Journal of Cardiothoracic and Vascular Anesthesia

Masthead

2012-02-01

Editorial Board

2012-02-01

Articles to Appear in Future Issues

2012-02-01

Guide for Authors

2012-02-01

Hands-on…Handoff

Ala Haddadin, Hossam Tantawy, Paul G. Barash — 2012-02-01

ALL CARDIAC ANESTHESIOLOGISTS have been confronted by suboptimal intensive care unit (ICU) patient handoffs. Simply put, handoffs are a risky business. The protocols involved in this area have been identified as one of the weakest links in patient management. The often-cited Institute of Medicine report Crossing the Quality Chasm asserts that patient handoffs provide opportunity for error. The report notes, “In a safe environment, information is not lost, inaccessible, or forgotten in transitions.” Improved system design can enhance the ability of providers to (1) communicate more effectively, (2) create efficient means of transferring monitors, and (3) reduce the total number of steps in the process.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2011

2012-02-01

There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.

Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs

2011-09-05

Objectives: Perioperative handoffs are a particularly high-risk period given patients' postprocedural physiology, their physical transport through the hospital, and the triad transfer of personnel, information, and technology. The authors piloted a new perioperative handoff process to guide patient transfers from the cardiac operating room (OR) to the cardiac surgical intensive care unit (CSICU). The aim of the study was to evaluate the impact of a standardized handoff process on patient care and provider satisfaction. Design: A prospective, unblinded intervention study. Setting: A CSICU in a teaching hospital. Participants: Two hundred thirty-eight health care practitioners during the transfer of care of 60 patients. Interventions: The implementation of a standardized handoff protocol and checklist. Measurements and Main Results: After the protocol's implementation, the presence of all handoff core team members at the bedside increased from 0% at baseline to 68% after intervention. The percentage of missed information in the surgery report decreased from 26% to 16% (p = 0.03), but the percentage of missed information in the anesthesia report showed no significant change (19% to 17%, p > 0.05). Handoff satisfaction scores among intensive care unit (ICU) nurses increased from 61% to 81%. On average, the duration of handoff increased by 1 minute. Conclusions: A standardized handoff protocol that guides the transfer of care from the OR team to the CSICU team can reduce the risk of missed information and improve satisfaction among perioperative providers.

A Comparative Evaluation of Transesophageal and Transthoracic Echocardiography for Measurement of Left Ventricular Systolic Strain Using Speckle Tracking

2011-08-12

Objective: The authors hypothesized that the measurement of strain by speckle tracking with transesophageal echocardiography (TEE) is feasible and comparable to transthoracic echocardiography (TTE). Design: A prospective observational comparative study. Setting: A university hospital. Participants: Adult patients undergoing elective cardiac surgery. Interventions: Structured intraoperative TTE and TEE examination. Measurements and Main Results: Images were obtained after the induction of anesthesia from 25 patients to enable speckle tracking of the left ventricle in comparable short- and long-axis (SAX and LAX) views using TTE and TEE. Left ventricular strain was measured offline using both modalities and correlation assessed using the Pearson test with assessment of bias using the Bland-Altman method. Significantly more segments were tracked by TEE than TTE in LAX views but not SAX views. Correlation was moderate between TTE and TEE (r = 0.5-0.6) for longitudinal strain in the LAX views, whereas it was poor for regional radial strain (r = 0.07). Correlation for global circumferential strain was higher for the apical SAX views (r = 0.7) than the basal or mid- SAX views. Speckle tracking by TEE showed excellent reproducibility with small bias. Conclusions: Strain measured by speckle tracking in TEE correlated moderately with TTE for global strain and poorly for regional strain. This may be explained by differences in scanning frequency and other imaging factors. Nevertheless, because of the high degree of reproducibility, it may be a useful tool to quantify intraoperative changes in ventricular function with TEE. However, equivalence between TTE and TEE cannot be assumed, and limits of comparability should be recognized.

Comparison of Transthoracic and Transesophageal 2-Dimensional Speckle Tracking Echocardiography

2011-08-12

Objectives: Two-dimensional (2D) strain imaging has been established as a reliable and reproducible technique for the assessment of left and right ventricular function using transthoracic echocardiography (TTE). However, the reproducibility of transesophageal echocardiographic (TEE) 2D strain imaging and the agreement with TTE 2D strain imaging remains unclear. In the present study, the authors studied the reproducibility of TEE 2D strain imaging parameters. Design: A comparative, observational clinical study. Setting: The echocardiography laboratory of the tertiary referral center. Participants: Healthy individuals with a suspected patent foramen ovale. Interventions: None. Measurements and Main Results: Thirty-four patients were included in the study. None of the patients had any structural cardiovascular disease. TTE and TEE images of the subjects were recorded and analyzed offline (EchoPAC 6.1; GE Vingmed Ultrasound AS, Horten, Norway). Longitudinal strain and strain rate measurements of the 4 chambers, the apical long axis, 2 chambers, and the right ventricle were obtained for each record of TTE and TEE. The mean age of the patients in this study was 36 ± 9.2 years. Bland-Altman analysis showed that there were generally good agreements between strain and strain rate measurements on TEE and TTE. The inter- and intraobserver agreement for TEE parameters was good. Conclusions: Transesophageal 2D strain imaging is a reproducible method to measure ventricular function and has a good agreement with TTE 2D strain imaging.

