- Email: [email protected]
Dissecting Aneurysm of the Ascending Aorta with Aorto-caval Fistula
FIGURE 1. Lateral and AP chest roentgenograms .
lung. No instance of massive hemorrhage accompanying bronchoscopy was noted. Linton" reported the results of treating longstanding foreign bodies in 16 patients. In six of these patients, the foreign body could be removed through the bronchoscope. One of the six required lobectomy because of abscess. One of the 16 patients required bronchocotomy for removal of the foreign body, and six required pulmonary resection . No instance of massive hemorrhage at the time of bronchoscopy was recorded. Foreign body bronchiectasis may require lung resection following prolonged sojourn of foreign bodies in the tracheobronchial tree. Cooley et aF reported on 14 such patients at the Mayo Clinic. As noted by Bogedain," foreign bodies in the pulmonary parenchyma may migrate to an intrabronchial position and be removed transbronchoscopically many years later. In a review of the over 2,500 documented cases,I.3.4.6,(;.11 the author was unable to find another instance of massive hemorrhage accompanying removal of an intrabronchial foreign body, whether performed acutely or after prolonged sojourn. CONCLUSION
The tracheobronchial endoscopist should have this possible complication in mind and manage to meet it by: 1) tamponading the bronchial system on the side that is bleeding; 2) carrying out endotracheal intubation; 3) suctioning the contralateral side for blood that has spilled over from the hemorrhage; and 4) and performing immediate thoracotomy on the affected side. REFERENCES 1 Jackson C , Jackson CL. Diseases of the air and food passages of
478
foreign -body origin. Philadelphia: W. B. Saunders, 1936. 2 ClerfL. Foreign bodies in the air and food passages: observations on end-results in a series of nine hundred fifty cases. Surg Gynecol Obstet 1940; 328-39 3 Abdulmajid OA, Ebeid AM, Motawen MM , Kleibo IS. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases. Thorax 1965; 31 :635-40 4 Kosloske AM. Bronchoscopic extraction of aspirated foreign bodies in children. Am J Dis Child 1982 ; 136:924-27 5 Schloss, MD , Pham -Dang H, Rosales JK. Foreign bodies in the tracheobronchial tree-a retrospective study of 217 cases. J Otolaryn 1983; 12:212-16 6 Linton JSA. Long-standing intrabronchial foreign bodies. Thorax 1957; 12:164-70 7 Cooley JC , Ginsberg RL , Olsen AM , Kirklin Jw. Foreign body bronchiectasis. J Thorac Surg 1956 ; 51:615-17 8 Bogedain W. Migration of schrapnel from lung to bronchus. JAMA 1984; 251 :1862-1963 9 Aytac A, Yurdakul Y, Ikizler C , Olga R, Saylam A. Inhalation of fore ign bodies in children. Report of 500 cases. J Thorac Cardiovasc Surg 1977; 74:145-50 10 Cohen SR, Lewis GB Jr, Herbert WI, Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otoll960; 89 :437-42 11 Slim MS, Yacoubian HD. Complications offoreign bodies in the tracheobronchial tree. Arch Surg 1966 ; 92:388-93
Dissecting Aneurysm of the Ascending Aorta with Aorto-caval Fistula· Flberoptlc Oximetric Findings and Surgical Management ]. B. Martinot , M.D.;t O. Pedemonte, M.D.;t P. L. Baele, M.D .;:/: ]. Dautrebande, M.D .;§ P. ]aumin, M .D. ;~ and M. Coenen , M.D . t *From the Cliniques Universitaires Saint-Luc, Brussels, Belgium. tlntensive Care Unit. :/:Department of Anesthesiology. § Department of Radiology. ~Department of Thoracic and Cardiovascular Surgery.
