Prior Inferior Myocardial Infarction Research Articles

161 ABLATION OF EPICARDIAL VENTRICULAR TACHYCARDIA ORIGINATING IN THE AREA OF PERICARDIAL ADHESIONS INDUCED BY STEREOTACTIC RADIOABLATION IN A PATIENT WITH ISCHEMIC CARDIOMYOPATHY

Abstract This is the case of a 64-year-old male patient with prior inferior wall myocardial infarction, wearing a cardiac resynchronization therapy defibrillator and suffering from recurrent ventricular tachycardia (VT). The patient had undergone a transitory successful endocardial radiofrequency catheter ablation (RFCA) in 2013 and a stereotactic ablative body radiotherapy (SABR) in 2021, targeting the VT originating in the inferior wall myocardial scar. The patient was referred to our institution due to recurrent highly symptomatic slow-VT. A coronary angiography ruled out coronary artery disease (CAD) progression and a RFCA was rescheduled. Given the suspected epicardial origin of VT based on a 12-lead ECG, the decision was made to perform a combined epi-endocardial ablation. SABR-induced pericardial adhesions prevented posterior pericardial access, thus requiring an anterior access approach (Figure 1, Panel A, yellow star). Following epicardial and endocardial electroanatomic mapping (EAM), VT ablation relied on a substrate-based approach. Local abnormal ventricular activities (LAVAs), detected both in the accessible epicardial inferior wall of the left ventricle and at the opposite endocardial site, were eliminated by radiofrequency (RF) current. Upon completion of endocardial ablation, ventricular pacing induced hemodynamically unstable VT, exiting from the epicardial region corresponding to the SABR-induced pericardial adhesions. Mechanical adhesiolysis, using the elbow of the open-irrigated ablation catheter, was performed to disrupt SABR-induced pericardial adhesions in the inferior wall. The epicardial EAM performed with the open-irrigated catheter recorded LAVAs in the infero-posterior wall of the left ventricle, corresponding to the SABR-disrupted pericardial adhesions. A RF current was delivered, targeting LAVAs at this site (Figure 1, Panel B: the central green dot corresponds to the area of disrupted pericardial adhesions). At the end of the procedure, no sustained VT was induced by programmed ventricular stimulation. Conclusion SABR constitutes a novel and promising non-invasive radioablative treatment of VT, potentially associated with cardiac toxicity. To our knowledge, this is the first reported case of combined epicardial and endocardial RFCA of recurrent VT after SABR. Based on the first RFCA report and exclusion of CAD progression, we hypothesized that SABR might have favoured progression of the inferior low voltage area. With this case report, we would like to demonstrate that even if pericardial adhesions could be a consequence of SABR, gentle catheter-driven manoeuvres can be enough to disrupt the adhesions and to achieve full EAM. Further research is mandatory to shed light on SABR's long-term arrhythmogenic role.

Suspected COVID-19 Immunization-Induced Probable Catastrophic Antiphospholipid Syndrome

In this report, we describe the case of a woman with suspected COVID-19 immunization-induced probable catastrophic antiphospholipid syndrome. The patient is a 35-year-old female with a past medical history significant for antiphospholipid syndrome, not on anticoagulation, who presented with a 5-day history of abdominal pain and distention, nausea, vomiting, and shortness of breath. She had received her first dose of the Pfizer COVID-19 vaccine one day prior to the onset of symptoms. After extensive workup at an outside hospital, she was found to be in acute heart failure exacerbated by severe mitral and tricuspid regurgitation. She was transferred to our hospital for escalation of care. EKG showed evidence of prior inferior and septal myocardial infarction. Transesophageal echocardiogram (TEE) showed reduced ejection fraction, severe mitral and tricuspid regurgitation, and a left ventricular thrombus. Cardiac MRI showed subendocardial late gadolinium enhancement indicative of ischemia. However, CTA of the coronary vessels showed no signs of obstruction. Therefore, her acute heart failure was thought to be due to small vessel thrombosis secondary to antiphospholipid syndrome. During admission, she had several absence seizure-like episodes. CT head showed several hypodensities of the deep white matter and brain MRI demonstrated multiple hyperintense T2 FLAIR signal foci with restriction diffusion and enhancement involving the cerebral hemisphere, consistent with subacute strokes attributed to being secondary to antiphospholipid syndrome or embolic from the left ventricular thrombus. She was treated with heparin for suspected catastrophic antiphospholipid syndrome and high-dose corticosteroid therapy for concomitant Systemic Lupus Erythematosus (SLE). She was discharged in a stable condition.