Evaluation of Tricuspid and Pulmonary Valves Using Epicardial and Transesophageal Echocardiography—A Comparative Study

2011-09-05

Objective: To compare measurements obtained by transesophageal echocardiography (TEE) and epicardial echocardiography (EE) for evaluation of the tricuspid valve (TV) and pulmonary valve (PV). Design: Prospective observational. Setting: University hospital. Participants: Patients undergoing elective coronary artery bypass grafting with or without aortic valve replacement. Interventions: After routine intraoperative TEE, EE was performed to compare measurements obtained by the 2 methods. Measurements and main results: After institutional review board approval, 25 patients >18 years old were recruited. Biases with EE versus TEE for E and A waves were 11.9 cm/second (95% confidence interval [CI], 48.2 to −24.4) and 6.8 cm/second (95% CI, 28 to −15), respectively, and for E/A ratio was 0.08 (95% CI, 1.2 to −1). Pulmonary velocity bias was 57.94 cm/second (95% CI, 192.9 to −76.98), with higher values using EE. Bias for pulmonary trunk diameter was −0.31 cm (95% CI, 1.5 to −2.1). For quality of images, means were 2.4 (standard deviation [SD], 1.0) for EE and 2.3 (SD, 0.57) with TEE for TV and 2.4 (SD, 1.0) with EE and 2.5 (SD, 1.0) with TEE for PV. For the number of leaflets visualized, means were 2.2 (SD, 1.0) with EE and 2.5 (SD, 0.5) with TEE for TV and 2.5 (SD, 0.5) for EE and 1.3 (SD, 1.1) with TEE for PV. Conclusions: There was good agreement for Doppler measurements across TVs; however, measurements across PVs were significantly higher with EE versus TEE. TV Doppler measurements were difficult to acquire even for surgeons experienced in epiaortic scanning.

Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Pediatric Patients Undergoing Cardiac Surgery

Da Zhu, Hai Yu, Yin Zhou, Qian Li, Long Zhao, Li-Qing Peng, Bin Liu — 2011-08-25

Objective: To evaluate the feasibility of measuring renal blood flow (RBF) using transesophageal echocardiography (TEE) in pediatric patients undergoing cardiac surgery. Design: A prospective noninterventional study. Setting: A university hospital. Participants: Twenty-three pediatric patients who underwent surgical repair for complex congenital heart defects were included in this study. Intervention: None. Measurements and Main Results: The authors evaluated the accuracy of using TEE to visualize the left renal artery by comparing TEE images with preoperative computed tomography angiographic images. RBF was measured during the cardiopulmonary bypass (CPB) period. TEE images and Doppler studies from all subjects were interpreted by 2 blinded independent assessors. Inter- and intraobserver reproducibility was quantified by calculating the variability and intraclass correlation coefficients. Linear regression models were used to further investigate the relationship between volumetric RBF and CPB perfusion rate. The left renal artery was indentified successfully in 96% of the study population, with a mean Doppler angle of 19.5° ± 6.7° (all of them <30°). Both inter- and intraobserver variability was <10%. Inter- and intraobserver reproducibility in the RBF measurements were excellent. The volumetric RBF showed a linear relationship with the CPB perfusion rate (r = 0.881, p < 0.001) and the mean artery pressure (r = 0.457, p = 0.032). Conclusion: For 96% of pediatric patients undergoing cardiac surgery, it is feasible to measure RBF using intraoperative TEE during CPB. Volumetric RBF was related to the perfusion rate and the mean artery pressure during CPB.

Increased Chest Tube Drainage Is Independently Associated With Adverse Outcome After Cardiac Surgery

Michael C. Christensen, Frank Dziewior, Angela Kempel, Christian von Heymann — 2011-11-21

Objective: To investigate the clinical relevance of specific volume criteria for hemorrhage in a patient population undergoing cardiac surgery with cardiopulmonary bypass (CPB). Design: A retrospective analysis; postoperative hemorrhage was defined by a fixed set of criteria ≥200 mL/h in any 1 hour or part thereof, or (2) ≥2 mL/kg/h for 2 consecutive hours in the first 6 hours after surgery. Classification and regression tree (CART) analysis were used to validate the results of the specific volume criteria. Multivariate regression analysis was applied to investigate the association of specific volume criteria for hemorrhage with clinical outcomes. Setting: A university hospital. Participants: All adult cardiac surgery patients undergoing surgery with CPB at the authors' center in 2006. Interventions: None. Measurements and Main Results: A total of 1,188 patients underwent cardiac surgery, and 76 patients (6.4%) experienced postoperative hemorrhage according to the fixed criteria for blood loss. Blood loss as measured by these criteria was associated with a higher 30-day mortality (odds ratio [OR] = 2.9, p < 0.001), incidence of stroke (OR = 3.3, p = 0.0033), re-exploration (OR = 103.655, p < 0.0001), intensive care unit stay >72 hours (OR = 1.3, p < 0.0001), and mechanical ventilation >24 hours (OR = 3.4, p = 0.0002). The clinical relevance of these criteria is supported by CART analysis. Conclusions: Postoperative hemorrhage (drainage loss) exceeding 200 mL/h in 1 hour or 2 mL/kg for 2 consecutive hours occurring within 6 hours after cardiac surgery is associated with higher 30-day mortality and other postoperative complications. Further research is needed to validate these results.

