Impact of Renal Dysfunction on Liver Transplantation: a Retrospective Study in 708 Orthotopic Liver Transplant Recipients

Renal dysfunction often complicates the course of orthotopic liver transplant recipients and is associated with increased morbid -mortality. The aims of this study were to determine the incidence of chronic renal disease and its impact on patient survival. Clinical data included age, gender and weight,aetiology of hepatic failure, presence of diabetes,hypertension, hepatitis B and C infection, renal dysfunction pretransplant and immunosuppression. Laboratory data included serum creatinine at days 1, 7, 21, month 6, 12 and yearly. The glomerular filtration rate was determined by Cockcroft-Gault equation. We studied retrospectively from September 1992 to March 2007 708 orthotopic liver transplant recipients. Mean age 44±12.6 years, 64% males, 17% diabetic, 18.8% hypertensive, 19.9% with hepatitis C and 3.8% hepatitis B. Renal dysfunction pretransplant was known in 21.6%. Mean follow-up was 3.6 years. Mean transplant survival 75% at 12 months. 154 patients died. Univariate and multivariate analyses were performed and a p<0.05 was considered significant. Acute kidney injury occurred in 33.2%. Chronic kidney disease stage 3 was observed in 34.3%,stage 4 in 6.2% and stage 5 in 5.1%. At the time of this study, 46.4% were on Cyclosporine A, 44.7% on tacrolimus and 8.9% on sirolimus. Using multivariate analysis, renal dysfunction was correlated with renal dysfunction pre -orthotopic liver transplant (p<0.001), acute kidney injury (p<0.001), haemodialysis development (p<0.001), and inversely correlated with the use of mycophenolate mophetil (p<0.001); mortality was positively correlated with renal dysfunction pretransplant (p=0.03),chronic kidney disease stage 4 (p=0.001), chronic kidney disease stage 5 (p<0.001) and inversely correlated with the use of tacrolimus (p=0.006). In conclusion orthotopic liver transplant recipients are disposed to renal complications that have a negative impact on survival of these patients.

One Anastomosis Gastric Bypass versus Roux en Y Gastric Bypass as Salvage Technique after Failed Gastric Band: a Retrospective Analysis of 80 Cases

The classical “Roux en Y Gastric Bypass” (RYGBP) is still the standard technique between all the ones being used nowadays. The “One anastomosis gastric bypass” (OAGBP), is an evolution of the “Minigastic bypass” described by Robert Rutledge in 2001, is a well known and progressively frequent but still controversial technique. In our group, after an experience of 10 years using the RYGBP as a salvage surgery after failed gastric banding, in 132 cases, we decided to adopt the OAGBP as our preferential bariatric technique also in this situation. The theoretical main reasons for that shift are related to the increased safety, maximized weight loss, long term weight loss maintenance and reversibility of the operation. Method: Retrospectively we evaluated data of the surgical management of revisional cases for conversion, after failed or complicated gastric bands to gastric bypass. We selected the last 40 cases of each technique since May 2010. Results: All cases were performed by laparoscopy without any conversion. In both groups the conversion has been performed in one single step (17 cases, 42,5%). Data showed lower morbidity with OAGBP (2,5% against 7,5%) and better weight loss in theOAGBP cohort after a median follow up of 16months (67%against 55%) in patients revised after gastric band failure or complications. None had statistic significance (p>0,1) by the chi-square contingency table analysis.Conclusion: It seems to there is a difference in favour of OAGBP for conversion of complicated gastric bands. In this study we didn’t found statistic significance probably because of the short numbers. Prospective and more powerful studies are necessary to evaluate the benefit of the studied procedure.

Phototherapy in Childhood: a 17-Year Retrospective Study Regarding Effectiveness and Safety

