Journal of Cardiothoracic and Vascular Anesthesia

Masthead

2010-06-01

Journal of Cardiothoracic and Vascular Anesthesia (ISSN 1053-0770) is published bimonthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Months of issue are February, April, June, August, October, and December. Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2010-06-01

Articles to Appear in Future Issues

2010-06-01

Comparability of Spectral Entropy and Bispectral Index Electroencephalography in Coronary Artery Bypass Graft Surgery W. Baulig, B. Seifert, E.R. Schmid, and U. Schwarz; Zurich, Switzerland

Guide for Authors

2010-06-01

The Journal of Cardiothoracic and Vascular Anesthesia will consider for publication suitable articles on all topics related to anesthesia for cardiac, vascular, and thoracic surgery. The scope of this Journal is broad and seeks to consolidate all material pertinent to cardiothoracic anesthesiology, including topics from critical care medicine, pharmacology, monitoring, perfusion technology, internal medicine, surgery, and transplantation.

The New-Generation Hydroxyethyl Starch Solutions: The Holy Grail of Fluid Therapy or Just Another Starch?

Glenn S. Murphy, Steven B. Greenberg — 2010-04-16

THE OPTIMIZATION OF fluid status in the cardiac surgical patient is a primary management objective of anesthesiologists and critical care clinicians in the perioperative period. Appropriate volume restoration will maximize cardiac output, systemic perfusion pressures, and microcirculatory flow. Recent evidence suggests that intraoperative goal-directed fluid administration may reduce postoperative morbidity and hospital length of stay. However, achieving the goal of “optimal fluid status” in a cardiac surgical patient population may present a challenge for clinicians. Patients often arrive to the operating room with intravascular volume depletion because of aggressive diuresis or critical illness in the preoperative period. Significant and underappreciated blood loss may occur in the operating room. Furthermore, activation of the inflammatory response system during cardiopulmonary bypass (CPB) produces endothelial injury and increased vascular permeability, resulting in a fluid shift from the intravascular to the interstitial compartment. A mean weight gain of 4 kg has been reported on the first postoperative day after cardiac surgery, which was attributed to a 2-L positive fluid balance administered in the operating room and intensive care unit.

A New Plasma-Adapted Hydroxyethyl Starch Preparation: In Vitro Coagulation Studies

Joachim Boldt, Andinet Mengistu — 2009-12-11

Objective: Preparing hydroxyethyl starch (HES) in a plasma-adapted solution is supposed to improve safety with regard to coagulation. The influence of a new plasma-adapted HES preparation on coagulation was studied.Design: Operator-blinded, randomized study.Setting: Laboratory in vitro study.Participants: Fifteen healthy young men scheduled for blood donation.Interventions: Blood was diluted by 10%, 30%, and 50% using either a plasma-adapted or nonplasma-adapted (prepared in saline solution) potato-derived 6% HES 130/0.42. Only the composition of the solvent of the 2 HES preparations was different.Measurements and Main Results: Rotation thromboelastometry (ROTEM; Pentapharm, Munich, Germany) was used to assess changes in coagulation; whole blood aggregometry with 3 inducers was used to assess effects of dilution with HES on platelet function. Clotting time (CT) and clot formation time were significantly prolonged by 30% and 50% dilution, showing significantly longer times in the non–plasma-adapted than in the plasma-adapted HES group (eg, intrinsic CT at the 30% dilution level: plasma-adapted HES 228 ± 26 seconds [within normal range] v 269 ± 29 seconds in the nonplasma-adapted HES group). Clot strengthening and clot firmness were significantly reduced by the non–plasma-adapted HES at the 30% dilution level. Platelet aggregation was significantly more reduced by the non–plasma-adapted HES at the 30% and 50% dilution levels.Conclusions: Dilution with the nonplasma-adapted HES 130/0.42 was associated with more negative effects on thromboelastometry and platelet aggregation than the same HES 130/0.4 dissolved in a plasma-adapted solution. The benefits of using a plasma-adapted modern HES preparation on blood loss and use of blood/blood products in cardiac surgery need to be studied.

Volume Replacement With a Balanced Hydroxyethyl Starch (HES) Preparation in Cardiac Surgery Patients

Joachim Boldt, Jochen Mayer, Christian Brosch, Andreas Lehmann, Andinet Mengistu — 2010-06-01