Combined Central Venous Oxygen Saturation and Lactate as Markers of Occult Hypoperfusion and Outcome Following Cardiac Surgery

BeeBee Y. Hu, Greg A. Laine, Suwei Wang, R. Thomas Solis — 2011-09-16

Objective: To assess the association between postoperative central venous oxygen saturation (ScvO2) and arterial lactate with outcome after cardiac surgery. Design: Prospective observational study. Setting: University-affiliated tertiary care hospital. Participants: Patients after coronary artery bypass and/or valve surgery. Interventions: None. Measurements and Main Results: Postoperative ScvO2 and arterial lactate were obtained on arrival to the intensive care unit (ICU). ScvO2 and lactate were drawn again at 8 and 24 hours, respectively, after ICU admission. Moderate global tissue hypoxia (GTH) was defined as ScvO2 <70% and lactate ≥2 to <4 mmol/L, and severe GTH was defined as ScvO2 <70% and lactate ≥4 mmol/L. Occult hypoperfusion was defined as moderate-to-severe GTH with mean arterial pressure ≥65 mmHg, central venous pressure ≥8 mmHg, and urine output ≥0.5 mL/kg/h. ScvO2 on ICU admission negatively correlated with postoperative 24-hour lactate (p = 0.009), which was a strong predictor of time on mechanical ventilation, total complications, and ICU and hospital lengths of stay (p < 0.001 for all comparisons). On admission to the ICU, 19 patients (32%) exhibited occult hypoperfusion. Patients with severe GTH (n = 8) had longer ICU lengths of stay (p = 0.04) and a trend toward longer length of mechanical ventilation (p = 0.17) and number of complications per patient (p = 0.09) compared with those without GTH (n = 10). Conclusions: The incidence of GTH is high after cardiac surgery. Postoperative ScvO2 and lactate may be valuable measurements to identify patients with occult hypoperfusion and subsequently guide hemodynamic optimization to positively affect postoperative outcomes in patients after cardiac surgery.

β-Blockers to Optimize Peripheral Oxygenation During Extracorporeal Membrane Oxygenation: A Case Series

2011-07-18

Objectives: Veno-venous extracorporeal membrane oxygenation (ECMO) is a well-established therapy in patients affected by respiratory failure and unresponsive to conventional therapy. Despite technical innovations, some limitations still exist, the most important one being refractory hypoxemia. This problem is linked partially to the mixture between patients' blood and ECMO fully oxygenated blood. In the present work, the reduction of cardiac output was proposed for the treatment of refractory hypoxemia in patients with high-flow ECMO and high endogenous cardiac output. Design: An observational study. Setting: A university hospital. Participants: Three consecutive patients suffering from persisting severe hypoxemia despite high-flow ECMO and with concomitant high cardiac output (>7 L/min). Intervention: A bolus dose of 500 μg/kg and a continuous infusion of esmolol was used and titrated to an SpO2 >92%. Measurements and Main Results: Esmolol administration was safe and highly beneficial in terms of peripheral oxygenation. PaO2 increased from 54 to 90 mmHg, from 50 to 94 mmHg, and from 49 to 66 mmHg during the first 12 hours of esmolol treatment in the 3 patients. Conclusions: In selected septic, tachycardic patients with a high cardiac output, veno-venous ECMO, led to improvement of peripheral oxygenation with the addition of a short-acting β-blocker infusion.

Association Between Postoperative Acute Kidney Injury and Duration of Cardiopulmonary Bypass: A Meta-Analysis

Avinash B. Kumar, Manish Suneja, Emine O. Bayman, Garry D. Weide, Michele Tarasi — 2011-09-16

Objective: This meta-analysis examined the association between cardiopulmonary bypass (CPB) time and acute kidney injury (AKI). Design: Meta-analysis of previously published studies. Setting: Each single-center study was conducted in a surgical intensive care unit and/or academic or university hospital. Participants: Adult patients undergoing heart surgery with CPB. Interventions: A systematic literature review was conducted using PubMed, EMBASE, and Cochrane Library databases and Google Scholar from January 1980 through September 2009. Initial search results were refined to include human subjects, age >18 years, randomized controlled trials, and prospective and retrospective cohort studies, meet the Acute Kidney Injury Network definition of renal failure, and report times on CPB. Measurements and main results: The length of time on CPB has been implicated as an independent risk factor for development of AKI after CPB (AKI-CPB). The 9 independent studies included in the final meta-analysis had 12,466 patients who underwent CPB. Out of these, 756 patients (6.06%) developed AKI-CPB. In 7 of the 9 studies, the mean CPB times were statistically longer in the AKI-CPB cohort compared with the control group (cohort without AKI). The absolute mean differences in CPB time between the 2 groups were 25.65 minutes with the fixed-effects model and 23.18 minutes with the random-effects model. Conclusions: Longer CPB times are associated with a higher risk of developing AKI-CPB, which, in turn, has a significant effect on overall mortality as reported by the individual studies.

Milrinone and Mortality in Adult Cardiac Surgery: A Meta-analysis

2011-09-26

Objective: The authors conducted a review of randomized studies to show whether there are any increases or decreases in survival when using milrinone in patients undergoing cardiac surgery. Design: A meta-analysis. Setting: Hospitals. Participants: Five hundred eighteen patients from 13 randomized trials. Interventions: None. Measurements and Main Results: BioMedCentral, PubMed EMBASE, the Cochrane central register of clinical trials, and conference proceedings were searched for randomized trials that compared milrinone versus placebo or any other control in the setting of cardiac surgery that reported data on mortality. Overall analysis showed that milrinone increased perioperative mortality (13/249 [5.2%] in the milrinone group v 6/269 [2.2%] in the control arm, odds ratio [OR] = 2.67 [1.05-6.79], p for effect = 0.04, p for heterogeneity = 0.23, I2 = 25% with 518 patients and 13 studies included). Subanalyses confirmed increased mortality with milrinone (9/84 deaths [10.7%] v 3/105 deaths [2.9%] with other drugs as control, OR = 4.19 [1.27-13.84], p = 0.02) with 189 patients and 5 studies included) but did not confirm a difference in mortality (4/165 [2.4%] in the milrinone group v 3/164 [1.8%] with placebo or nothing as control, OR = 1.27 [0.28-5.84], p = 0.76 with 329 patients and 8 studies included). Conclusions: This analysis suggests that milrinone might increase mortality in adult patients undergoing cardiac surgery. The effect was seen only in patients having an active inotropic drug for comparison and not in the placebo subgroup. Therefore, the question remains whether milrinone increased mortality or if the control inotropic drugs were more protective.