671 First-in-man mapping and ablation of ventricular tachycardia using a novel ablation catheter with microelectrodes and thermocouples

Abstract Aims Catheter ablation (CA) is an important therapeutic option for patients with recurrent ventricular tachycardia (VT). Recently, a novel contact-force sensing catheter (QDOT, Biosense Webster) allowing radiofrequency ablation in a temperature-controlled fashion, equipped with microelectrodes and thermocouples has been developed and tested in very-high power short duration CA of atrial fibrillation. As of today, this catheter has never been used for VT ablation. To describe the safety and short-term clinical performance of the novel QDOT catheter for the ablation of recurrent VT/electrical storm. Methods and results Case 1: a 43-year-old male patient with prior anterior myocardial infarction (MI), left ventricular (LV) dysfunction with an apical aneurysm, and recurrent VT episodes was admitted to our hospital for CA of VT. The patient underwent high-density electroanatomical mapping of the left ventricle using a multipolar catheter (PentaRay, Biosense Webster), which showed an extensive apical dense scar region, corresponding to the ventricular aneurysm. When the QDOT catheter was advanced in that region, late/fragmented potentials were detected by microelectrodes as well as by conventional electrodes. During the procedure, a sustained VT with right bundle branch block (RBBB)-inferior axis morphology and transition in V2 could be induced. We recorder diastolic fragmented potentials inside the aneurysm, where the novel catheter previously showed late/fragmented potentials; radiofrequency energy delivery with conventional settings (40 W) in that area led to rapid arrhythmia termination (Figure A). At the end of the procedure, VTs were no more inducible. Case 2: a 79-year-old male patient with prior inferior MI, mild LV dysfunction with a 5 cm × 5 cm × 3 cm aneurysm of the basal-mid inferior wall, and two previous CAs for recurrent VT presented to our hospital for electrical storm due to multiple episodes of slow VT (cycle, 470 ms, RBBB morphology, inferior axis, transition in V6), which were refractory to antiarrhythmic drug treatment. We decided to perform redo CA using the QDOT catheter, which revealed long and fragmented low-amplitude diastolic potentials inside the LV aneurysm (Figure B). VT was rapidly terminated by means of radiofrequency energy delivery with usual settings (40 W) in this region, and was no more inducible afterwards. Conclusions The novel ablation catheter showed favourable manoeuverability in the ventricle, while also allowing a precise characterization of the tachycardia circuitry and of the arrhythmogenic myocardial substrate, which was enhanced by the availability of microelectrodes. We believe that this preliminary experience may pave the way for further assessments of this new technology in the so far unexplored ventricular milieu.

Coronary Perforation Leading to a Large Intramural Hematoma: Visualization With Echocardiography

A 76-year-old patient with prior inferior myocardial infarction and multiple previous stenting in all 3 vessels had shortness of breath and recurrent sustained ventricular tachycardia, seriously affecting his quality of life. Thus, he was referred for treatment of a severely diseased right coronary

Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry.

The effects of cardiac resynchronization therapy (CRT) on secondary mitral regurgitation (MR), and mitral valve (MV) and left ventricular (LV) geometry, in patients with prior inferior myocardial infarction is not clearly defined. We assessed these outcomes utilizing two-dimensional echocardiography, and analyzed echocardiographic geometric variables that may correlate with follow-up MR severity. Between 2009 and 2012, 229 CRT were implanted. Twenty-two had prior inferior myocardial infarction, ≥mild MR at baseline, and serial echocardiography. A left bundle branch block was present in 12 (54.5%) patients. The pre-CRT and follow-up echocardiograms were analyzed for: (1) MR severity; (2) MV and LV geometry; and (3) LV remodeling. The median follow-up time was 2.2 years (interquartile range, 0.7-4). In 16 patients without an inferior myocardial scar, there was a reduction in MR jet area/left atrial area ratio (33.2%vs 25.8%; P=0.06) and MR grade (2.3vs 1.8; P=0.05), and an increased LV ejection fraction (26.1%vs 30.9%; P=0.04) and end-systolic posterior ventricular sulcus-anterolateral papillary muscle angle (133.9vs 143.9 degrees; P=0.01). In six patients with scar, there was no change in LV or MR parameters. Regression analysis revealed linear associations between baseline MV tenting height (r=0.57; P=0.006), LV end-diastolic diameter index (r=0.5; P=0.02), mitral septolateral annular diameter (r=0.48; P=0.03), and MV tenting area (r= 0.46; P = 0.03), with follow-up MR jet area/left atrial area ratio. In patients with prior inferior myocardial infarction and no scar, CRT is associated with decreased MR severity, and improved papillary muscle alignment and LV systolic function at follow-up.