Reprint requests: Dr: Goenen, Service Soins lntensifs, Cliniques Universitaires St. Luc, 10, Av Hippocrate , 1200 Brussels , Belgium Dissecting Aneurysm 01 Ascending Aorta (MlJf1inot et eI)
A patient presented the rare complication of a dissecting aneurysm of the ascending aorta ruptured into the superior vena cava producing a left-right fistula. Continuous oximetric measurements by a fiberoptic pulmonary artery floated catheter was used to localize the site of the shunt. Emergency surgical repair was successfully performed. rupture of a dissecting aortic aneurysm is a I ntracardiac rare event. Although previous cases of rupture into the
right atrium (RA) have been reported, we are unaware of any other report of communication into the superior vena cava (5VC). I We recently had the opportunity to study and localize the site of fistula by continuous fiberoptic measurement of 5v02 • This was confirmed by aortic angiogram and surgery. CASE REPORT
This 66-year-oldwhite man had a regurgitant aortic valve replaced in July, 1984with a Carpentier bioprothes is. The valve was tricuspid and of a myxoid degenerative type . The postoperat ive course was uneventful and the patient was discharged on oral acenocoumarol therapy. In September, increased venous circulation on the upper chest was noticed ; blood pressure was 1801110 mm Hg. In mid-November. the patient experienced. at rest, sharp pain on the right side of his neck radiating to his chest and lasting several hours . Since then , the patient has complained ofgeneral malaise and loss of appetite. On the 25th of November, he developed sudden dyspnea and discomfort in the right upper quadrant of the abdomen, and on the 28th he was admitted to a local hospital with biventricular card iac failure. He developed ventricular tachycardia and fibrillation reversed by cardioversion. The patient was transferred to our hospital for presumed prosthesis dysfunction. Pulse rate was llO/min; blood pressure, 160/80mm Hg. Neck veins were distended, as were the veins on the upper chest . The liver was
: _: _1 I
f
+
'
I
I
! I
FIGURE 1. Aortic angiogram. Right posterior oblique position. 1,5 seconds after aortic injection. Open arrow: path between the sac and the SVC. Large black arrow: pulmonary artery. Medium black arrows: aneurysm 'sfalse lumen . SmaU arrows: right coronary artery and opacified right cavities.
tender and enlarged 4 cm below the costal margin. A grade 4/6 diastolic murmur was maximal on the right sternal border. Laboratory studies disclosed a fibrinogen of 480 mg/loo ml, a white blood cell count of 16,loo/cu mm with 87 percent neutrophils. Serum glutamic oxaloacetic transaminase was 80 units; glutamic
l -L .. -1-~ -
J. . ~ .. L.
_1...1. _J
I. _ l.
·~--ti !
. .
I
-_...-
.....
'
.
5
.~.
I
FIGURE 2. Simultaneous recording of pressures and oximetry during fiberoptic catheter insertion. Upper tracing: systemic blood pressure; middle tracing: pressures at the tip of the catheter (CV = superior vena cava; RA: right atrium ; RV: right ventricle; PA: pulmonary artery; PW: pulmonary arter wedge pressure); bottom tracing: oxygen saturations at the tip of the catheter (SVOJ. Arrow 1: initial stepwise increase of oxygen saturation; arrow 2: pressure gradient reflects narrowing of the cava-atrialjunction .
CHEST I 88 I 3 I SEPTEMBER, 1985
477
pyruvic transaminase was 82 units ; plasma creatinine was 2.55 mgfl00 ml, prothrombin time was 24 seconds and syphilis serology was positive (VDRL(-); TPHA:lJl60; IF :lJ800.) The electrocardiogram showed left axis deviation and left ventricular hypertrophy. Cardiomegaly was marked on the chest x-ray film. Pulsed Doppler echocardiography results ruled out aortic, mitral or tricuspid regurgitation . We then looked for an aorto-cardiac fistula. Blood samples obtained after pulmonary artery (PA) catheter placement showed high oxygen saturation in RA (93 percent) and PA (83 percent). The aortic angiogram showed an enlarged aortic root, with an intimal tear which started from its left anterior side. Contrast medium revealed the dissection, filled a right antero-lateral sac, and ended up in the RA. Later x-ray films showed contrast medium in a thin path extending from the sac to the SVC (Fig 1). The patient's condition deteriorated and it was decided to carry out an emergency repair. After induction of anesthesia, a fiberoptic pulmonary artery floated catheter (Opticath, Oximetric, Mt View, CAl was inserted, providing continuous measurement of hemoglobin oxygen saturation . The catheter was externally calibrated and inserted via the right internal jugular vein. It could not progress from the SVC into the RAwith the balloon inflated. A sudden increase in saturation from 54 percent to 94 percent occurred 18 cm from the puncture site, while on fluoroscopy the end of the catheter was located just above the RA. A gradient of 5 mm Hg was noted from SVC to RA. The auricular V wave was markedly enlarged (Fig 2). Surgery was performed under cardiopulmonary bypass. The prosthesis appeared in perfect shape. The aneurysm was corrected by a Dacron graftinterposition. The fistula was dissected and shown close to the vena cava. All cultures remained sterile . Postoperative oximetric and hemodynamic measurement results were normal. The patient did well and was discharged on December 19, 1984 (Table 1). DISCUSSION Dissecting aneurysms of the ascending aorta may have unusual clinical presentations resulting from the compression of surrounding structures, occlusion of other vessels, perforation, hemorrhage (eg, into the tracheobronchial tree), extension into the atrial septum, or from aorta-right heart fistula.