Thoracic Epidural or Paravertebral Catheter for Analgesia After Lung Resection: Is the Outcome Different?

Hany Elsayed, James McKevith, James McShane, Nigel Scawn — 2011-11-17

Objective: The aim of this study was to determine whether thoracic epidural analgesia (TEA) or a paravertebral catheter block (PVB) with morphine patient-controlled analgesia influenced outcome in patients undergoing thoracotomy for lung resection. Design: A retrospective analysis. Setting: A tertiary referral center. Participants: The study population consisted of 1,592 patients who had undergone thoracotomy for lung resection between May 2000 and April 2008. Interventions: Not applicable. Measurements and Main Results: Patients who received PVBs were younger, had a higher forced expiratory volume in 1 second, had a higher body mass index, a higher incidence of cardiac comorbidity, fewer pneumonectomies, and more wedge resections. A multivariable logistic regression model was used to develop a propensity-matched score for the probability of patients receiving an epidural or a paravertebral catheter. Four patients with an epidural to one with a paravertebral catheter were matched, with 488 patients and 122 patients, respectively. Postmatching analysis now showed no difference between the groups for preoperative characteristics or operative extent. Postmatching analysis showed no significant difference in outcome between the two groups for the incidence of postoperative respiratory complication (p = 0.67), intensive therapy unit (ITU) stay (p = 0.51), ITU readmission (p = 0.66), or in-hospital mortality (p = 0.67). There was a significant reduction in the hospital length of stay in favor of the paravertebral group (6 v 7 days, p = 0.008). Conclusions: Paravertebral catheter analgesia with morphine patient-controlled analgesia seems as effective as thoracic epidural for reducing the risk of postoperative complications. The authors additionally found that paravertebral catheter use is associated with a shorter hospital stay and may be a better form of analgesia for fast-track thoracic surgery.

A Randomized, Double-Blind Trial Comparing Continuous Thoracic Epidural Bupivacaine With and Without Opioid in Contrast to a Continuous Paravertebral Infusion of Bupivacaine for Post-thoracotomy Pain

Jay S. Grider, Timothy W. Mullet, Sibu P. Saha, Michael E. Harned, Paul A. Sloan — 2011-11-18

Objective: To compare the results of continuous epidural bupivacaine analgesia with and without hydromorphone to continuous paravertebral analgesia with bupivcaine in patients with post-thoracotomy pain. Design: A prospective, randomized, double-blinded trial. Setting: A teaching hospital. Participants: Patients at a tertiary care teaching hospital undergoing throracotomy for lung cancer. Interventions: Subjects were assigned randomly to receive a continuous thoracic epidural or paravertebral infusion. Patients in the epidural group were randomized to receive either bupivacaine alone or in combination with hydromorphone. Visual analog scores as well as incentive spirometery results were obtained before and after thoracotomy. Methods and Main Results: Seventy-five consecutive patients presenting for thoracotomy were enrolled in this institutional review board–approved study. On the morning of surgery, subjects were randomized to either an epidural group receiving bupvicaine with and without hydromorphone or a paravertebral catheter–infused bupvicaine. Postoperative visual analog scores and incentive spirometry data were measured in the postanesthesia care unit, the evening of the first operative day, and daily thereafter until postoperative day 4. Analgesia on all postoperative days was superior in the thoracic epidural group receiving bupivacaine plus hydromorphone. Analgesia was similar in the epidural and continuous paravertebral groups receiving bupivacaine alone. No significant improvement was noted by combining the continuous infusion of bupivacaine via the paravertebral and epidural routes. Incentive spirometry goals were best achieved in the epidural bupivacaine and hydromorphone group and equal in the group receiving bupivacaine alone either via epidural or continuous paravertebral infusion. Conclusions: The current study provided data that fill gaps in the current literature in 3 important areas. First, this study found that thoracic epidural analgesia (TEA) with bupivacaine and a hydrophilic opioid, hydromorphone, may provide enhanced analgesia over TEA or continuous paravertebral infusion (CPI) with bupivacaine alone. Second, in the bupivacaine-alone group, the increased basal rates required to achieve analgesia resulted in hypotension more frequently than in the bupivacaine/hydromorphone combination group, underscoring the benefit of the synergistic activity. Finally, in agreement with previous retrospective studies, the current data suggest that CPI of local anesthetic appears to provide acceptable analgesia for post-thoracotomy pain.

Thoracic Paravertebral Block for Video-Assisted Thoracoscopic Surgery: Single Injection Versus Multiple Injections