Objective: Balanced fluids appear to be have advantages over unbalanced fluids for correcting hypovolemia. The effects of a new balanced hydroxyethyl starch (HES) were studied in cardiac surgery patients.Design: Prospective, randomized, unblinded study.Setting: Clinical study in a single cardiac surgery institution.Participants: Sixty patients undergoing elective cardiac surgery with cardiopulmonary bypass.Intervention: Patients received either a balanced 6% HES 130/0.4 plus a balanced crystalloid (n = 30) or an unbalanced HES-in-saline plus saline (n = 30) to keep cardiac index >2.5 L/min/m2.Measurements and Main Results: Base excess (BE), kidney function, inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1 [ICAM]), and coagulation (thromboelastometry, whole blood aggregation) were measured after induction of anesthesia, after surgery and 5 hours later, and at the 1st and 2nd postoperative days; 2,950 ± 530 mL of balanced and 3,050 ± 560 mL of unbalanced HES were given. BE was reduced significantly in the unbalanced group (from 1.11 ± 0.71 mmol/L to −5.11 ± 0.48 mmol/L after surgery) and remained unchanged in the balanced group. Balanced volume replacement resulted in significantly lower IL-6, IL-10, and ICAM plasma concentrations and lower urine concentrations of kidney-specific proteins than in the unbalanced group. After surgery, thromboelastometry data and platelet function were changed significantly in both groups; 5 hours thereafter they were significantly changed only in the unbalanced group.Conclusion: A plasma-adapted HES preparation in addition to a balanced crystalloid resulted in significantly less decline in BE, less increase in concentrations of kidney-specific proteins, less inflammatory response and endothelial damage, and fewer changes in hemostasis compared with an unbalanced fluid strategy.

In Vitro Comparative Study of Hemostatic Components in Warfarin-Treated and Fibrinogen-Deficient Plasma

2009-10-12

Objective: The authors hypothesized that various hemostatic products may differently affect viscoelastic clot formation depending on their respective procoagulant activity and fibrinogen content.Design: In vitro coagulopathy modeling using warfarin-treated plasma (international normalized ratio, 2.8-3.8) and fibrinogen-deficient plasma evaluated by rotational thromboelastometry (ROTEM; Pentapharm, Munich, Germany).Setting: A university laboratory.Intervention: Different volumes of cryoprecipitate, fresh frozen plasma (FFP), fibrinogen concentrate, and platelet concentrate were mixed with each abnormal plasma to simulate the in vivo transfusions of 250 mL to 1,000 mL. Three thromboelastometric variables that reflect the rate and extent of clot growth were measured: (1) coagulation time (CT), (2) angle, and (3) maximal clot firmness (MCF).Measurements and Main Results: In warfarin-treated plasma, the addition of FFP, cryoprecipitate, and platelets led to a dose-dependent improvement of CT and angle, whereas MCF increased with cryoprecipitate or platelets only. The addition of fibrinogen concentrate improved MCF and angle but not CT. In fibrinogen-deficient plasma, the addition of cryoprecipitate, platelets, and fibrinogen concentrate led to a dose-dependent improvement of ROTEM variables, whereas the addition of FFP resulted in significantly longer CT and lower MCF values compared with other hemostatic products. The addition of platelets in the presence of cytochalasin D (a platelet inhibitor) resulted in improvements of ROTEM variables that were similar to when FFP was added to warfarin-treated and fibrinogen-deficient plasma.Conclusions: Cryoprecipitate supports clot formation on ROTEM more efficiently than FFP because of the high fibrinogen content. Improved ROTEM variables after platelet addition are presumably caused by increased interaction among thrombin-activated platelets and fibrinogen.

Risk Factors for Red Blood Cell Transfusion After Coronary Artery Bypass Graft Surgery

2010-03-15

Objectives: Perioperative transfusion of red blood cells is associated with increased morbidity and mortality. The authors investigated the correlation between preoperative risk factors and the number of red blood cell units received in patients undergoing coronary artery bypass graft surgery.Design: A retrospective analysis of prospectively collected data.Setting: A single-center study performed in an educational hospital.Participants: All patients who underwent isolated coronary artery bypass graft surgery between 1998 and 2007 (N = 10,626) were included.Interventions: Isolated coronary artery bypass graft surgery.Measurements and Main Results: Univariate and multivariate logistic regression analyses were performed to investigate the impact of preoperative and perioperative factors on transfusion of 1 or more units of red blood cells. The following independent risk factors for receiving red blood cell units were identified: age, female sex, low body surface area, low left ventricular ejection fraction (<35%), emergency operation, previous cardiac surgery, low preoperative hemoglobin, and low preoperative creatinine clearance. Perioperative risk factors were the use of extracorporeal circulation, longer bypass time, use of crystalloid cardioplegia, the need for intra-aortic balloon pump, perioperative myocardial infarction, and re-exploration for any cause.Conclusions: In this study, the authors identified risk factors for receiving red blood cells in patients undergoing coronary artery bypass graft surgery. The authors were able to implement these factors in their daily practice by sharpening the criteria for the direct availability of red blood cells in the operating room.