Type IV dual left anterior descending coronary artery: a case report

BackgroundDual left anterior descending (LAD) artery or duplication of LAD is a rarely reported coronary anomaly, consisting of two branches supplying the usual distribution of the LAD. Type IV dual LAD, in which a short LAD arises from the left main coronary artery and a long LAD arises from the right coronary artery is remarkably rare, and has not been reported in a Bangladeshi subject.Case presentationWe describe the case of a 70-year old Bangladeshi male who presented with breathlessness in the background of a prior inferior myocardial infarction. Coronary angiography revealed an anomalous dual LAD. The short LAD which arose from the left main coronary artery gave off the first septal branch and terminated after giving off a large diagonal branch which continued further down towards the apex. The long LAD arose from the proximal right coronary artery and after traversing a distance, arrived at the interventricular septum, terminating at the apex after giving off diagonal branches. The right coronary artery was totally occluded from its early mid part and well-collateralized with retrograde flow from the left system.ConclusionWe describe a case with unique variation of dual LAD type IV, which has previously not been described in a Bangladeshi subject thus far. Coronary angiography is vital to determine this coronary anomaly, which is usually detected incidentally on routine angiography for chest pain, sometimes with involvement of significant lesion of other coronary arteries, as in this case.

A successful epicardial ablation from the middle cardiac vein for ventricular tachycardia with prior inferior myocardial infarction

A successful epicardial ablation from the middle cardiac vein for ventricular tachycardia with prior inferior myocardial infarction

陳旧性心筋梗塞による左室下壁低電位領域－僧帽弁輪間に拡張期電位を認め，同部位へのアブレーションで治療し得た下壁中隔側mitral isthmus心室頻拍の1例

陳旧性心筋梗塞による左室下壁低電位領域－僧帽弁輪間に拡張期電位を認め，同部位へのアブレーションで治療し得た下壁中隔側mitral isthmus心室頻拍の1例

First Experience With Implantation of a Percutaneous Right Ventricular Impella Right Side Percutaneous Support Device as a Bridge to Recovery in Acute Right Ventricular Infarction Complicated by Cardiogenic Shock in the United States

We report the first implantation in the United States of a novel percutaneous right ventricular (RV) support device as a bridge to recovery in a patient with RV infarction with cardiogenic shock refractory to standard care. A 64-year-old man, with prior inferior wall myocardial infarction treated with percutaneous coronary intervention, presented with late drug-eluting stent thrombosis inferoposterior ST-segment–myocardial infarction complicated by cardiac arrest requiring defibrillation of ventricular tachycardia (Figure 1; Movie I and II in the online-only Data Supplement). Despite revascularization, fluid administration to a central venous pressure of 20 mm Hg, dobutamine and vasopressin infusions, and intra-aortic balloon pump counterpulsation, he remained in RV shock (cardiac index of 1.8 L/min per m2). With use of antiplatelet drugs, surgical cannulation for extracorporeal support was deemed an excessive risk. Figure 1. Acute inferoapical ST-elevation–myocardial infarction (STEMI) treated …

Optimized electrocardiographic criteria for prior inferior and anterior myocardial infarction

Background and PurposeThe first purpose of the study was to optimize empirically the detection of prior inferior myocardial infarction (IMI) and prior anterior myocardial infarction (AMI) by electrocardiogram (ECG). The second purpose was to compare the diagnostic performances of the new criteria with those of 3 widely used commercial diagnostic ECG algorithms. Materials and MethodsWe analyzed the digital ECG data from 1138 subjects with suspected coronary artery disease in whom the presence or absence of prior IMI or AMI was documented by coronary angiography and left ventriculography. We used receiver operating characteristic curves to develop the new criteria for prior IMI and AMI using a training set of 562 subjects and then tested their diagnostic performances using a separate test set of 576 subjects. In both the training and test sets, we used χ2 test to compare the performances of the new criteria with those of 3 commercial computerized diagnostic algorithms. ResultsThe best criterion for prior IMI was the algebraic sum of the Q and T amplitudes in leads III and aVF. Its sensitivities/specificities were 71%/98% and 74%/98% in the training and test sets, respectively. The best criterion for prior AMI was the algebraic sum of the Q, R, and T amplitudes minus the Q duration in leads V2, V3, and V4. Its sensitivities/specificities were 68%/98% and 65%/98% in the training and test sets, respectively. In both the training and test sets, these diagnostic performances were generally superior to those of the 3 commercial algorithms. ConclusionsUsing digital ECG data, we developed and tested new criteria for prior IMI and AMI whose diagnostic performances are generally superior to each of 3 widely used commercial ECG diagnostic algorithms.