Fatma Nur Kaya, Gurkan Turker, Elif Basagan Mogol, Selcan Bayraktar — 2011-11-07

Objective: Thoracic paravertebral blocks (PVBs) have been shown to be effective for analgesia after video-assisted thoracoscopic surgery (VATS) with single- and multiple-injection techniques. The efficacy of single-injection PVB was compared with multiple-injection PVB on postoperative analgesia in VATS was studied. Design: Prospective, randomized study. Setting: Single university hospital. Participants: Fifty patients undergoing VATS. Interventions: A nerve stimulator-guided PVB was performed in the sitting position before surgery using a solution of 20 mL 0.5% bupivacaine with 1:200,000 epinephrine by a single injection at T6 (group S, n = 25) or by 5 injections of 4 mL each at T4 to T8 (group M, n = 25). Measurements and Main Results: A successful PVB was achieved in all patients. The times to perform the blocks were 6.8 ± 1.9 minutes in the S group and 17.9 ± 3.0 minutes in the M group (p < 0.001). The times to block onset were 8.3 ± 1.8 minutes in the S group and 7.2 ± 0.9 minutes in the M group (p = 0.014). The numbers of anesthetized dermatomes were 5.8 ± 0.8 for the S group and 6.6 ± 1.1 for the M group (p = 0.009). The postoperative pain scores and morphine consumption with patient-controlled analgesia were comparable in the two groups. There were no significant differences in times to the first mobilization and hospital discharge for two groups. Patient satisfaction with the analgesic procedure was greater in the S group (p < 0.05). No complications were attributed to the blocks. Conclusions: The two techniques provided comparable postoperative analgesia. However, single-injection PVB may represent an advantage over multiple-injection PVB in patients undergoing VATS, with greater patient satisfaction associated with a shorter procedure and the likelihood of decreased complications.

Use of a Miniaturized Transesophageal Echocardiographic Probe in the Intensive Care Unit for Diagnosis and Treatment of a Hemodynamically Unstable Patient After Aortic Valve Replacement

2011-03-28

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has shown the ability to identify treatable causes of shock in patients after cardiac surgery. Unfortunately, the use of TEE in unstable patients after cardiac surgery is limited by the availability of trained echocardiographers, equipment and resource availability, and physician bias that a diagnosis can be established by other means. Some but not all of these limitations may be overcome through technologic innovation.

Iatrogenic Thoracoscopic Right Ventricular Laceration Resulting in Cardiovascular Collapse Treated With Extracorporeal Membrane Oxygenation

Kuen-Bao Chen, Albert Wai-Cheung Lau, Menfil Andres Orellana-Barrios, Weiwu Pang — 2011-02-07

IATROGENIC CARDIAC LESION is an uncommon yet dangerous complication of thoracoscopic surgery. Its management is complicated by several factors including rapid blood loss with ensuing instant hemodynamic instability, difficulty of repair because of lateral positioning and limited access to the heart, heart motion, and blood in the pleural cavity obstructing the surgical visual field. The use of extracorporeal membranous oxygenation (ECMO) provides a valuable tool to manage iatrogenic laceration of the right ventricle (RV) during video-assisted thoracoscopic surgery (VATS) that results in cardiopulmonary arrest. ECMO allows aggressive and prompt volume expansion while diminishing blood flow to the RV, helping ease the repair of a right ventricular laceration and postoperative life support in the intensive care unit.

Arterial Injury Complicating Subclavian Central Venous Catheter Insertion

2011-02-11

INADEQUATE PLACEMENT of a subclavian venous catheter in the subclavian artery is a well-known complication. Three cases of accidental arterial puncture occurred with the implantation of subclavian venous catheters, 2 of which involved the subclavian artery leading to percutaneous treatment; and the other involved the aortic arch, resulting in surgical management, are described.

Tension Pneumothorax and Pneumomediastinum Caused by a Malpositioned Mediastinal Drain in a Patient Following Closure of an Atrial Septal Defect

Shanmukh Hiremath, Harihar V. Hegde, P.R. Sreedhara Swamy, Rohini Bhat Pai — 2011-01-13

MEDIASTINAL AND pleural drains are inserted after cardiac surgery to evacuate the postoperative bleeding, fluids, and air from the mediastinum or pleural cavity. These drains usually are removed as soon as the bleeding is minimal and cardiac and respiratory functions are stable. Even though the incidence of pneumothorax after cardiac surgical procedures in adults is low (1.4%-3%), a slightly higher incidence (13.6%) has been reported in pediatric patients. Most of these cases are clinically identifiable. A case of a malpositioned mediastinal drain causing pneumothorax has not been reported. An 8-year-old boy who underwent surgical closure of an atrial septal defect and developed a right tension pneumothorax and pneumomediastinum postoperatively in the presence of a functioning pleural drain because of the malpositioned mediastinal drain is presented.

Lest We Forget: Heparin-Induced Hyperkalemia

Balu Bhaskar, John F. Fraser, Dan Mullaney — 2011-01-20

HEPARIN IS used widely in intensive care, yet the awareness of its adverse effects, other than bleeding and thrombocytopenia, remains generally poor. An example of heparin-induced hyperkalemia (HIH) after administration for cardiopulmonary bypass (CPB) is presented. This is a rare but serious complication of heparin therapy. The renal physiology leading to HIH and the options available for its management are reviewed.

Remifentanil in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

2011-08-08

Objective: The authors conducted a review of randomized controlled trials to identify advantages in clinically relevant outcomes in patients undergoing cardiac surgery with remifentanil. Design: Meta-analysis. Setting: Hospitals. Participants: A total of 1,473 patients from 16 randomized trials. Interventions: None. Measurements and Main Result: PubMed, BioMedCentral, and conference proceedings were searched (updated May 2010) for randomized trials that compared remifentanil with fentanyl or sufentanil in cardiac anesthesia. Four independent reviewers performed data extraction, with divergences resolved by consensus. Overall analysis showed that the use of remifentanil was associated with a significant reduction in postoperative mechanical ventilation (WMD = −139 min [−244, −32], p for effect = 0.01, p for heterogeneity < 0.001, I2 = 89%); length of hospital stay (WMD = −1.08 days [−1.60, −0.57], p for effect < 0.0001, p for heterogeneity = 0.004, I2 = 71%); and cardiac troponin-I release (WMD = −2.08 ng/mL [−3.93, −0.24], p for effect = 0.03, p for heterogeneity < 0.02, I2 = 74%). No difference was noted in mortality (3/344 [0.87%] in the remifentanil group vs [1.06%] the control group, OR 0.76 [0.17-3.38], p for effect = 0.72, p for heterogeneity = 0.35, I2 = 5%). Conclusions: Remifentanil reduces cardiac troponin release, time of mechanical ventilation, and length of hospital stay in patients undergoing cardiac surgery.