The Effect of the Suspension of the License for Aprotinin on the Care of Patients Undergoing Cardiac Surgery: A Survey of Cardiac Anesthesiologists' and Surgeons' Opinions in the United Kingdom

Victoria McMullan, R. Peter Alston — 2010-01-07

Objective: The primary aim was to poll the opinions of cardiac anesthesiologists and surgeons as to the effect of the suspension of the license for aprotinin on patients undergoing cardiac surgery.Design: A mailed questionnaire.Setting: United Kingdom.Participants: Members of the Association of Cardiothoracic Anaesthetists and the Society for Cardiothoracic Surgery in Great Britain and Ireland with a UK address.Interventions: A structured questionnaire.Measurements and Main Results: Of the 546 dispatched surveys, 285 (52%) were returned. While the majority of respondents (61%) felt it had not had any effect, 29% of respondents felt the suspension of the license for aprotinin had had a detrimental effect on patient care and 2% an extremely detrimental effect. Eight percent of respondents reported a beneficial effect. Since license suspension, the reported use of aprotinin had declined and tranexamic acid use had risen. The majority of respondents reported no change in the use of packed red cells (66%), blood products (53%), mechanical cell salvage (84%), factor VIIa (79%), or frequency of reopening for bleeding (65%). Respectively, 32%, 45%, 24%, and 20% of respondents reported a perceived increased use of these products, and 30% reported an increased frequency of reopening for bleeding. Apart from knowledge regarding local aprotinin stock, there was no significant difference in opinions between surgeons and anesthesiologists.Conclusions: While the majority of respondents felt that the suspension of the license for aprotinin had no effect, almost a third felt it had impacted negatively on the care of patients undergoing cardiac surgery.

Profound Effects of Cardiopulmonary Bypass Priming Solutions on the Fibrin Part of Clot Formation: An Ex Vivo Evaluation Using Rotation Thromboelastometry

2010-01-07

Objectives: Dilutional coagulopathy as a consequence of cardiopulmonary bypass (CPB) system priming may also be affected by the composition of the priming solution. The direct effects of distinct priming solutions on fibrinogen, one of the foremost limiting factors during dilutional coagulopathy, have been minimally evaluated. Therefore, the authors investigated whether hemodilution with different priming solutions distinctly affects the fibrinogen-mediated step in whole blood clot formation.Design: Prospective observational laboratory study.Setting: University hospital laboratory.Participants: Eight male healthy volunteers.Interventions: Blood samples diluted with gelatin-, albumin-, or hydroxyethyl starch (HES)-based priming solutions were ex-vivo evaluated for clot formation by rotational thromboelastometry.Measurements and Main Results: The intrinsic pathway (INTEM) coagulation time increased from 186 ± 19 seconds to 205 ± 16, 220 ± 17, and 223 ± 18 seconds after dilution with gelatin-, albumin-, or HES-containing prime solutions (all p < 0.05 v baseline). The extrinsic pathway (EXTEM) coagulation time was only minimally affected by hemodilution. Moreover, all 3 priming solutions significantly reduced the INTEM and EXTEM maximum clot firmness. The HES-containing priming solution induced the largest decrease in the maximum clot firmness attributed to fibrinogen, from 13 ± 1 mm (baseline) to 6 ± 1 mm (p < 0.01 v baseline).Conclusions: All studied priming solutions prolonged coagulation time and decreased clot formation, but the fibrinogen-limiting effect was the most profound for the HES-containing priming solution. These results suggest that the composition of priming solutions may distinctly affect blood clot formation, in particular with respect to the fibrinogen component in hemostasis.

Association of the 98T ELAM-1 Polymorphism With Increased Bleeding After Cardiac Surgery

2010-01-07

Objective: Hemorrhage continues to be a major problem after cardiac surgery despite the routine use of antifibrinolytic drugs, with striking inter-patient variability poorly explained by already known risk factors. The authors tested the hypothesis that genetic polymorphisms of inflammatory mediators and cellular adhesion molecules are associated with bleeding after cardiac surgery.Design: Prospective, observational study.Setting: Single, tertiary referral university heart center.Participants: Adult patients undergoing aortocoronary surgery with cardiopulmonary bypass.Interventions: Patients (n = 759) had 10 mL of blood drawn preoperatively and genomic DNA isolated then genotyped for 17 polymorphisms in 7 candidate genes: tumor necrosis factor, interleukins 1β and 6, interleukin 1 receptor antagonist, intercellular adhesion molecule-1 (ICAM-1), P-selectin and endothelial leucocyte adhesion molecule-1 (E-selectin). Multivariate analyses were used to relate clinical and genetic factors to bleeding and transfusion.Measurements and Main Results: The 98G/T polymorphism of the E-selectin gene was independently associated with bleeding after cardiac surgery (p = 0.002), after adjusting for significant clinical predictors (patient size and baseline hemoglobin concentration). There was a gene dose effect according to the number of minor alleles in the genotype; carriers of the minor allele bled 17% (GT) and 54% (TT) more than wild type (GG) genotypes, respectively (p = 0.01). Carriers of the minor allele also had longer activated partial thromboplastin times (p = 0.0023) and increased fresh frozen plasma transfusion (p = 0.03) compared with wild type.Conclusions: The authors found a dose-related association between the 98T E-selectin polymorphism and bleeding after cardiac surgery, independent of and additive to standard clinical risk factors.