Introduction: Skin diseases in paediatric age are often distressing conditions with significant impact in children’s psychosocial development. Additionally, systemic therapeutic options are often limited in childhood, due to its potential toxicity in this vulnerable group. Phototherapy is therefore an endorsed option for photo-responsive dermatological conditions. Objective and Methods:This observational retrospective study aims to access efficacy and safety of Phototherapy in our paediatric population. Relevant clinical data from 1996 to present concerning patients aged 18 years or less was collected. Results: 78 patients were included, of which64,1%was female. Mean age was 12,9 years (range 2-18). Distribution according to diagnosis was:47,4%psoriasis, 34,6% alopecia areata, 9,0% vitiligo, 9,0% other diagnosis. Mean number of cycles was 1,5 (range 1-7), with an average of 16,3 treatments per cycle and mean cumulative dose 134 J/cm2. 70,5% was treated with one single cycle. Topic and systemic PUVA were the first choice in 37,2% and 39,7%, respectively, while UVB TL01 and broadband UVB were used in 11,5% each. On the first cycle 67,5% improved, 14,3% showed no sustained clinical response and 19,5% were lost to follow-up. Psoriasis patients had the best response rates (81,8%), followed by alopecia areata (59,3%). Side effects occurred in 21%, being erythema the most common (12%). None led to therapeutic interruption. Discussion: Phototherapy is a safe and effective option in childhood, yet the withdraw rate might be an important limitation.

Perinatal Ischemic Stroke: a Five-Year Retrospective Study in a Level-III Maternity

Objective To study the incidence, clinical presentation, risk factors, imaging diagnosis, and clinical outcome of perinatal stroke. Methods Data was retrospectively collected from full-term newborns admitted to the neonatal unit of a level III maternity in Lisbon with cerebral stroke, from January 2007 to December 2011. Results There were 11 cases of stroke: nine were arterial ischemic stroke and two were cerebral venous sinus thrombosis. We estimated an incidence of arterial ischemic stroke of 1.6/5,000 births and of cerebral venous sinus thrombosis of 7.2/100,000 births. There were two cases of recurrent stroke. Eight patients presented with symptoms while the remaining three were asymptomatic and incidentally diagnosed. The most frequently registered symptoms (8/11) were seizures; in that, generalized clonic (3/8) and focal clonic (5/8). Strokes were more commonly left-sided (9/11), and the most affected artery was the left middle cerebral artery (8/11). Transfontanelle ultrasound was positive in most of the patients (10/11), and stroke was confirmed by cerebral magnetic resonance in all patients. Electroencephalographic recordings were carried out in five patients and were abnormal in three (focal abnormalities n=2, burst-suppression pattern n=1). Eight patients had previously identified risk factors for neonatal stroke which included obstetric and neonatal causes. Ten patients were followed up at outpatients setting; four patients developed motor deficits and one presented with epilepsy. Conclusions Although a modest and heterogeneous sample, this study emphasizes the need for a high level of suspicion when it comes to neonatal stroke, primarily in the presence of risk factors. The prevalence of neurological sequelae in our series supports the need of long-term follow-up and early intervention strategies.

Infections After Liver Transplantation: A Retrospective, Single-Center Study

Objective. To access the incidence of infectious problems after liver transplantation (LT). Design. A retrospective, single-center study. Materials and Methods. Patients undergoing LT from January 2008 to December 2011 were considered. Exclusion criterion was death occurring in the first 48 hours after LT. We determined the site of infection and the bacterial isolates and collected and compared recipient’s variables, graft variables, surgical data, post-LT clinical data. Results. Of the 492 patients who underwent LT and the 463 considered for this study, 190 (Group 1, 41%) developed at least 1 infection, with 298 infections detected. Of these, 189 microorganisms were isolated, 81 (51%) gram-positive bacteria (most frequently Staphylococcus spp). Biliary infections were more frequent (mean time of 160.4 167.7 days after LT); from 3 months after LT, gram-negative bacteria were observed (57%). Patients with infections after LT presented lower aminotransferase levels, but higher requirements in blood transfusions, intraoperative vasopressors, hemodialysis, and hospital stay. Operative and cold ischemia times were similar. Conclusion. We found a 41% incidence of all infections in a 2-year follow-up after LT. Gram-positive bacteria were more frequent isolated; however, negative bacteria were commonly isolated later. Clinical data after LT were more relevant for the development of infections. Donors’ variables should be considered in future analyses.