Table I-Herrnxlynamic and Oximetric Values Measurements Systemic blood (mmHg) pressure Mean central (mmHg) venous pressure Mean pulmonary (mmHg) arterial pressure Oxygen saturation (%) in SVC Oxygen saturation (%)inRA Mixed venous (%) oxygen saturation Oxygen saturation (%) in radial artery Right cardiac (Umin) output (Fick)
Asleep before repair
Asleep after repair
81/35
125n2
17
4
23
15
42 to 58-
71
93 .9
69
91.1
66
97.2
97
17.3
5
-Range of fiberoptic measurements during placement.
478
FIGURE
3. Diagram of defects found at operation .
Rupture into the SVC has been documented from a sinus of Valsalva aneurysm but not from a proximal aortic dissec-
tion." Postoperative false aneurysms of the ascending aorta are unusual complications of cardiac surgery and develop from cannulation, clamping or needle puncture sites. 3 Our patient had a classic dissecting aneurysm of the ascending aorta starting at some distance from previous surgical sutures and rupturing into the SVC. To our knowledge, this is the first case to be documented (Fig 3). Massive left-right shunt led to "ventricularization" of the RA pressure curve. The cavo-atrial pressure gradient could only be explained by external compression ofthe SVC, which was confirmed at operation. No arterial wave was recorded in the proximal SVC. Two explanations are proposed for this fact : the stream of the leftright shunt was directed towards the RA and the compression of cavo-atrial junction resulted in damping ofthe venous wave
form .
For many years, technical problems prevented the use of fiberoptic oximetry for diagnostic purposes during cardiac catheterization.' We used a new kind of equipment, with success, to localize the outlet of the aortocaval fistula. Originally designed for continuous monitoring of blood oxygen saturation at one given site over long periods of time, this system updates and displays every second the averaged value for the preceding five seconds. 5.' This feature, as well as incomplete blood mixing, may explain why the printout showed a stepwise increase in saturation where an abrupt rise was expected. Obviously, shorter averaging times are needed for diagnostic use of this technique. Later controls showed that the external calibration of the system had overestimated all values by 8 ·percent. As a result, the small differences between high saturation levels in the RA, right ventricle and PA were not detected. REFERENCES Nicod P, Firth BG, Peshock RM, Gaffney FA, Hillis LD. Rupture of dissecting aortic aneurysm into the right atrium: clinical and electrocardiographic recognition. Am Heart] 1984; 107 :1276-78 2 KayeGC, Edmondson S], Caplin ]L, Tunstall-Pedoe DS. Rupture of an aneurysm of the sinus ofValsalvainto the superior vena cava. Dl8sectlng Aneurysm 01 Ascending Aorta (Martinot 8/ aJ)
Thorax 1984; 39:475-76 3 Photiou SA, Kaul TK, Mercer JL. Faise aneurysm of the ascending aorta with artico-right atrial fistula. Thorax 1981; 36:796-97 4 Frommer PL, Ross JJr, Mason D1; Gault JH , Braunwald E. Clinical applications ofan improved, rapidly responding fiberoptic catheter. Am J Cardioll965; 15:672-79
5 Baele PL, McMihan JC, Marsh HM, Sill JC, Southern PA. Continuous monitoring of mixed venous oxygen saturation in critically ill patients . Anesth Analg 1982; 61:513-17 6 Gore JM, Sloan K. Use of continuous monitoring of mixed venous saturation in the coronary care unit. Chest 1984; 86:757-61
Ischaemic Heart Disease, Exercise and Related Topics The Toronto Rehabilitation Centre will host the third international symposium November 2-4 at the Royal YorkHotel, Toronto , Ontario. For information, contact Ms. Johanna Kennedy or Ms. Anna Ceci at the center, 345 Rumsey Road, Toronto M4G 1R7 (416:425-6630).