A Comparison of Central and Mixed Venous Oxygen Saturation in Circulatory Failure

Kwok M. Ho, Richard Harding, Jenny Chamberlain, Max Bulsara — 2008-01-21

Objective: The purpose of this study was to evaluate whether central venous oxygen saturation can be used as an alternative to mixed venous oxygen saturation in patients with cardiogenic and septic shock.Design: Prospective clinical study.Setting: A tertiary intensive care unit in a university hospital.Participants: Twenty patients with cardiogenic or septic shock requiring a pulmonary artery catheter and inotropic support.Interventions: None.Measurements and Main Results: The central venous oxygen saturation overestimated the mixed venous oxygen saturation by a mean bias (or an absolute difference) of 6.9%, and the 95% limits of agreement were large (−5.0% to 18.8%). The difference between central and mixed venous oxygen saturation appeared to be more significant when mixed venous oxygen saturation was <70%. The changes in central and mixed venous oxygen saturation did not follow the line of perfect agreement closely in different clinical conditions. The central or mixed venous oxygen saturation had a significant ability to predict the status of cardiac output state, but this ability was reduced when the effect of hyperoxia was not considered.Conclusion: Central and mixed venous oxygen saturation measurements are not interchangeable numerically.

Intensive Care Unit Utilization and Outcome After Esophagectomy

Remzi Iscimen, Daniel R. Brown, Stephen D. Cassivi, Mark T. Keegan — 2008-05-08

Objective: To establish the frequency of intensive care unit (ICU) admission after esophagectomy and to determine the associated outcomes.Design: Retrospective cohort study.Setting: Tertiary referral center.Participants: Four hundred thirty-two patients who underwent esophagectomy between January 2000 and June 2004.Interventions: NoneMeasurements and Main Results: Data relating to demographics, patient co-morbidities, perioperative management, complications, and Acute Physiology and Chronic Health Evaluation (APACHE) III variables were abstracted. Statistical analyses were performed to compare survivors with non-survivors and ICU patients with non-ICU patients. Of 432 patients included in the study, 123 (28.5%) were admitted to the ICU. Arrhythmias, new infiltrates on chest radiograph, and documented aspiration were common reasons for ICU admission. Patients admitted to ICU were of high acuity (mean APACHE III score 54.5, mean prediction of ICU death 6.4%). Of 352 patients originally not sent to the ICU, 43 (12.2%) were subsequently admitted to the ICU, often for aspiration. Overall in-hospital mortality was 3.7% (16 of 432 patients). Fifteen of the 123 ICU patients (12.2%) did not survive to hospital discharge.Conclusions: A significant minority of patients will require ICU admission after esophagectomy, often for aspiration pneumonitis and arrhythmias. Despite high severity of illness scores, the perioperative mortality rate for patients after esophagectomy at a high-volume center is low.

A Propensity-Matched Comparison of the Incidence of New-Onset Postoperative Atrial Arrhythmias in Cardiac and Noncardiac Thoracic Surgery Patients

2009-10-05

Objective: The primary aim of this investigation was to compare the incidence of new-onset postoperative atrial arrhythmias (POAAs) in cardiac versus noncardiac thoracic surgery patients. A subgroup analysis also was performed in the cardiac surgery patients comparing POAAs in patients who underwent cardiac surgery on and off cardiopulmonary bypass (CPB).Design: This was a retrospective study using the Department of Cardiothoracic Anesthesia patient registry. All patients (n = 33,500) undergoing cardiac (n = 29,057) and noncardiac thoracic (n = 4,443) surgeries between 1993 and 2004 were identified from the patient registry. Two propensity-matched comparisons for the incidence of POAAs were made: (1) in cardiac surgery patients versus noncardiac thoracic surgery patients and (2) in patients undergoing cardiac surgery with versus without CPB.Setting: A large metropolitan multidisciplinary clinic.Participants: Patients.Intervention: No interventions were done because this was a retrospective study.Measurements and Main Results: The cardiac patients had a significantly higher incidence of POAAs when compared with noncardiac thoracic surgery patients (11.6% v 7.5%, p < 0.001). There was no significant difference in the incidence of POAAs between patients undergoing CPB versus off-pump CPB (13.3% v 12.3%, p = 0.3).Conclusion: The incidence of new-onset POAAs was higher in patients undergoing cardiac surgery than in patients undergoing noncardiac thoracic surgery in propensity-matched patient groups. CPB was not associated with new-onset POAAs.