Cirurgia do Timo num Serviço de Cirurgia Geral

AIMS: Evaluation of thymectomy cases between 1990-2003, in a General Surgery Department. Evaluation of the therapeutic efficacy in Miastenia Gravis patients. PATIENTS AND METHODS: Retrospective study based on evaluation of data from Serviço de Cirurgia, Neurologia and Consult de Neurology processes, between 1990-2003, of 15 patients submitted to total thymectomy. RESULTS: 15 patients, aged 17 to 72, 11 female and 4 male. Miastenia Gravis was the main indication for surgery, for uncontrollable symptoms or suspicion of thymoma. In patients with myasthenia, surgery was accomplish after compensation of symptoms. There weren't post-surgery complications. Pathology were divided in thymic hyperplasia and thymoma. Miastenia patients have there symptoms diminished or stable with reduction or cessation of medical therapy. CONCLUSIONS: Miastenia was the most frequent indication for thymectomy. Surgery was good results, with low morbimortality, as long as the protocols are respected.

Coarctação Isolada da Aorta: Experiência em 100 Doentes Consecutivos

INTRODUCTION: Coarctation of the aorta (CoA) is a stenosis usually located in the descending aorta. Treatment consists of surgical or percutaneous removal of the obstruction and presents excellent immediate results but significant residual problems often persist. OBJECTIVES: To describe the presentation, treatment and long-term evolution of a population of 100 unselected consecutive patients with isolated CoA in a single pediatric cardiology center. METHODS: This was a retrospective study of all patients with isolated CoA treated during4 the last 21 years (1987-2008). RESULTS: The patients (n=100, 68.3% male) were diagnosed at a median age of 94 days (1 day to 16 years). The clinical presentation differed between patients aged less or more than one year, the former presenting with heart failure and the latter being asymptomatic with evidence of hypertension (88 and 63%, respectively; p < 0.01). Treatment, a median of 8 days after diagnosis, was surgical in 79 cases (20 end-to-end anastomosis, 31 subclavian flap, 28 patch) and percutaneous in the remaining 21 (15 balloon angioplasty, 6 with stenting). The mean age of surgical patients was younger than in those treated percutaneously (3.4 vs. 7.5 years; p < 0.01). Immediate mortality was 2% and occurred in the surgical group. There was no late mortality, in a mean follow-up of 7.2 +/- 5.4 years. Recoarctation occurred in 8 patients (6 surgical, 2 percutaneous). There are 46 patients who currently have hypertension (19 at rest, 27 with effort), their median age at diagnosis being older than the others (23 vs. 995 days; p < 0.01). CONCLUSIONS: Isolated CoA has an excellent short-term prognosis but a significant incidence of long-term complications, and should thus no longer be seen as a simple obstruction in the descending aorta, but rather as a complex pathology that requires careful follow-up after treatment. Its potentially insidious presentation requires a high level of clinical suspicion, femoral pulse palpation during physical examination of newborns and older children being particularly important. Delay in treatment has an impact on late morbidity and mortality. Taking into account the data currently available on late and immediate results, the final choice of therapeutic technique depends on the patient's age, associated lesions and the experience of the medical-surgical team. Hypertension should be closely monitored in the follow-up of these patients, as well as its risk factors and complications.

Lupus and Pregnancy. 15 Years of Experience in a Tertiary Center

This retrospective study was designed to evaluate the outcome of pregnancies in women diagnosed with systemic lupus erythematosus (SLE) followed in a tertiary fetal–maternal center. Data were collected from clinical charts between January 1993 and December 2007, with a total of 136 pregnancies (107 patients). Mean maternal age was 29 years, with the vast majority of patients being Caucasian. Most patients were in remission 6 months prior to pregnancy (93%) and the most frequently affected organs were the skin and joints. Renal lupus accounted for 14% of all cases. Twenty-nine percent of patients were positive for at least one antiphospholid antibody (aPL) and nearly 50% had positive SSa/SSb antibodies. All patients with positive aPL received low-dosage aspirin and low molecular- weight heparin (LMWH). There were no pregnancy complications in more than 50% of cases and hypertensive disease and intrauterine growth restriction were the most common adverse events. There were 125 live births, one neonatal death, eight miscarriages, and three medical terminations of pregnancy. Preterm delivery occurred in 25% of pregnancies. Our results are probably the conjoined result of a multidisciplinary approach together with a systematic management of SLE pregnancies, with most patients keeping their prior SLE medication combined with low-dosage aspirin and LMWH in the presence of aPL.

