, Austin, TX) mechanical valve and repair of the mitral valve perforation with a bovine pericardial patch. Throughout the procedure, he received intermittent retrograde cardioplegia via a coronary sinus catheter that was placed without difficulty under transesophageal echocardiography (TEE) guidance in the prebypass period. The patient's postoperative course was complicated by persistent high grade fevers and respiratory failure. A repeat TEE examination on postoperative day 10 revealed an ejection fraction (EF) of 45% and multiple echodense masses adherent to both the atrial and ventricular aspects of the patient's mitral valve. In addition, an elliptical sessile mass was discovered adhering to the lateral wall of the right atrium and impinging on the anterior leaflet of the tricuspid valve. There was moderate tricuspid regurgitation secondary to leaflet restriction. The mechanical aortic valve appeared to be functioning normally. No abnormalities of the coronary sinus were noted at the time. The patient returned to the operating room for reexploration and debridement of presumed recurrent endocarditis. Intraoperative TEE once again revealed a low normal EF and echogenic masses adherent to the mitral valve (Fig. 1A) and to the lateral wall of the right atrium (Fig. 1B). In addition, a dilated coronary sinus was noted in the midesophageal views (Fig. 1A). Further inspection of the coronary sinus in a modified four-chamber view demonstrated the presence of thrombus with near complete occlusion of the coronary sinus which measured nearly 2 cm in diameter (Figs. 2A and B, Video Clip 1; please see video clips available at www.anesthesia-analgesia.org).Figure 1.: (A) Midesophageal two-chamber view demonstrating dilated coronay sinus seen in short axis (arrow) and thrombus adherent to the left atrial side of the anterior leaflet of the mitral valve (asterisk). (B) Midesophageal four-chamber view of the right heart demonstrating thrombus adherent to the lateral wall of the right atrium (*).Figure 2.: (A) A modified midesophageal four-chamber view focused on the right atrium and coronary sinus (RA = right atrium; RV = right ventricle; LV = left ventricle). Thrombus is seen completely occluding the dilated coronary sinus (white arrow). (B) Illustration demonstrating visualized structures in a modified midesophageal four-chamber view (RA = right atrium; RV = right ventricle; LV = left ventricle; IVC = inferior vena cava; CS = coronary sinus).Surgical exploration confirmed the presence of multiple thrombi that did not seem infectious in origin. Examination of the coronary sinus verified complete occlusion of the sinus with thrombus. The patient underwent thrombectomy of the tricuspid valve, mitral valve, and coronary sinus without complication. Postcardiopulmonary bypass TEE demonstrated normal mitral and tricuspid valve function. The postprocedure left ventricular function was markedly improved, with an EF of 65%, compared to 45% before operation (Video Clip 2; please see video clips available at www.anesthesia-analgesia.org). Pathologic examination confirmed noninfectious organized thrombus recovered from the mitral valve, tricuspid valve, and coronary sinus. The coronary sinus is responsible for the venous drainage of the heart under normal conditions. It receives contributions from the small, middle, oblique and great cardiac veins, courses through the coronary sulcus and empties into the right atrium between the inferior vena cava inlet and the septal leaflet of the tricuspid valve. On TEE examination, the coronary sinus is reliably visualized in a modified midesophageal four-chamber view (with slight insertion and retroflexion of the probe) and in the bicaval view (where it can be seen adjacent to the junction of the inferior vena cava and the right atrium). In one study, the coronary sinus was successfully visualized in 100% of patients using TEE and the mean maximum diameter measured 9 ± 2 mm.1 Coronary sinus dilation may be encountered in patients with persistent left superior vena cava, congenital abnormalities, and elevated right atrial pressures with right atrial dilation.2 Coronary sinus thrombosis, as described in this case, is a rare complication of heart transplantation, infection and coronary sinus instrumentation.3 Case reports in humans suggest that coronary sinus thrombosis can precipitate myocardial infarction and is often fatal.4 Our patient may have been predisposed to thrombus formation due to a hypercoagulable state secondary to chronic infection and anabolic steroid use.5 Additionally, coronary sinus cannulation for retrograde cardioplegia administration during the initial surgery may have resulted in endothelial injury that may have served as a nidus for thrombus formation within the sinus. Although the clinical course after coronary sinus thrombectomy is unclear, there are reported cases of recovery of ventricular function after coronary sinus thrombectomy.6 The immediate improvement of this patient's left ventricular EF after separation from bypass suggests that coronary sinus thrombosis and cardiac venous congestion may have played a role in his depressed preoperative EF. This case demonstrates the utility of intraoperative TEE in the evaluation of patients with intracardiac thrombosis. When intracardiac thrombus is suspected, a complete and comprehensive examination of all structures is mandatory to exclude occult locations and to direct surgical management. When coronary sinus involvement is visualized, surgical exploration and thrombectomy may dramatically improve ventricular function. ACKNOWLEDGMENTS The authors wish to thank Mr. Jack Segall for assistance in the preparation of the manuscript.

this report, we haveendeavored to derive the optimal design parameters for the NGST Near Infrared (NIR)spectrograph based on the instrument parameters outlined in the telescope definition study,the scientific requirements for the programs outlined in the Ad Hoc Science Working Group(ASWG) Design Reference Mission (DRM) and more general and broad scientific and technicalconsiderations

BACKGROUND:Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient. METHODS:A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period. RESULTS:Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41–0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia. CONCLUSIONS:Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.

the tracheal tube through the oropharynx until visualizing the tip of the tube adjacent to the glottic opening on the Glidescope monitor. It was during this blind pass of the tube that the anterior tonsillar pillar was perforated. 2. We used a standard tracheal tube and the manufacturer recommended Rigid StyletTM. The combination of the stylet and the sharp edge of the tracheal tube may have contributed to perforation of the anterior tonsillar pillar. 3. Patients with myotonia congenita can be resistant to the effects of nondepolarizing muscle relaxants in the setting of direct stimulation (3). Inadequate relaxation of the palatoglosseus muscle may predispose to anterior tonsillar pillar perforation. The already thin tonsillar pillar membrane may have been pulled taut by palatoglosseus muscle contraction, making it more susceptible to perforation.

