An unusual cause of acute cardiogenic shock in the operating room

A 51-year-old man with a renal carcinoma with inferior vena cava (IVC) invasion was referred to our hospital for the performance of a radical nephrectomy with IVC thrombus excision. To prevent embolism, an IVC filter was implanted the day before surgery below the suprahepatic veins. On nephrectomy completion, the clinical status of the patient started to deteriorate and an unsuccessful attempt was made to excise the IVC thrombus. The patient developed profound refractory hypotension without significant bleeding and worsening splanchnic stasis was noted. A transesophageal echocardiogram was immediately performed in the operating room, revealing a hemispheric mass protruding from the IVC ostium to the right atrium, completely blocking all venous return. Volume depletion was evident by low left and right atrial volumes and increased septum mobility. No other abnormalities were found that could explain the shock, namely ventricular dysfunction or valvular disease. Cardiac surgery consultation was immediately obtained, ultimately deciding to perform a median sternotomy with direct exploration of right atrium. Under cardiopulmonary bypass, a 6-cm long thrombotic mass was identified, involving the IVC filter, blocking all lower body venous return; the removal of the mass reversed the shock. The patient had an uneventful recovery. Adverse outcomes associated with IVC filters are common. Our case highlights the importance of a team approach to rapid changes in hemodynamic status in the operating room, including the surgeon, the anesthesiologist, and the cardiologist. It also emphasizes the pivotal role of transesophageal echocardiogram in the clinical evaluation of severely unstable patien

Some Inequalities in 2-inner Product Spaces

In this paper we extend some results on the refinement of Cauchy-Buniakowski-Schwarz's inequality and Aćzel's inequality in inner product spaces to 2-inner product spaces

On Some Grüss Type Inequality in 2-Inner Product Spaces and Applications

In this paper, we shall give a generalization of the Grüss type inequality and obtain some applications of the Grüss type inequality in terms of 2-inner product spaces

Some Boas-Bellman Type Inequalities in 2-Inner Product Spaces

Some inequalities in 2-inner product spaces generalizing Bessel's result that are similar to the Boas-Bellman inequality from inner product spaces, are given. Applications for determinantal integral inequalities are also provided

A Consistent Orbital Stability Analysis for the GJ 581 System

We apply a combination of N-body modeling techniques and automated data fitting with Monte Carlo Markov Chain uncertainty analysis of Keplerian orbital models to radial velocity data to determine long term stability of the planetary system GJ 581. We find that while there are stability concerns with the 4-planet model as published by Forveille et al. (2011), when uncertainties in the system are accounted for, particularly stellar jitter, the hypothesis that the 4-planet model is gravitationally unstable is not statistically significant. Additionally, the system including proposed planet g by Vogt et al. (2012) also shows some stability concerns when eccentricities are allowed to float in the orbital fit, yet when uncertainties are included in the analysis the system including planet g also can not be proven to be unstable. We present revised reduced chi-squared values for Keplerian astrocentric orbital fits assuming 4-planet and 5-planet models for GJ~581 under the condition that best fits must be stable, and find no distinguishable difference by including planet g in the model. Additionally we present revised orbital element estimates for each assuming uncertainties due to stellar jitter under the constraint of the system being gravitationally stable.Comment: 26 pages, 8 figures, 6 tables, accepted for publication in the Astrophysical Journa