Update on Blood Conservation for Cardiac Surgery

Bhanu P. Nalla, John Freedman, Gregory M.T. Hare, C. David Mazer — 2011-10-17

PATIENTS UNDERGOING CARDIAC SURGERY are at risk of excessive bleeding, leading to increased usage of allogeneic blood and hemostatic blood products. Although this patient population represents a relatively small proportion of surgical patients, cardiac surgery consumes about 20% of the available blood supply in the United States, with similar numbers reported worldwide. The potential for beneficial effects of transfusing blood to maintain tissue oxygen perfusion and prevent organ ischemia may be greatest in patients with cardiovascular disease. Indeed, life-threatening hemorrhage, an absolute indication for blood transfusion, may be relatively frequent in these patients, with repeat surgery for bleeding occurring in up to 5% of patients. In addition, the risks of preexisting anemia and acute perioperative hemodilution have become more apparent. However, there is a lack of clinical outcome data to support the liberal use of blood transfusion in cardiac surgery.

Anesthesia for Interventional Cardiology

Mark Hayman, Paul Forrest, Peter Kam — 2011-11-07

THE DEMAND FOR anesthetic support for interventional cardiology procedures is increasing as the number and complexity of these procedures rapidly expand. Providing safe anesthesia care to patients undergoing these procedures requires comprehensive preoperative assessment, involvement in the multidisciplinary planning of these cases, and a detailed understanding of the procedures and their potential complications. This article reviews the common implantation and electrophysiology (EP) procedures undertaken in cardiac catheterization laboratories. An outline of the procedures undertaken and their major periprocedural complications are addressed along with recommendations for their anesthetic management. The first section covers closure of intracardiac shunts, closure of patent ductus arteriosus (PDA), left atrial appendage (LAA) occlusion devices, transcatheter valves, and the implantation and removal of pacemaker and rhythm management devices. The second section covers EP procedures and anesthetic management issues in patients with congenital heart disease (CHD). It also covers the anesthetic implications of ionizing radiation and practice in a remote location.

Anesthetic Management of Patients Undergoing Aortic Valve Bypass (Apicoaortic Conduit) Surgery

2011-07-04

AORTIC VALVE BYPASS (AVB) surgery is the creation of a valved conduit from the apex of the left ventricle (LV) to the descending aorta in patients with left ventricular outflow tract obstruction (). In adults, the outflow tract obstruction usually is caused by aortic valve (AV) stenosis. The typical patient is elderly and presents with a pre-existing medical condition that significantly increases perioperative risk for morbidity and mortality with conventional AV replacement (AVR). AVB usually can be accomplished without cardiopulmonary bypass (CPB), one of the major excess risk factors in conventional AVR. Other significant factors that increase the risk for adverse outcomes are advanced aortic atherosclerosis with calcification (“porcelain aorta”), previous sternotomy, prior intrathoracic procedures, or prior coronary artery bypass graft surgery with patent critical grafts. summarizes more recent published experience with AVB surgery in adult patients.

Case 1—2012 A Perfect Storm: Fatality Resulting From Metoclopramide Unmasking A Pheochromocytoma and Its Management

2012-02-01

A PHEOCHROMOCYTOMA IS AN UNCOMMON catecholamine-secreting neuroendocrine tumor with typical symptoms of paroxysmal headache, palpitations, and severe hypertension. Pheochromocytomas can be associated with labile hemodynamics. However, hemodynamic shock is infrequent, occurring in approximately 2%. Before 1960, mortality in patients with pheochromocytoma was >50%. Currently, the mortality is <2%. The authors present a case of pheochromocytoma-induced cardiogenic shock after metoclopromide administration that was managed with an intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO).

Advances in the Management of Carotid Artery Disease: Focus on Recent Evidence and Guidelines

John G.T. Augoustides — 2012-02-01

Recent landmark randomized trials and society guidelines have significantly revised the management of carotid artery disease. Duplex ultrasonography is the recommended initial diagnostic test for the assessment of extracranial carotid artery stenosis. Carotid artery imaging is reasonable in select patients scheduled for coronary artery bypass graft (CABG) surgery. Carotid revascularization can be achieved safely and effectively with carotid endarterectomy or carotid artery stenting. Because each procedure has a different risk/benefit profile, the optimal approach is to match the particular patient to the intervention that maximizes outcome benefit. Carotid revascularization is recommended in patients scheduled for CABG surgery when the carotid artery stenosis is symptomatic and/or bilateral. Further trials are required to guide the management of asymptomatic unilateral carotid artery stenosis in patients undergoing CABG surgery. Aggressive medical therapy remains the gold standard for intracranial carotid artery disease because landmark trials have shown no outcome improvement with vascular bypass or percutaneous angioplasty and stenting. A large recent trial showed that local anesthesia, as compared with general anesthesia, for carotid endarterectomy has no major clinical outcome advantage. Although carotid artery stenting is associated with a reduced risk of myocardial ischemia, it still has important risks of stroke and hemodynamic instability that significantly affect clinical outcome. The timing and choice of carotid revascularization technique ultimately depends on multiple clinical factors.