Factores Preditivos de Depressão Pós-Acidente Vascular Cerebral. Estudo Retrospectivo numa Unidade de Reabilitação

INTRODUÇÃO/OBJECTIVOS: O Acidente Vascular Cerebral (AVC) pode limitar de forma importante a funcionalidade. As complicações psiquiátricas têm sido identificadas como factores determinantes na reabilitação pós-AVC, sendo a Depressão a complicação psiquiátrica mais frequente e a que está associada a pior prognóstico. Subsiste ainda incerteza quanto à sua etiologia e factores de risco. Na revisão sistemática mais recente, reconhecem-se como factores preditivos a gravidade do AVC, o grau de incapacidade do doente e o défice cognitivo. Questões metodológicas impediram a determinação de outros factores. Assim, urge definir novos factores que facilitem um diagnóstico atempado, que possa diminuir os efeitos negativos sobre o processo de reabilitação. Objectivos: determinação da incidência da Depressão de novo pós-AVC (DPA) e o estudo das variáveis descritas na literatura como possíveis factores preditivos de DPA: sexo, idade, tipo de AVC, lateralidade, território vascular e presença de afasia. Foi definido como endpoint secundário o estudo do tipo de afasia. MATERIAIS E MÉTODOS: Estudo longitudinal retrospectivo, envolvendo todos os doentes admitidos no internamento de um Serviço de MFR com o diagnóstico de AVC de novo, entre 1-1-2009 e 31-12-2009. Foram colhidos elementos demográficos e clínicos dos processos clínicos, num total de 74 doentes. Critérios de exclusão: ‘AVC prévio’, ‘Doença psiquiátrica com perturbação do humor prévia’ e ‘Medicação antidepressiva à data do AVC’. Para o tratamento estatístico usou-se o SPSS 11.5. RESULTADOS: A incidência da DPA observada foi de 44,6%. Dos possíveis factores preditivos testados, apenas a presença de afasia apresentou uma relação estatisticamente significativa com a depressão (p=0.02). Não se encontrou relação com o tipo de afasia. Os restantes factores preditivos testados não mostraram correlação estatística significativa. Parece existir uma relação entre o sexo masculino e a DPA (p=0.07), que não atingiu significância no tamanho da amostra conseguido (n). CONCLUSÕES: Este estudo estabelece a afasia como factor preditivo da DPA. A elevada incidência de DPA nesta população particular concorda com os estudos existentes, sendo necessário outro tipo de estudo que permita justificar o valor encontrado. São necessários mais estudos não só para aumentar o conhecimento dos factores de risco para a DPA, como para melhorar os resultados dos programas de reabilitação.

Clinical Outcome and Morphologic Analysis after Endovascular Aneurysm Repair Using the Excluder Endograft

OBJECTIVE: Long-term follow-up after endovascular aneurysm repair (EVAR) is very scarce, and doubt remains regarding the durability of these procedures. We designed a retrospective cohort study to assess long-term clinical outcome and morphologic changes in patients with abdominal aortic aneurysms (AAAs) treated by EVAR using the Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz). METHODS: From 2000 to 2007, 179 patients underwent EVAR in a tertiary institution. Clinical data were retrieved from a prospective database. All patients treated with the Excluder endoprosthesis were included. Computed tomography angiography (CTA) scans were retrospectively analyzed preoperatively, at 30 days, and at the last follow-up using dedicated tridimensional reconstruction software. For patients with complications, all remaining CTAs were also analyzed. The primary end point was clinical success. Secondary end points were freedom from reintervention, sac growth, types I and III endoleak, migration, conversion to open repair, and AAA-related death or rupture. Neck dilatation, renal function, and overall survival were also analyzed. RESULTS: Included were 144 patients (88.2% men; mean age, 71.6 years). Aneurysms were ruptured in 4.9%. American Society of Anesthesiologists classification was III/IV in 61.8%. No patients were lost during a median follow-up of 5.0 years (interquartile range, 3.1-6.4; maximum, 11.2 years). Two patients died of medical complications ≤ 30 days after EVAR. The estimated primary clinical success rates at 5 and 10 years were 63.5% and 41.1%, and secondary clinical success rates were 78.3% and 58.3%, respectively. Sac growth was observed in 37 of 142 patients (26.1%). Cox regression showed type I endoleak during follow-up (hazard ratio, 3.74; P = .008), original design model (hazard ratio, 3.85; P = .001), and preoperative neck diameter (1.27 per mm increase, P = .006) were determinants of sac growth. Secondary interventions were required in 32 patients (22.5%). The estimated 10-year rate of AAA-related death or rupture was 2.1%. Overall life expectancy after AAA repair was 6.8 years. CONCLUSIONS: EVAR using the Excluder endoprosthesis provides a safe and lasting treatment for AAA, despite the need for maintained surveillance and secondary interventions. At up to 11 years, the risk of AAA-related death or postimplantation rupture is remarkably low. The incidences of postimplantation sac growth and secondary intervention were greatly reduced after the introduction of the low-permeability design in 2004.