CHEST I 88 I 3 I SEPTEMBER. 1985
479
lung. No instance of massive hemorrhage accompanying bronchoscopy was noted. Linton" reported the results of treating longstanding foreign bodies in 16 patients. In six of these patients, the foreign body could be removed through the bronchoscope. One of the six required lobectomy because of abscess. One of the 16 patients required bronchocotomy for removal of the foreign body, and six required pulmonary resection . No instance of massive hemorrhage at the time of bronchoscopy was recorded. Foreign body bronchiectasis may require lung resection following prolonged sojourn of foreign bodies in the tracheobronchial tree. Cooley et aF reported on 14 such patients at the Mayo Clinic. As noted by Bogedain," foreign bodies in the pulmonary parenchyma may migrate to an intrabronchial position and be removed transbronchoscopically many years later. In a review of the over 2,500 documented cases,I.3.4.6,(;.11 the author was unable to find another instance of massive hemorrhage accompanying removal of an intrabronchial foreign body, whether performed acutely or after prolonged sojourn. CONCLUSION
The tracheobronchial endoscopist should have this possible complication in mind and manage to meet it by: 1) tamponading the bronchial system on the side that is bleeding; 2) carrying out endotracheal intubation; 3) suctioning the contralateral side for blood that has spilled over from the hemorrhage; and 4) and performing immediate thoracotomy on the affected side. REFERENCES 1 Jackson C , Jackson CL. Diseases of the air and food passages of
478
foreign -body origin. Philadelphia: W. B. Saunders, 1936. 2 ClerfL. Foreign bodies in the air and food passages: observations on end-results in a series of nine hundred fifty cases. Surg Gynecol Obstet 1940; 328-39 3 Abdulmajid OA, Ebeid AM, Motawen MM , Kleibo IS. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases. Thorax 1965; 31 :635-40 4 Kosloske AM. Bronchoscopic extraction of aspirated foreign bodies in children. Am J Dis Child 1982 ; 136:924-27 5 Schloss, MD , Pham -Dang H, Rosales JK. Foreign bodies in the tracheobronchial tree-a retrospective study of 217 cases. J Otolaryn 1983; 12:212-16 6 Linton JSA. Long-standing intrabronchial foreign bodies. Thorax 1957; 12:164-70 7 Cooley JC , Ginsberg RL , Olsen AM , Kirklin Jw. Foreign body bronchiectasis. J Thorac Surg 1956 ; 51:615-17 8 Bogedain W. Migration of schrapnel from lung to bronchus. JAMA 1984; 251 :1862-1963 9 Aytac A, Yurdakul Y, Ikizler C , Olga R, Saylam A. Inhalation of fore ign bodies in children. Report of 500 cases. J Thorac Cardiovasc Surg 1977; 74:145-50 10 Cohen SR, Lewis GB Jr, Herbert WI, Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otoll960; 89 :437-42 11 Slim MS, Yacoubian HD. Complications offoreign bodies in the tracheobronchial tree. Arch Surg 1966 ; 92:388-93
Dissecting Aneurysm of the Ascending Aorta with Aorto-caval Fistula· Flberoptlc Oximetric Findings and Surgical Management ]. B. Martinot , M.D.;t O. Pedemonte, M.D.;t P. L. Baele, M.D .;:/: ]. Dautrebande, M.D .;§ P. ]aumin, M .D. ;~ and M. Coenen , M.D . t *From the Cliniques Universitaires Saint-Luc, Brussels, Belgium. tlntensive Care Unit. :/:Department of Anesthesiology. § Department of Radiology. ~Department of Thoracic and Cardiovascular Surgery.