Narrow QRS ventricular tachycardia from the posterior mitral annulus without involvement of the His-Purkinje system in a patient with prior inferior myocardial infarction

A 54-year-old man with prior inferior myocardial infarction suffered from monomorphic ventricular tachycardia (VT) with narrow QRS complex of 120 ms. During VT, a fragmented prepotential preceding QRS onset by 30 ms at the right ventricular posterior septum and a late diastolic potential preceding QRS onset by 70 ms at the infarcted posterior mitral annulus were recorded. Radiofrequency energy delivered to the late diastolic potential at the posterior mitral annulus eliminated VT. During sinus rhythm, the late diastolic potential shifted to the end of QRS complex and no Purkinje potentials were observed. Synchronized excitation of both ventricles from the posterior infarcted mitral annulus in this patient may make the QRS width during VT narrow, without involvement of the His-Purkinje system.

Pitfalls of internal cardioverter defibrillator implantation: Part I

A 68-year-old male with a previous medical history consisting of a prior inferior myocardial infarction and colon cancer with curative treatment by operation and combined radiotherapy and chemotherapy was brought to the emergency room feeling unwell with nausea and dizziness that occurred when he was watching the professional soccer competition. Broad complex tachycardia with a heart rate of 191/min was recorded on the 12 lead ECG ( Figure 1 ). Because of haemodynamic instability, patient underwent immediate electrical cardioversion …

Different Mechanisms of Ischemic Mitral Regurgitation in Patients With Inferior and Anterior Myocardial Infarction

Background. Basic mechanism of ischemic mitral regurgitation (MR) is displacement of papillary muscles (PMs) due to left ventricular (LV) remodeling. Variability in LV remodeling can potentially cause heterogeneous PM displacements. The aim of this study is to compare the mitral valve complex geometry in patients with ischemic MR due to inferior and anterior myocardial infarction (MI).Methods. In 33 patients with prior inferior MI, 61 with anterior MI, and 22 controls, LV volume, mitral annular area, PM tethering distance, and MR were quantified by echocardiography.Results. Significant MR (MR fraction > 20%) was observed in 12 of the 33 with inferior MI and 7 of the 61 with anterior MI. In patients with MR due to inferior MI, tethering distance was significantly longer in medial compared to lateral PM (42.6 ± 4.9 vs. 36.1 ± 1.7 mm, p Conclusions. Although patients with ischemic MR due to inferior MI have asymmetrically predominant medial PM displacement, those with ischemic MR due to anterior MI have symmetric bilateral PM displacements.

Evaluation of right ventricular volume and function by 2D and 3D echocardiography compared to MRI

Radionuclide techniques, and recently MRI, have been used for clinical evaluation of right ventricular (RV) volumes function (RVEF) and volumes; but with the introduction of 3D echocardiography, new echocardiographic possibilities for RV evaluation independent of geometrical assumptions have emerged. This study compared classic and new echocardiographic and radionuclide estimates, including gated blood pool single-photon emission computed tomography (SPECT) of RV size and function to RV volumes, and ejection fraction (RVEF) measured by magnetic resonance imaging (MRI). Thirty-four subjects with (a) prior inferior ST-elevation myocardial infarction (n=17), (b) a history of pulmonary embolism and persistent dyspnea (n=7) or (c) normal subjects (n=10) had 2D and 3D echocardiography, SPECT and MRI within 24h. End-diastolic volume and peak tricuspid regurgitation velocity were increased in patients with a history of pulmonary embolism compared to healthy subjects, 130+/-26 ml vs. 94+/-26 ml, P<0.05, and 3.3+/-1.1m/s vs. 2.3+/-0.3m/s, P<0.05, respectively, whereas no differences in RVEF were seen in the three groups. Echocardiographic as well as SPECT estimates of RV volume showed significant correlation to RV volumes by MRI. Tricuspid annular plane systolic excursion (TAPSE) had the better correlation to RVEF by MRI, r=0.48, P<0.01; whereas 3D echocardiography had a correlation of 0.42, P<0.05. Compared to MRI, 3D echocardiography underestimated RVEF by 5.9%, 95% limits of agreement 1.6-10.2%. 3D echocardiographic estimates of RV size and RVEF show only moderate correlation to MRI measures of these parameters, and simple 2D echocardiographic estimates of RV size and function show similar correlations. For routine clinical purposes the simple TAPSE may be preferred over 3D and SPECT techniques for RVEF estimation.