Weaning Mechanical Ventilation After Off-Pump Coronary Artery Bypass Graft Procedures Directed by Noninvasive Gas Measurements

2009-09-04

Objective(s): Partial pressure of carbon dioxide and oxygen were transcutaneously measured in adults after off-pump coronary artery bypass (OPCAB) surgery. The clinical use of such measurements and interchangeability with arterial blood gas measurements for weaning patients from postoperative mechanical ventilation were assessed.Design: This was a prospective observational study.Setting: Tertiary referral heart hospital.Participants: Postoperative OPCAB surgical patients.Interventions: Transcutaneous oxygen and carbon dioxide measurements.Measurements and Main Results: In this prospective observational study, 32 consecutive adult patients in a tertiary care medical center underwent OPCAB surgery. Noninvasive measurement of respiratory gases was performed during the postoperative period and compared with arterial blood gases. The investigator was blinded to the reports of arterial blood gas studies and weaned patients using a “weaning protocol” based on transcutaneous gas measurement. The number of patients successfully weaned based on transcutaneous measurements and the number of times the weaning process was held up were noted. A total of 212 samples (pairs of arterial and transcutaneous values of oxygen and carbon dioxide) were obtained from 32 patients. Bland-Altman plots and mountain plots were used to analyze the interchangeability of the data. Twenty-five (79%) of the patients were weaned from the ventilator based on transcutaneous gas measurements alone. Transcutaneous carbon dioxide measurements were found to be interchangeable with arterial carbon dioxide during 96% of measurements, versus 79% for oxygen measurements.Conclusion: More than three fourths of the patients were weaned from mechanical ventilation and extubated based on transcutaneous gas values alone after OPCAB surgery. The noninvasive transcutaneous carbon dioxide measurement can be used as a surrogate for arterial carbon dioxide measurement to manage postoperative OPCAB patients.

The Effect of Thoracic Epidural Anesthesia on Pulmonary Shunt Fraction and Arterial Oxygenation During One-Lung Ventilation

2009-11-30

Objective: To compare the effect of thoracic epidural local anesthetic, epidural opioid, and intravenous opioid on pulmonary shunt fraction, arterial oxygenation, and hemodynamic changes during one-lung ventilation (OLV) in patients undergoing thoracic surgery.Design: A prospective, randomized, double-blind study.Setting: A university hospital.Participants: Thirty-nine patients undergoing OLV for pulmonary resection.Interventions: Patients were randomized into 1 of 3 groups: epidural bupivacaine (TEA-B group, n = 13), epidural sufentanil (TEA-S group, n = 13), or intravenous remifentanil (IV-R group, n = 13) during general anesthesia with propofol. A double-lumen tube was inserted, and mechanical ventilation with 100% oxygen was used in the lateral decubitus position.Measurements and Main Results: Hemodynamic variables and arterial and mixed venous blood gas analysis from the radial and pulmonary artery catheter were measured and shunt fraction was calculated during two-lung ventilation (TLV), 15, 30, and 60 minutes after the initiation of OLV, and 15 minutes after the reinstitution of TLV. Although mean arterial pressures 15 and 30 minutes after OLV in the IV-R group were significantly higher than the value in TEA-S group, cardiac output and pulmonary vascular resistance were maintained. Decreases in PaO2, SaO2, PvO2, and SvO2 and an increase in the shunt fraction after OLV were not different among groups and returned to baseline value after the resumption of TLV.Conclusions: Thoracic epidural bupivacaine, epidural sufentanil, and intravenous remifentanil-combined general intravenous anesthesia have comparable effects on shunt fraction and arterial oxygenation during OLV in patients undergoing thoracic surgery.

Methylene Blue for Vasopressor-Resistant Vasoplegia Syndrome During Liver Transplantation

Gregory W. Fischer, Ylva Bengtsson, Suzanne Scarola, Edmond Cohen — 2008-10-06

THE NUMBER OF liver transplant procedures is increasing worldwide. The ischemia-reperfusion syndrome seen during liver transplant surgery can manifest as a state of vasoplegia that frequently requires vasopressor support to maintain stable hemodynamics. Occasionally, the conventional treatment for vasoplegic syndrome (VS) (eg, phenylephrine, norepinephrine, or vasopressin) does not suffice to restore adequate systemic vascular resistance (SVR) and support systemic pressures. The first utilization of methylene blue (MB) as a last resort pharmacologic agent to treat vasopressor-refractory vasoplegic syndrome during liver transplantation surgery is reported.

Treatment of Refractory Hypotension With Low-Dose Vasopressin in a Patient Receiving Clozapine

Annie John, Clement Yeh, Jonathan Boyd, Philip E. Greilich — 2009-11-20

CLOZAPINE (Clozaril; Novartis Pharmaceuticals, Basel, Switzerland) is an atypical antipsychotic that is increasingly being used to treat refractory schizophrenia. It is classified as a tricyclic dibenzodiazepine derivative that was first introduced in Finland in 1975 and approved by the Food and Drug Administration for use in the United States in 1989. Clozapine exerts its influence by antagonizing a wide range of dopaminergic, serotonergic, cholinergic, histaminergic, and adrenergic receptors. Despite an incidence of agranulocytosis of up to 2% when first introduced, clozapine's relative freedom from extrapyramidal side effects and improved symptom control has led to its resurgence when used in conjunction with close monitoring of white blood cell counts. More recently, it has been discovered that these agents also cause α-adrenergic-receptor blockade, which can contribute to significant hemodynamic disturbances. A case of a patient receiving clozapine who experienced severe, intraoperative hypotension during general anesthesia, which was refractory to high-dose α-adrenergic agents, is presented.