Dizziness in a Patient With a Right Atrial Mass

Zafar Iqbal, Steven Sivils, Paul S. Pagel — 2010-09-20

A 63-YEAR-OLD, 93-kg, 170-cm man with an extensive history of cardiovascular disease presented to the cardiology clinic in the authors' institution complaining of “feeling lightheaded and dizzy.” The patient stated that his symptoms initially began 3 months before this admission. His dizziness occurred as often as once per minute, was often accompanied by dyspnea, and caused him to awaken several times per night. The patient further reported that he could feel his heart “pause.” He denied syncope, chest pain, and other constitutional complaints including fever, night sweats, and weight loss. The past medical history was notable for coronary artery and peripheral vascular disease. The patient had suffered 3 myocardial infarctions; a left anterior descending coronary artery stent was implanted after the most recent of these events. Global left ventricular (LV) hypokinesis and LV systolic dysfunction (ejection fraction of 30%) were present on a previous transthoracic echocardiogram, consistent with the diagnosis of ischemic cardiomyopathy. Several previous hospital admissions for congestive heart failure also were described. The patient was treated chronically with carvedilol, lisinopril, furosemide, and warfarin. An electrocardiogram was performed in the clinic that showed a 10-second pause. Carvedilol immediately was discontinued, the patient was admitted to a telemetry unit, and several additional pauses in cardiac electrical activity ranging between 5 and 10 seconds in duration were noted. Transesophageal echocardiography was performed as part of the evaluation ( and [supplementary video is available online]). What is the diagnosis?

A Large Mass on a Newly Implanted Pulmonary Artery Catheter: Thrombus, Vegetation, or an Anatomic Explanation?

Robert K. Loveday, Brendan T. Wanta, Alfred C. Nicolosi, Paul S. Pagel — 2010-09-24

A 62-YEAR-OLD, 92-kg, 168-cm woman was admitted to the authors' medical center for elective coronary artery bypass graft surgery. The patient described a 3-week history of progressive exertional chest pain, dyspnea, and dizziness relieved with rest. She recently had been evaluated at another hospital for similar symptoms, and an acute myocardial infarction was excluded based on analysis of serial cardiac enzymes. The patient denied a past medical history of fever, chills, nausea, vomiting, diaphoresis, orthopnea, and leg swelling. No murmurs were heard during cardiac auscultation. The remainder of the physical examination was otherwise noncontributory. An electrocardiogram showed normal sinus rhythm without ischemic changes. The laboratory analysis, including a coagulation panel, was unremarkable. The cardiac catheterization revealed a 90% stenosis of the left anterior descending (LAD) coronary artery distal to the first diagonal branch and a series of discrete high-grade stenoses in the left circumflex coronary artery (LCCX) proximal and distal to a large second marginal branch. The left ventricular ejection fraction was estimated at 65%. The patient was transported to the operating room for coronary artery bypass graft surgery. A pulmonary artery catheter (PAC) was inserted through the right internal jugular vein using local anesthesia, conscious sedation (intravenous midazolam and fentanyl), and ultrasound guidance. A transesophageal echocardiographic (TEE) probe was placed immediately after anesthetic induction, endotracheal intubation, and gastric decompression. TEE revealed an apparent “mass” associated with the PAC ( and [supplementary videos are available online]). What is the diagnosis?

Noncardiogenic Pulmonary Edema in a Cardiac Surgery Patient: Never a Welcome Sight for the Anesthesiologist

Michael G. Wong, James A. Helliwell — 2010-11-25

A 78-YEAR-OLD woman presented for redo aortic and mitral valve replacement and primary tricuspid valve repair. Aside from New York Heart Association Class IV congestive heart failure on the basis of a ruptured bioprosthetic mitral valve, her past medical history was relatively noncontributory. Anesthesia was induced in a hemodynamically neutral fashion, and anticoagulation was achieved with 30,000 IU of heparin and supplemented to maintain an activated coagulation time of greater than 500 seconds. The patient received a 4-g bolus of tranexamic acid followed by an infusion of 1 g/h. Intravenous hydrocortisone (100 mg) was administered because of the anticipated duration of cardiopulmonary bypass (CPB) time.

Cardiac Calendar—2012 to 2013

George Silvay — 2012-02-01

Fifty-Eighth Annual Meeting of Indian Association of Cardiovascular and Thoracic Surgeons. Kolkata, India. February 10-12, 2012. Contact: http://www.iacts2012.com. Cardiothoracic Symposium 2012. Iguazu Falls, Argentina. March 19-21, 2012. Contact: ctsymposium2012@mci-group.com.

A Word of Caution Regarding Transesophageal Echocardiography and Penetrating Chest Trauma

Neal Stuart Gerstein — 2011-09-29

In their recent Case Conferenence, Stein et al described the use of transesophageal echocardiography (TEE) to assist in the diagnosis and management of a stab wound to the left chest. I would like to proffer a word of caution regarding the use of TEE in a patient who recently had sustained a penetrating chest injury.

Iatrogenic Acute Aortic Dissection During Cardioplegic Cannula Insertion Detected by Transesophageal Echocardiography

Parag Gharde, Vikram Aggarwal, Sandeep Chauhan, Usha Kiran, V. Devagourou — 2011-10-17

Iatrogenic acute aortic dissection (IAAD) is a rare but potentially lethal complication. Fortunately, the reported incidence of IAAD is low (approximately 0.16% to 0.35%), perhaps because of underreporting or underdetection (small or posteriorly located, precluding visual detection). The authors report a case of IAAD with an intimal tear in the posterior wall of the ascending aorta during cardioplegic cannula insertion detected intraoperatively by transesophageal echocardiography (TEE).