Reprint requests: Dr: Goenen, Service Soins lntensifs, Cliniques Universitaires St. Luc, 10, Av Hippocrate , 1200 Brussels , Belgium Dissecting Aneurysm 01 Ascending Aorta (MlJf1inot et eI)
A patient presented the rare complication of a dissecting aneurysm of the ascending aorta ruptured into the superior vena cava producing a left-right fistula. Continuous oximetric measurements by a fiberoptic pulmonary artery floated catheter was used to localize the site of the shunt. Emergency surgical repair was successfully performed. rupture of a dissecting aortic aneurysm is a I ntracardiac rare event. Although previous cases of rupture into the
right atrium (RA) have been reported, we are unaware of any other report of communication into the superior vena cava (5VC). I We recently had the opportunity to study and localize the site of fistula by continuous fiberoptic measurement of 5v02 • This was confirmed by aortic angiogram and surgery. CASE REPORT
This 66-year-oldwhite man had a regurgitant aortic valve replaced in July, 1984with a Carpentier bioprothes is. The valve was tricuspid and of a myxoid degenerative type . The postoperat ive course was uneventful and the patient was discharged on oral acenocoumarol therapy. In September, increased venous circulation on the upper chest was noticed ; blood pressure was 1801110 mm Hg. In mid-November. the patient experienced. at rest, sharp pain on the right side of his neck radiating to his chest and lasting several hours . Since then , the patient has complained ofgeneral malaise and loss of appetite. On the 25th of November, he developed sudden dyspnea and discomfort in the right upper quadrant of the abdomen, and on the 28th he was admitted to a local hospital with biventricular card iac failure. He developed ventricular tachycardia and fibrillation reversed by cardioversion. The patient was transferred to our hospital for presumed prosthesis dysfunction. Pulse rate was llO/min; blood pressure, 160/80mm Hg. Neck veins were distended, as were the veins on the upper chest . The liver was
: _: _1 I
f
+
'
I
I
! I
FIGURE 1. Aortic angiogram. Right posterior oblique position. 1,5 seconds after aortic injection. Open arrow: path between the sac and the SVC. Large black arrow: pulmonary artery. Medium black arrows: aneurysm 'sfalse lumen . SmaU arrows: right coronary artery and opacified right cavities.
tender and enlarged 4 cm below the costal margin. A grade 4/6 diastolic murmur was maximal on the right sternal border. Laboratory studies disclosed a fibrinogen of 480 mg/loo ml, a white blood cell count of 16,loo/cu mm with 87 percent neutrophils. Serum glutamic oxaloacetic transaminase was 80 units; glutamic
l -L .. -1-~ -
J. . ~ .. L.
_1...1. _J
I. _ l.
·~--ti !
. .
I
-_...-
.....
'
.
5
.~.
I
FIGURE 2. Simultaneous recording of pressures and oximetry during fiberoptic catheter insertion. Upper tracing: systemic blood pressure; middle tracing: pressures at the tip of the catheter (CV = superior vena cava; RA: right atrium ; RV: right ventricle; PA: pulmonary artery; PW: pulmonary arter wedge pressure); bottom tracing: oxygen saturations at the tip of the catheter (SVOJ. Arrow 1: initial stepwise increase of oxygen saturation; arrow 2: pressure gradient reflects narrowing of the cava-atrialjunction .
CHEST I 88 I 3 I SEPTEMBER, 1985
477
pyruvic transaminase was 82 units ; plasma creatinine was 2.55 mgfl00 ml, prothrombin time was 24 seconds and syphilis serology was positive (VDRL(-); TPHA:lJl60; IF :lJ800.) The electrocardiogram showed left axis deviation and left ventricular hypertrophy. Cardiomegaly was marked on the chest x-ray film. Pulsed Doppler echocardiography results ruled out aortic, mitral or tricuspid regurgitation . We then looked for an aorto-cardiac fistula. Blood samples obtained after pulmonary artery (PA) catheter placement showed high oxygen saturation in RA (93 percent) and PA (83 percent). The aortic angiogram showed an enlarged aortic root, with an intimal tear which started from its left anterior side. Contrast medium revealed the dissection, filled a right antero-lateral sac, and ended up in the RA. Later x-ray films showed contrast medium in a thin path extending from the sac to the SVC (Fig 1). The patient's condition deteriorated and it was decided to carry out an emergency repair. After induction of anesthesia, a fiberoptic pulmonary artery floated catheter (Opticath, Oximetric, Mt View, CAl was inserted, providing continuous measurement of hemoglobin oxygen saturation . The catheter was externally calibrated and inserted via the right internal jugular vein. It could not progress from the SVC into the RAwith the balloon inflated. A sudden increase in saturation from 54 percent to 94 percent occurred 18 cm from the puncture site, while on fluoroscopy the end of the catheter was located just above the RA. A gradient of 5 mm Hg was noted from SVC to RA. The auricular V wave was markedly enlarged (Fig 2). Surgery was performed under cardiopulmonary bypass. The prosthesis appeared in perfect shape. The aneurysm was corrected by a Dacron graftinterposition. The fistula was dissected and shown close to the vena cava. All cultures remained sterile . Postoperative oximetric and hemodynamic measurement results were normal. The patient did well and was discharged on December 19, 1984 (Table 1). DISCUSSION Dissecting aneurysms of the ascending aorta may have unusual clinical presentations resulting from the compression of surrounding structures, occlusion of other vessels, perforation, hemorrhage (eg, into the tracheobronchial tree), extension into the atrial septum, or from aorta-right heart fistula.