Anticoagulation Management in a Patient With Antiphospholipid Antibodies Requiring Repeat Sternotomy

Michael Mazzeffi, Marc Stone, Paul Stelzer, David L. Reich — 2009-06-15

THE MANAGEMENT OF anticoagulation for cardiopulmonary bypass (CPB) in patients with antiphospholipid antibodies is challenging because antiphospholipid antibodies increase the risk for arterial and venous thrombosis and affect commonly used in vitro coagulation assays such as the kaolin-activated coagulation time.

Undiagnosed Type IIIc Gaucher Disease in a Child With Aortic and Mitral Valve Calcification: Perioperative Complications After Cardiac Surgery

Samuel A. Mireles, Jeannie Seybold, Glyn Williams — 2009-07-27

GAUCHER DISEASE, the most common form of lysosomal storage disease, is caused by an inherited deficiency of the β-glucocerebrosidase enzyme. Pathology results from the accumulation of glucocerebroside in the reticuloendothelial system; Gaucher disease generally manifests as 1 of 3 clinical variants: type I, type II, and type III. Type I (adult, chronic, nonneuronopathic) is the most common and mildest form. Patients often present with hepatosplenomegaly and a combination of anemia, thrombocytopenia, and leucopenia. They may have skeletal disease including osteopenia and Erlenmeyer flask deformity of the distal femur. A small number of type I patients develop interstitial lung disease and pulmonary hypertension. Patients with type II (infantile, acute, neuronopathic) have severe neurologic abnormalities; it is usually fatal within 2 years. Patients with type III (juvenile, subacute, neuronopathic) exhibit slowly progressive neurologic symptoms, including seizures and oculomotor apraxia that start in childhood or early adult life.

Real-Time Three-Dimensional Transesophageal Echocardiography and a Congenital Bilobar Left Atrial Appendage

Kevin Cummisford, Sugantha Sundar, Robert Hagberg, Feroze Mahmood — 2009-06-26

LIGATION/ISOLATION OF THE left atrial appendage (LAA) is often performed concomitantly with open cardiac procedures using cardiopulmonary bypass or as part of the thoracoscopic Maze procedure for arrhythmia surgery. During the thoracoscopic Maze procedure, bilateral successive minithoracotomies are performed for pulmonary vein isolation and LAA ligation via the left minithoracotomy. Intraoperative transesophageal echocardiography (TEE) is routinely performed during this procedure to rule out the presence of LAA thrombi, ensure complete ligation, and evaluate for a residual stump of the LAA after ligation. A case in which real-time 3-dimensional (RT3D) TEE was used to evaluate a questionable mass in the LAA before ligation and confirmed the diagnosis is presented.

Percutaneous Left Ventricular Assist Devices: Clinical Uses, Future Applications, and Anesthetic Considerations

Juan N. Pulido, Soon J. Park, Charanjit S. Rihal — 2010-01-07

THE EVOLUTION OF cardiovascular medicine has been dictated by the prevalence and high mortality of cardiovascular disease. The past 30 years have yielded an exponential increase in both knowledge and technologic progress in this field, from preventive cardiology and the movement toward gene therapy, to complex interventional therapeutics expanding the frontiers of minimally invasive procedures performed in the catheterization laboratory. These include high-risk percutaneous coronary interventions (PCIs) requiring temporary circulatory support and valvular interventions (percutaneous aortic valve replacement, mitral valvuloplasty).

Arterial Pressure Variation and Goal-Directed Fluid Therapy

Maxime Cannesson — 2009-12-18

FLUID MANAGEMENT AND OPTIMIZATION are daily problems in anesthesiology and in the critical care setting. Hemodynamic management is related to the optimization of oxygen delivery to the tissues and has been shown to be able to improve postoperative outcome and to decrease the cost of surgery. Schematically, in the operating room, the anesthesiologist and his/her patients have to deal with 2 distinct risks: hypovolemia on one side and hypervolemia on the other side. Both risks potentially can lead to a decrease in oxygen delivery to the tissues and to an increase in postoperative morbidity (). However, despite evidence showing that organ perfusion requires 2 physiologic objectives, adequate perfusion pressure in order to force blood into the capillaries of all organs and adequate cardiac output to deliver oxygen and substrates and to remove carbon dioxide and other metabolic products, and despite data showing the impact of cardiac output optimization on postoperative outcome, cardiac output monitoring rarely is used in the daily anesthesiology practice; clinicians still rely on clinical judgment, blood loss estimates, and the vague concept of third-space losses.