Late outcomes after isolated coronary artery bypass grafting for ischemic mitral regurgitation

Although ischemic mitral regurgitation (IMR) is one of the most important issues to determine therapeutic strategy for ischemic heart disease, long-term outcome after coronary artery bypass grafting (CABG) for IMR is still unclear. It is also controversial how patients who would benefit from mitral valve (MV) surgery in combination with CABG should be identified. The purpose of this study is to elucidate late outcomes after isolated CABG for moderate IMR and to assess the indication of combined MV surgery. Two hundred and seventy-nine patients who had grade 2 or 3 IMR preoperatively and underwent isolated CABG between 1980 and 2002 in our institute were enrolled. Mitral regurgitation was assessed by 2-dimensional Doppler echocardiography and left ventriculography. Among them, 84 patients (30.1%) had left ventricular ejection fraction (LVEF) less than 30% and 186 patients (66.7%) had prior inferior myocardial infarction (MI). One hundred and twenty-nine patients (46.2%) remained grade 2 or greater MR early postoperatively. Actuarial survival and freedom from cardiac events, analyzed by the Kaplan-Meier method, were 90.9% and 87.7% at 1 year, 79.2% and 68.8% at 5 years, 54.9% and 49.1% at 10 years and 48.8% and 18.9% at 15 years. Independent predictive risk factors for cardiac events, analyzed by multivariate analysis using the Cox proportional hazard model, were grade 2 or greater MR which remained early postoperatively (p = 0.0002), LVEF < 30% preoperatively (p = 0.0006), no inferior MI preoperatively (p = 0.007) and no internal thoracic artery-left anterior descending artery graft (p = 0.049). More than a 15% decrease in LVEF at more than 3 years after the operation was seen despite patent bypass grafts in 17.2% of patients who received a late follow-up catheterization, although 41.4% of patients showed an increase or less than 5% decrease in LVEF during this period. Combined MV surgery with CABG for IMR should be considered in patients with poor LVEF or without prior inferior MI.

Left Ventricular Remodeling is Less While Left Atrial Remodeling is Greater in Inferior Compared to Anterior Myocardial Infarction: Importance of Ischemic Mitral Regurgitation

Background. Left ventricular (LV) remodeling is greater in patients with anterior myocardial infarction (MI) compared to those with inferior MI. Left atrial (LA) remodeling is expected to have influences from both LV remodeling and mitral valve dysfunction or mitral regurgitation (MR), which is more frequent in inferior MI. Therefore, LA remodeling may not necessarily be less in inferior MI compared to anterior MI. The purpose of the study is comparison of LV and LA remodeling in patients with anteroseptal and inferior MI with or without MR.Methods. In 61 consecutive patients with prior anterior MI, 33 with prior inferior MI, and 22 normal control subjects, LV and LA volumes were measured using biplane Simpson's method, and MR fraction was quantified by Doppler echocardiography.Results. Although patients with inferior MI had significantly less LV dilatation (LV end-diastolic volume: 91±11 vs. 125±45 vs. 106±19 ml, control vs. anterior vs. inferior, p 20%) was significantly higher in patients with inferior MI compared to anterior MI (7/61 vs. 12/33, p<0.01). In selected patients without significant ischemic MR, LA dilatation was comparable between inferior and anterior MI (60±28 vs. 61±16 ml, n.s.).Conclusions. Compared to patients with anterior MI, LV remodeling is significantly less but LA remodeling is significantly greater in inferior MI, suggesting the important role of ischemic MR to induce LA remodeling.