Sudden Intraoperative Hypertension During Endovascular Abdominal Aortic Repair as a First Sign of Massive Fatal Atheroembolism

Paolo Grassi, Filomena Capone — 2011-10-10

Endovascular aortic repair (EVAR) is considered a relatively safe treatment of abdominal aortic aneurysms, with an advantage in early mortality with respect to the open procedure. EVAR is offered to patients with limited life expectancy or considered unfit for open repair. However, endovascular aortic procedures are not devoid of complications, with endoleaks being the most frequently observed complication. Atheroembolism is another known EVAR complication, but it has been described rarely as an event with fatal consequences. We report here the case of an 80-year-old man who, while undergoing EVAR, developed unexplained severe hypertension and died of multiple-organ failure on the second postoperative day.

Reasons Elevated B-Type Natriuretic Peptide Levels Are Associated With Adverse Outcome in Patients Undergoing Cardiac Surgery

Yongxin Liang, Miaoning Gu, Shiduan Wang — 2011-10-17

We read with interest the recent article by Nozohoor et al who studied a total of 407 consecutive patients undergoing cardiac surgery and found that elevated B-type natriuretic peptide (BNP) levels were associated with adverse postoperative outcome (prolonged ventilation and inotropic support) and were predictive of impaired late survival. However, they did not point out why elevated BNP was associated with adverse outcome in patients undergoing cardiac surgery.

Noncardiac Surgery in the Prone Position in Patients With Ventricular Assist Devices

Christopher W. Connors, Justin M. Poltak, Angus A. Christie — 2011-11-18

After a literature review and PubMed search using the key words “prone,” “ventricular assist device,” “noncardiac surgery,” and “position,” we report the first case of surgery in the prone position in a patient with a ventricular assist device (VAD). A 72-year-old woman with a previously implanted Heartmate II (Thoratec Corporation, Pleasanton, CA) Left Ventricular Assist Device presented to the authors' institution with an expanding right frontoparietal hematoma and left-sided hemiplegia. As such, the patient proceeded to the operating room for a right parietal craniotomy for decompression of an intracerebral hematoma.

Journal of Cardiothoracic and Vascular Anesthesia

Masthead

Editorial Board

Contents

Articles to Appear in Future Issues

Guide for Authors

Hands-on…Handoff

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2011

Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs

A Comparative Evaluation of Transesophageal and Transthoracic Echocardiography for Measurement of Left Ventricular Systolic Strain Using Speckle Tracking

Comparison of Transthoracic and Transesophageal 2-Dimensional Speckle Tracking Echocardiography

Evaluation of Tricuspid and Pulmonary Valves Using Epicardial and Transesophageal Echocardiography—A Comparative Study

Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Pediatric Patients Undergoing Cardiac Surgery

Increased Chest Tube Drainage Is Independently Associated With Adverse Outcome After Cardiac Surgery

Combined Central Venous Oxygen Saturation and Lactate as Markers of Occult Hypoperfusion and Outcome Following Cardiac Surgery

β-Blockers to Optimize Peripheral Oxygenation During Extracorporeal Membrane Oxygenation: A Case Series

Association Between Postoperative Acute Kidney Injury and Duration of Cardiopulmonary Bypass: A Meta-Analysis

Milrinone and Mortality in Adult Cardiac Surgery: A Meta-analysis

Thoracic Epidural or Paravertebral Catheter for Analgesia After Lung Resection: Is the Outcome Different?

A Randomized, Double-Blind Trial Comparing Continuous Thoracic Epidural Bupivacaine With and Without Opioid in Contrast to a Continuous Paravertebral Infusion of Bupivacaine for Post-thoracotomy Pain

Thoracic Paravertebral Block for Video-Assisted Thoracoscopic Surgery: Single Injection Versus Multiple Injections

Use of a Miniaturized Transesophageal Echocardiographic Probe in the Intensive Care Unit for Diagnosis and Treatment of a Hemodynamically Unstable Patient After Aortic Valve Replacement

Iatrogenic Thoracoscopic Right Ventricular Laceration Resulting in Cardiovascular Collapse Treated With Extracorporeal Membrane Oxygenation

Arterial Injury Complicating Subclavian Central Venous Catheter Insertion

Tension Pneumothorax and Pneumomediastinum Caused by a Malpositioned Mediastinal Drain in a Patient Following Closure of an Atrial Septal Defect

Lest We Forget: Heparin-Induced Hyperkalemia

Remifentanil in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

Update on Blood Conservation for Cardiac Surgery

Anesthesia for Interventional Cardiology

Anesthetic Management of Patients Undergoing Aortic Valve Bypass (Apicoaortic Conduit) Surgery

Case 1—2012 A Perfect Storm: Fatality Resulting From Metoclopramide Unmasking A Pheochromocytoma and Its Management

Advances in the Management of Carotid Artery Disease: Focus on Recent Evidence and Guidelines

Dizziness in a Patient With a Right Atrial Mass

A Large Mass on a Newly Implanted Pulmonary Artery Catheter: Thrombus, Vegetation, or an Anatomic Explanation?

Noncardiogenic Pulmonary Edema in a Cardiac Surgery Patient: Never a Welcome Sight for the Anesthesiologist

Cardiac Calendar—2012 to 2013

A Word of Caution Regarding Transesophageal Echocardiography and Penetrating Chest Trauma

Iatrogenic Acute Aortic Dissection During Cardioplegic Cannula Insertion Detected by Transesophageal Echocardiography

Sudden Intraoperative Hypertension During Endovascular Abdominal Aortic Repair as a First Sign of Massive Fatal Atheroembolism

Reasons Elevated B-Type Natriuretic Peptide Levels Are Associated With Adverse Outcome in Patients Undergoing Cardiac Surgery

Noncardiac Surgery in the Prone Position in Patients With Ventricular Assist Devices