Transcatheter Aortic Valve Implantation—Part 1: Development and Status of the Procedure

Jens Fassl, John G.T. Augoustides — 2009-11-27

AORTIC VALVE STENOSIS is the most frequently acquired heart valve disease. Conventional aortic valve replacement (AVR) with cardiopulmonary bypass (CPB) is the gold standard and has yielded excellent results. In line with an increasing patient age, anesthesiologists, cardiologists, and surgeons are confronted with elderly patients and more comorbidities. The risk of surgery is higher in elderly patients with significant comorbidities. These include compromised left ventricular function, pulmonary hypertension, severe respiratory dysfunction, renal insufficiency, general atherosclerosis, and possible neurologic dysfunction. The criteria for high-risk patients are based on the EuroSCORE, the logistic EuroSCORE, and the Society of Thoracic Surgeons (STS) risk calculator. The European Association of Cardio-Thoracic Surgery, the European Society of Cardiologists, and the European Association of Percutaneous Cardiovascular Interventions published a position statement saying that transcatheter aortic valve implantation techniques should be restricted to high-risk patients or those with contraindications for surgery. The Edwards company advises the use of the Edwards SAPIEN transcatheter heart valve (Edwards Lifescienes, Irvine, CA) for use in patients with severe symptomatic aortic stenosis (aortic valve area <0.8 cm2) requiring aortic valve replacement who have high risk for operative mortality or are “nonoperable” as determined by one of the following risk assessments: a logistic EuroSCORE higher than 20 or an STS score higher than 10. Thus, it is of utmost interest to further develop minimally invasive therapeutic options in order to minimize the perioperative trauma and eventually improve postoperative patient outcome. The AVR with partial sternotomy and its advantages over AVR with full sternotomy may be one option for higher-risk patients. The advantages of the AVR with partial sternotomy are a shorter ventilation time, less blood loss, and shorter hospital and intensive care stays. This technique avoids a full sternotomy and minimizes the tissue dissection and trauma, even in redo surgery, but CPB is still necessary to perform this procedure. The conversion rate to conventional AVR is still 3%.

CASE 3—2010 Dynamic Partial Obstruction of the Tricuspid Valve Inlet Produced by Anterior Mediastinal Aspergillosis Invading the Right Atrium

2010-06-01

INVASIVE PULMONARY INFECTIONS caused by the opportunistic fungus Aspergillus fumigatus are common in immunocompromised patients and are notoriously difficult to treat successfully. Such infections frequently are encountered after solid organ or bone marrow transplantation and may also occur in patients with severe acquired immunodeficiency syndrome or those receiving chronic corticosteroid therapy for other indications. Primary cardiac aspergillosis or the spread of invasive pulmonary A fumigatus to the mediastinum, pericardium, or heart is exceedingly rare in the absence of previous cardiac surgery and carries a very high mortality rate. Long-term antifungal therapy combined with aggressive surgical management appear to afford patients with pulmonary or cardiac A fumigatus with the optimal chance for survival. In the current report, the authors describe their perioperative management of a debilitated, immunocompromised patient with a large anterior mediastinal Aspergillus abscess that invaded the right atrium and caused dynamic partial obstruction of the tricuspid valve inlet. The mediastinal abscess was debrided, the intracardiac fungal mass was excised, and the right atrium was repaired using femoral cardiopulmonary bypass (CPB) without the need for deep hypothermic circulatory arrest. The pathophysiology and management of disseminated pulmonary and cardiac aspergillosis are also discussed.

A Cavity in the Left Ventricular Outflow Tract: A Disastrous Consequence of Tooth Decay?

2009-03-13

A 55-YEAR-OLD, 122-kg, 178-cm man was admitted to the authors' institution for the evaluation of fever, weight loss, fatigue, and progressive dyspnea on exertion of 8 weeks' duration. The patient had undergone an uncomplicated minimally invasive aortic valve replacement with a 25-mm St Jude BioCor Epic bioprosthesis (St Jude Medical, Minneapolis, MN) for severe aortic stenosis 6 months before the current admission. Dental extractions were performed 3 months after this operation with appropriate antibiotic prophylaxis following established guidelines, but several dental caries extending into the tooth pulp and severe, generalized periodontal disease remained to be treated. The past medical history was also notable for poorly controlled diabetes mellitus (glycosylated hemoglobin = 10.1%), essential hypertension, hyperlipidemia, and chronic renal insufficiency (serum creatinine concentration = 1.6 mg/dL). The physical examination was significant for a coarse III of VI systolic murmur heard best at the right upper sternal border. A leukocytosis was observed (white blood cell count = 11.6 K/μL), 3 sets of blood cultures grew gram-positive cocci in chains, and antimicrobial therapy (consisting of vancomycin and ceftriaxone) was initiated. Transesophageal echocardiography (TEE) was performed as part of the evaluation and revealed the following images (). What is the diagnosis?