Resting cardiac SPECT with inhomogeneous attenuation correction in patients with prior inferior myocardial infarction

Resting cardiac SPECT with inhomogeneous attenuation correction in patients with prior inferior myocardial infarction

Exercise-induced precordial ST depression in prior inferior myocardial infarction

Exercise-induced precordial ST depression in prior inferior myocardial infarction

Comparative study of QRST values from body surface potential mapping, 12-lead ECGs, VCGs in detecting inferior myocardial infarction, and evaluating the severity of left ventricular wall motion abnormalities in simulated left bundle branch block

The authors compared the ability of QRST time-integral values (QRST values) from body surface potential maps (BSPM), 12-lead electrocardiograms (ECGs), and Frank lead vectorcardiograms (VCGs) in diagnosing a prior inferior myocardial infarction (MI) in simulated left bundle branch block (LBBB). The study included 32 patients whose digitized ECGs were recorded simultaneously for BSPM, ECGs, and VCGs during normal sinus rhythm and during right ventricular pacing simulating LBBB (18 with and 14 without an inferior MI). QRST values were calculated in each lead point of ECGs. Data on 608 normal subjects were used as controls; mean ± 2 SD was regarded as the normal range. The following parameters were derived: ΣDM, ΣDE, ΣDV, the sum of the differences between the normal mean QRST value, and the QRST value of a given patient in leads where the QRST value was less than the normal range (“−2 SD are”) in BSPM, ECGs, and VCGs (Y lead). The correlation coefficients for ΣDM, ΣDE, and ΣDV between the two activation sequences were highly significant. Sensitivity and specificity were as follows: 89% and 93% for ΣDM > 100 mV·ms, 89% and 93% for ΣDE > 50 mV·ms, and 56% and 100% for ΣDV > 10 mV·ms, respectively. Although ΣDM, ΣDE, and ΣDV were significantly ( P < .01) correlated with the asynergy index calculated from left ventriculograms, ΣDM showed the best correlation. QRST values from BSPM, ECGs, and VCGs provide information that is useful in detecting an inferior MI and in estimating the severity of left ventricular wall motion abnormalities in the setting of LBBB. Of the three parameters, BSPM showed the best correlation with the severity of left ventricular wall motion abnormalities.

The use of a somatostatin analog in the treatment of refractory hypotension after cardiopulmonary bypass

The patient was a 59-year-old male status post-prior mitral valve replacement (MVR) for mitral regurgitation (MR) and coronary artery bypass grafting (CABG) 6 months previously. He presented with recurrent MR due to endocarditis and a perivalvular leak, and was admitted with congestive heart failure (CHF) and shaking chills. Blood cultures were positive for Staphylococcus epidermidis. He had undergone 14 days of treatment with intravenous (IV) antibiotics, including vancomycin, gentamycin, and rifampin, which was associated with cessation of fevers and chills. His past medical history included hypertension, prior inferior myocardial infarction, and peripheral vascular disease. Additional medications included IV heparin, 1,000 u/h, and nitropaste, 2 inches every 6 hours. Laboratory values included a white blood cel1 count of 8,400 without bands, platelet count of 170,000/cc3, and a hematocrit of 29.7%. Cardiac catheterization revealed patent grafts, an enlarged left atrium (LA) and ventricle (LV), inferior and posterior hypokinesis, 3+ MR due to a perivalvular leak and a large LA vegetation. The patient was scheduled for a redo-MVR and debridement of his atrial vegetation. The patient was brought to the operating room where initial hemodynamics included a bloed pressure (BP) of 135165 mmHg, heart rate (HR) 65 beatsimin, centra1 venous pressure (CVP) 10 mmHg, pulmonary artery pressure (PAP) 43120 mmHg, pulmonary capillary wedge pressure (PCWP) 21 mmHg, with V waves to 38 mmHg, cardiac output (CO) of 5.0 Limin, systemic vascular resistance (SVR) of 1,200 dynes sec. cmes, and mixed venous oxygen saturation (SvOz) of 74%. Induction of anesthesia was carried out with 500 ug of sufentanil and 10 mg of pancuronium. After adequate relaxation, the trachea was intubated and mechanica1 ventilation was initiated with 100% oxygen. Maintenance of anesthesia was accomplished with sufentanil, pancuronium, and lorazepam (total sufentanil dose 1.5 mg, total lorazepam dose 4 mg). His antibiotics were continued in the operating room. The prebypass hemodynamics ranged from systolic bloed pressures (SBP) of 100-120 mmHg, HR 60-70 beatsimin, CVP 10-12 mmHg, PAP 35-40115-20 mmHg, CO 4-4.5 Limin, SVR of 1,300 dynes sec cmm5, and SvO2 68% to 80%.