Table I-Herrnxlynamic and Oximetric Values Measurements Systemic blood (mmHg) pressure Mean central (mmHg) venous pressure Mean pulmonary (mmHg) arterial pressure Oxygen saturation (%) in SVC Oxygen saturation (%)inRA Mixed venous (%) oxygen saturation Oxygen saturation (%) in radial artery Right cardiac (Umin) output (Fick)
Asleep before repair
Asleep after repair
81/35
125n2
17
4
23
15
42 to 58-
71
93 .9
69
91.1
66
97.2
97
17.3
5
-Range of fiberoptic measurements during placement.
478
FIGURE
3. Diagram of defects found at operation .
Rupture into the SVC has been documented from a sinus of Valsalva aneurysm but not from a proximal aortic dissec-
tion." Postoperative false aneurysms of the ascending aorta are unusual complications of cardiac surgery and develop from cannulation, clamping or needle puncture sites. 3 Our patient had a classic dissecting aneurysm of the ascending aorta starting at some distance from previous surgical sutures and rupturing into the SVC. To our knowledge, this is the first case to be documented (Fig 3). Massive left-right shunt led to "ventricularization" of the RA pressure curve. The cavo-atrial pressure gradient could only be explained by external compression ofthe SVC, which was confirmed at operation. No arterial wave was recorded in the proximal SVC. Two explanations are proposed for this fact : the stream of the leftright shunt was directed towards the RA and the compression of cavo-atrial junction resulted in damping ofthe venous wave
form .
For many years, technical problems prevented the use of fiberoptic oximetry for diagnostic purposes during cardiac catheterization.' We used a new kind of equipment, with success, to localize the outlet of the aortocaval fistula. Originally designed for continuous monitoring of blood oxygen saturation at one given site over long periods of time, this system updates and displays every second the averaged value for the preceding five seconds. 5.' This feature, as well as incomplete blood mixing, may explain why the printout showed a stepwise increase in saturation where an abrupt rise was expected. Obviously, shorter averaging times are needed for diagnostic use of this technique. Later controls showed that the external calibration of the system had overestimated all values by 8 ·percent. As a result, the small differences between high saturation levels in the RA, right ventricle and PA were not detected. REFERENCES Nicod P, Firth BG, Peshock RM, Gaffney FA, Hillis LD. Rupture of dissecting aortic aneurysm into the right atrium: clinical and electrocardiographic recognition. Am Heart] 1984; 107 :1276-78 2 KayeGC, Edmondson S], Caplin ]L, Tunstall-Pedoe DS. Rupture of an aneurysm of the sinus ofValsalvainto the superior vena cava. Dl8sectlng Aneurysm 01 Ascending Aorta (Martinot 8/ aJ)
Thorax 1984; 39:475-76 3 Photiou SA, Kaul TK, Mercer JL. Faise aneurysm of the ascending aorta with artico-right atrial fistula. Thorax 1981; 36:796-97 4 Frommer PL, Ross JJr, Mason D1; Gault JH , Braunwald E. Clinical applications ofan improved, rapidly responding fiberoptic catheter. Am J Cardioll965; 15:672-79
5 Baele PL, McMihan JC, Marsh HM, Sill JC, Southern PA. Continuous monitoring of mixed venous oxygen saturation in critically ill patients . Anesth Analg 1982; 61:513-17 6 Gore JM, Sloan K. Use of continuous monitoring of mixed venous saturation in the coronary care unit. Chest 1984; 86:757-61
Ischaemic Heart Disease, Exercise and Related Topics The Toronto Rehabilitation Centre will host the third international symposium November 2-4 at the Royal YorkHotel, Toronto , Ontario. For information, contact Ms. Johanna Kennedy or Ms. Anna Ceci at the center, 345 Rumsey Road, Toronto M4G 1R7 (416:425-6630).
CHEST I 88 I 3 I SEPTEMBER. 1985
479