Results of Endovascular Procedures Performed in Dysfunctional Arteriovenous Accesses for Haemodialysis

Aim. Percutaneous endovascular procedures have become the standard treatment of arteriovenous fistulae and graft stenosis. This study evaluates the immediate results of angiographic procedures performed by nephrologists in patients with dysfunctional arteriovenous fistulae and arteriovenous graft stenosis. Patients and Methods. A retrospective analysis was performed on patients referred to the three Interventional Nephrology units between April and June, 2010. Clinical data were recorded. Results. A total of 113 procedures were performed: 59 in arteriovenous fistulae and 54 in arteriovenous graft stenosis. The main reasons for referral were increased venous pressure (21%), limb oedema (21%) and decreased intra-access flow (20%). Stenoses were detected in 85% of the procedures, mostly in patients with arteriovenous graft stenosis (56%). The main locations of stenosis were the outflow vein (cephalic/basilic) in arteriovenous fistulae (34%) and venous anastomosis in arteriovenous graft stenosis(48%). Angioplasty was performed in 73% of procedures where stenoses were detected. The immediate success rate was 91% for arteriovenous fistulae and 83% for arteriovenous graft stenosis. Partial success was obtained in 11% of angiographies. The complication rate was 7%. Conclusions. Physical examination findings led, in at least half the cases, to angiography referral and enabled the diagnosis and treatment of stenoses. For this reason, we advocate that this tool should be included in any vascular access monitoring programme. Our results support the safety of these procedures performed by nephrologists and their efficacy in the recovery of dysfunctional arteriovenous fistulae and arteriovenous graft stenosis.

Tranexamic Acid for Major Spinal Surgery in Children. A Retrospective Study

Introduction: Paediatric patients who undergo posterior spinal fusion surgery to correct scoliosis often require multiple blood transfusions. Tranexamic acid is a synthetic antifibrinolytic drug that reduces transfusion requirements in scoliosis surgery (1),(2),(3). Methods: To evaluate the efficacy of prophylactic tranexamic acid (TA) (initial dose of 10mg/kg and infusion of 1mg.kg(-1).h(-1)) in reducing perioperative blood transfusion requirements, we reviewed patients files and compared the amount of blood lost and blood transfused in the perioperative period of 12 patients (54.5%) that received TA and 10 patients (45.5%) who did not received TA. T-Student test was applied. Results: The average difference of blood losses (2,67 +/- 6,06ml) and blood transfused (212,9 +/- 101,1ml) between the two groups was not statistically significant (p>0.05). No thrombotic complications were detected in either group. Discussion: Results of the current study showed that prophylactic low dose of TA did not have a significant effect in the management of intraoperative blood loss and transfusion requirements in children undergoing scoliosis surgery. It is important to emphasize that our study is retrospective and that the size of the sample is small. Further studies are needed to evaluate the efficacy and safety of TA on paediatric scoliosis surgery.

Achieving K/DOQI Targets with Cinacalcet in Dialysis Patients with Secondary Hyperparathyroidism. A Portuguese Observational Study

