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J Thorac Cardiovasc Surg 1994;107:317
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Disappearance of periodic breathing after heart operations

Korányi National Institute for Tuberculosis and Pulmonology^a
Department of Cardiovascular Surgery
Semmelweis University of Medicine^b
Budapest, Hungary

To the Editor:

Preoperative and postoperative transcutaneous oxygen monitoring of a patient with congestive left heart failure caused by severe aortic regurgitation resulting from infective endocarditis has been reported. We were able to see the disappearance of periodic breathing of Cheyne-Stokes type caused by heart failure after implantation of valvular prosthesis. To our knowledge, this is the first case of disappearance of periodic breathing after a heart operation. We report a case in which the preoperatively detected periodic breathing was completely abolished after heart valve replacement.

A 34-year-old cyanotic woman was admitted to our cardiology unit with biventricular failure. She had a tooth removed 2 weeks before her admission, after which fever and cough developed. These symptoms persisted despite oral antibiotic treatment. A routine chest radiograph showed an enlarged cardiac shadow (cardiothoracic ratio, 0.6). Electrocardiographic examination showed 100 beats/min sinus rhythm, with wide P waves and incomplete left bundle branch block but no repolarization abnormalities. The patient's white blood cell count was somewhat raised and her erythrocyte sedimentation rate was 64 mm/hour. Two-dimensional echocardiography confirmed the diagnosis of endocarditis with soft vegetation on both the mitral and aortic valves. The left ventricle was dilated but showed hyperkinetic wall motion; the left atrium was also dilated. Doppler echocardiography showed low-velocity aortic regurgitation, grade IV mitral regurgitation, and a functional tricuspid regurgitation (4 m/sec peak velocity).

The patient was apyretic, but Staphylococcus albus grew from blood cultures and a regimen of combined parenteral antibiotics (oxacillin 2 gm six times daily and gentamicin 80 mg three times daily) was started. Results of both abdominal ultrasonographic and gynecologic examinations were negative; possible dental foci were also eliminated.

On the seventh day of her treatment, after diuretic therapy, the patient's cardiac condition improved somewhat; she did not have any dyspneic attacks overnight. Repeatedly performed arterial blood gas analysis during the day showed normal oxygen tension values. The patient was put on overnight transcutaneous oxygen monitoring. The oxygen sensor was positioned in the right subclavian area and attached to the Radiometer TCM 2 device (Radiometer America, Inc., Westlake, Ohio). Although the measured tissue oxygen tension differs in adults from the absolute oxygen tension value of the arterial blood, it closely follows the changes of the capillary oxygen tension. Measuring the transcutaneous oxygen tension is therefore a useful method in detecting periodic breathing. The transcutaneous oxygen monitoring revealed periodic breathing through nearly the whole night (Fig. 1, A).

View larger version (59K): [in this window] [in a new window]   Fig. 1. Nocturnal transcutaneous oxygen pressure tracings(TcO2) were produced at a paper speed of 12min/cm.A, Preoperative oxygen pressures refer to periodic breathing during almost the whole night in the rangeof 40 to 60 mm Hg.B, Postoperative tracings have slight irregularity without periodic patterns at about the same pressurelevels.

On the fifteenth postoperative day transcutaneous oxygen tension monitoring was repeated, but no periodic breathing was revealed this time (Fig. 1, B). Chest radiography showed reduced heart size and control two-dimensional echocardiography also showed regressing dilation of the heart chambers, with only a modest degree of tricuspid regurgitation.

The exact mechanism of the nocturnal periodic breathing seen in congestive cardiac failure is not yet known. The Cheyne-Stokes breathing is probably the result of complex interactions in which the reduced oxygen reserve capacity of the lungs, the reduced tissue gas exchange as a consequence of the poor cardiac output, the elevated left atrial pressure, and the elevated plasma adenosine level all play important roles. Restoration of the badly impaired left ventricular function in our patient completely abolished the clinically detectable periodic breathing.

References

1. Dark DS, Pingleton SK, Kerby GR, et al. Breathing pattern abnormalities and arterial oxygen desaturation during sleep in congestive heart failure syndrome. Chest 1987;91:833-6.[Abstract/Free Full Text]
   
2. Hanly PJ, Millar TW, Steljes DG, Beart R, Frais MA, Kryger MH. The effect of oxygen on respiration and sleep in patients with congestive heart failure. Ann Intern Med 1989;111:777-82.
   

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