To the Editor: The Glidescope® video laryngoscope is an effective and well-established device for facilitating tracheal tube placement (1,2) Here we report an unusual complication of Glidescope® assisted intubation. A 72-yr-old man presented for resection of a thoracic spinal cord arteriovenous malformation. The patient had a past medical history significant for myotonia congenita and hiatal hernia with mild acid reflux. On physical examination he was found to have a Mallampati Class II view of the oropharynx with mouth opening slightly <4 cm and normal range of motion of the cervical spine. In addition, review of his previous records revealed that during a prior anesthetic he had a Cormack–Lehane Grade 3 laryngeal view necessitating three direct laryngoscopy attempts and the use of an intubating stylet to secure the airway. Anesthesia was induced with lidocaine, fentanyl, propofol, and cisatracurium. After 3 min of ventilation via mask, we easily inserted a Glidescope® video laryngoscopy blade and obtained a Grade I view of the vocal cords. An 8.0 mm internal diameter tracheal tube with the manufacturer recommended Rigid Stylet™ was passed through the vocal cords under Glidescope® visualization. The cuff was inflated and positive pressure ventilation through the tube produced a normal end tidal CO2 tracing and bilateral breath sounds. At this point a small amount of blood was noted in the retropharynx on the Glidescope® monitor. Upon withdrawal of the Glidescope® blade the tracheal tube was seen perforating the right anterior tonsillar pillar. After consulting with an otolaryngologist, we removed the tracheal tube and reintubated the trachea using a fiberoptic laryngoscope without difficulty. The trachea was extubated in the operating room following the procedure, and minimal throat soreness was reported on postoperative day one. We postulate several mechanisms for this unusual complication: After obtaining an adequate view of the vocal cords with the Glidescope®, we blindly passed the tracheal tube through the oropharynx until visualizing the tip of the tube adjacent to the glottic opening on the Glidescope® monitor. It was during this blind pass of the tube that the anterior tonsillar pillar was perforated. We used a standard tracheal tube and the manufacturer recommended Rigid Stylet™. The combination of the stylet and the sharp edge of the tracheal tube may have contributed to perforation of the anterior tonsillar pillar. Patients with myotonia congenita can be resistant to the effects of nondepolarizing muscle relaxants in the setting of direct stimulation (3). Inadequate relaxation of the palatoglosseus muscle may predispose to anterior tonsillar pillar perforation. The already thin tonsillar pillar membrane may have been pulled taut by palatoglosseus muscle contraction, making it more susceptible to perforation. To avoid similar complications when using the Glidescope® video laryngoscope we suggest the following: Use of a soft-edged endotracheal tube (such as the Parker Flex-Tip™) to avoid damage to pharyngeal structures, especially in conjunction with the Rigid Stylet™. Verathon Medical has recently introduced such a tube for use with the Glidescope® system (GVL® GlideRite™). Directly visualize the tracheal tube as it is inserted into the mouth along the curvature of the Glidescope® laryngoscope blade. Only after the tip of the tube has passed out of view should the Glidescope® video monitor be viewed. Asif M. Malik, MD Jonathan K. Frogel, MD Department of Anesthesiology Henry Ford Hospital 2799 West Grand Blvd. Detroit, MI 48202 [email protected]

OPERATIVE CANDIDATES for vascular surgery have a high incidence of coronary artery disease (CAD), which is responsible for 50% of their perioperative mortality. 1 Kragsterman B. Logason K. Ahari A. et al. Risk factors for complications after carotid endarterectomy—A population-based study. Eur J Vasc Endovasc Surg. 2004; 28: 98-103 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar , 2 Hertzer N.R. Young J.R. Kramer J.R. et al. Routine coronary angiography prior to elective aortic reconstruction Results of selective myocardial revascularization in patients with peripheral vascular disease . Arch Surg. 1979; 114: 1336-1344 Crossref PubMed Scopus (193) Google Scholar The authors present a patient scheduled for carotid endarterectomy (CEA) whose comprehensive preoperative cardiac evaluation showed him to be at low cardiac risk yet he suffered intraoperative catastrophic cardiovascular collapse. Appropriate preoperative evaluation of CEA patients, in whom CAD is prevalent, 3 Fleisher L.A. Eagle K.A. Shaffer T. et al. Perioperative and long-term mortality rates after major vascular surgery The relationship to preoperative testing in the medicare population . Anesth Analg. 1999; 89: 849-855 PubMed Google Scholar is discussed with regard to the American Heart Association (AHA)/American College of Cardiology (ACC) perioperative cardiovascular evaluation guidelines for noncardiac surgery. In addition, the authors describe the intraoperative course of this patient, review the pathophysiology that is often seen in perioperative myocardial infarction, and present results from postoperative coronary arteriography.