Secondary hyperparathyroidism is a common complication of chronic kidney disease. The elevated serum intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product have been independently associated with an increased relative risk of mortality. The standard therapy for secondary hyperparathyroidism, including active vitamin D analogues and phosphate binders, is often insufficient to allow patients to achieve the recommended Kidney Disease Outcomes Quality Initiative targets for bone and mineral metabolism. Randomised controlled phase III clinical studies in chronic kidney disease patients with secondary hyperparathyroidism have shown that cinacalcet treatment increases the proportion of patients achieving the recommended Kidney Disease Outcomes Quality Initiative targets for intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product. Aims: This observational multicentre study aims to evaluate cinacalcet’s ability to achieve and maintain Kidney Disease Outcomes Quality Initiative targets in a population with secondary hyperparathyroidism on chronic haemodialysis in Portugal. Patients and Methods: Patients on chronic dialysis that received cinacalcet during a free sampling programme were enrolled. Retrospective and prospective monthly data were collected from 3 months before until 6 months after the beginning of cinacalcet treatment. Additional assessment included a 12 month evaluation of all parameters. Results: 140 dialysis patients with secondary hyperparathyroidism were enrolled, 60% male, mean age 57.4±14.1 years. The mean intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product values at baseline were 751.7±498.8 pg/ml, 9.7±3.8 mg/dl, 5.5±1.5 mg/dl, and 52.7±25.3 mg2/dl2, respectively. After 6 months’ cinacalcet treatment, 26.2%, 53.6%, 59.3%, and 81.0% of the patients achieved the Kidney Disease Outcomes Quality Initiative recommended levels for intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product, respectively. The mean dose of cinacalcet at 6 months was 57.1±29.7 mg/day. Conclusions: The use of cinacalcet in clinical practice is an effective option for the treatment of secondary hyperparathyroidism in chronic dialysis patients, allowing more patients to reach and maintain the Kidney Disease Outcomes Quality Initiative targets.

Diabetes Mellitus and Renal Disease: When to Perform a Renal Biopsy?

Background: Several studies suggest that nondiabetic renal disease (NDRD) is common in patients with diabetes mellitus. The aim of this analysis of renal biopsies in diabetic patients was (a) to assess the prevalence and type of NDRD and (b) to identify its clinical and laboratory predictors. Methods: This retrospective study analysed clinical and laboratory data and biopsy findings in diabetic patients observed by a single pathologist over the past 25 years. Based on biopsy findings, patients were categorised as (i) isolated diabetic nephropathy,(ii) isolated NDRD and (iii) NDRD superimposed on diabetic nephropathy. Results: Of the 236 patients studied, 60% were male and the mean age was 56.3 (±14.2) years. Of these, 91% had known diabetes mellitus at the time of biopsy (13% type 1 and 87% type 2). Isolated diabetic nephropathy was found in 125 (53%), isolated NDRD in 89 (38%) and NDRD superimposed on diabetic nephropathy in 22 (9%) patients. The main indication for biopsy in the three groups was nephrotic proteinuria. Patients with isolated NDRD and NDRD superimposed on diabetic nephropathy presented acute deterioration of renal function more frequently (p<0.001) and had more microhaematuria(p<0.001) as indications for renal biopsy. Focal segmental glomerulosclerosis and membranous nephropathy were the most frequent diagnoses in patients with NDRD. Patients with isolated diabetic nephropathy were younger (p=0.02), presented a longer duration of diabetes mellitus (p<0.001) and had more frequent retinopathy (p<0.001). The prevalence of microhaematuria was higher in patients with isolated or superimposed NDRD (p=0.01). Conclusion: The prevalence of NDRD (either isolated or superimposed on diabetes mellitus) is remarkably frequent in diabetic patients in whom nephrologists consider renal biopsy an appropriate measure. Predictors of NDRD were older age, shorter duration of diabetes mellitus, absence of retinopathy and presence of microhaematuria.

Transoesophageal Echocardiography for Monitoring Liver Surgery: Data from a Pilot Study

A pilot study aimed to introduce intraoperative monitoring of liver surgery using transoesophageal echocardiography (TEE) is described. A set of TEE measurements was established as a protocol, consisting of left atrial (LA) dimension at the aortic valve plane; mitral velocity flow integral, calculation of stroke volume and cardiac output (CO); mitral annular plane systolic excursion; finally, right atrial area. A total of 165 measurements (on 21 patients) were performed, 31 occurring during hypotension. The conclusions reached were during acute blood loss LA dimension changed earlier than CVP, and, in one patient, a dynamic left ventricular (LV) obstruction was observed; in 3 patients a transient LV systolic dysfunction was documented. The comparison between 39 CO paired measurements obtained by TEE and PiCCO2 revealed a statistically significant correlation (P < 0.001, r = 0.83). In this pilot study TEE successfully answered the questions raised by the anesthesiologists. Larger cohort studies are needed to address this issue.