Echocardiography in Acute Native Aortic Valve Endocarditis

2009-06-25

A 75-YEAR-OLD man was urgently transferred from a peripheral hospital to the authors' institution with a diagnosis of acute native aortic valve endocarditis. At admission, the patient was hemodynamically stable. His past medical history included colectomy for colon cancer a year earlier. He had been admitted recently to the hospital for the onset of a low-grade fever (in the previous 6 months), increasing shortness of breath, and fatigue. He eventually underwent a splenectomy for a splenic abscess. A subsequent echocardiogram revealed a dilated left ventricle with preserved contractility and a large vegetation on the noncoronary cusp of the aortic valve, resulting in severe aortic valve regurgitation. Moreover, to clarify the extension of the valve lesion, an emergency transesophageal echocardiogram (TEE) was performed. What do these TEE images suggest ()?

Anterior Chest Discomfort and Right Neck Pain in a Young Woman 2 Days After an Appendectomy

2009-06-25

A 27-YEAR-OLD, 165-cm, 64-kg woman presented to the authors' institution for evaluation of a 1-day history of nausea and bilateral lower quadrant pain (right > left). The white blood cell count was elevated (13,700 cells/μL), and acute appendicitis was suspected. An abdominal computed tomography (CT) scan was performed that confirmed this diagnosis. The patient had a past medical history of temporomandibular joint (TMJ) disease and tobacco abuse. She had undergone several previous interventions for ovarian cysts and recurrent endometriosis that were complicated by postoperative nausea and vomiting. She reported jaw pain after these procedures but denied that she had been a difficult intubation, according to her previous anesthesiologists. Physical examination of the upper airway indicated limited mouth opening (approximately 3.5 cm) as a result of TMJ disease and a Mallampati score of II. The patient was transported to the operating room for an open appendectomy. After induction, a direct laryngoscopy was attempted by using a GlideScope video laryngoscope (Verathon, Bothell, WA), but the patient's restricted mouth opening made inserting the large flange of the video laryngoscope blade difficult. Instead, a blind intubation was easily accomplished on the first attempt by using a light wand stylet and a 7.0 endotracheal tube (Mallinckrodt, St Louis, MO). The stylet was removed immediately after a bright light was observed in the proximal sternal notch as recommended. The cuff of the endotracheal tube was inflated to seal and secured at 21 cm at the lips. The intraoperative course was uncomplicated, and the patient was extubated in the operating room without apparent complication. The patient initially made an uneventful recovery, but she subsequently reported anterior chest discomfort and right neck pain on the 2nd postoperative day. She denied shortness of breath. There were no signs or symptoms of respiratory insufficiency or distress. Arterial oxygen saturation (pulse oximetry) was normal with the patient breathing room air. A physical examination indicated the presence of extensive soft-tissue crepitus in the right neck and upper chest consistent with subcutaneous emphysema. A chest radiograph () and a thoracic CT scan () were obtained. What is the diagnosis?

Innovations in Aortic Disease Management: The Descending Aorta

Michael Andritsos, Nimesh D. Desai, Ashanpreet Grewal, John G.T. Augoustides — 2010-04-16

THERE HAVE BEEN major innovations in the clinical management for pathologies of the descending thoracic aorta. The beginning of this revolution began with the gradual introduction of endovascular interventions in the past decade. This section introduces the more recent advances that are reviewed in this article. Although serum markers such as matrix metalloproteinases and D-dimer have diagnostic utility in acute aortic dissection, C-reactive protein recently has emerged as an independent indicator of prognosis in acute type-B aortic dissection. Although thoracic endovascular aortic repair (TEVAR) has an emerging role in complicated type-B dissection, its role in acute uncomplicated type-B dissection is yet to be determined. Although underpowered, a recent landmark randomized trial showed that TEVAR is equivalent to the best medical therapy in the short term for this acute type-B subtype. Further prospective evaluation of TEVAR is required to establish conclusively whether it should replace the best medical therapy as the treatment of choice for acute uncomplicated type-B dissection. Because malperfusion in acute type-B dissection confers a significant risk for an adverse outcome, urgent intervention with open or endovascular reconstruction typically is indicated. A recent study has provided long-term acceptable data in this type-B subtype after percutaneous revascularization with intimal fenestration and/or aortic branch-vessel stenting. This management strategy deserves further attention as the optimal management of malperfusion in type-B dissection is investigated in future trials. The repair of a thoracoabdominal aortic aneurysm (TAAA) is associated with a significant risk of renal dysfunction caused, in part, by ischemia and also a myoglobin release from perioperative rhabdomyolysis. Recent studies have suggested at least 2 nephroprotective strategies. The first strategy entails intraoperative intermittent cold crystalloid renal perfusion during TAAA repair to decrease renal oxygen demand; the addition of cold blood in this strategy did not enhance nephroprotection. The second strategy is to ensure lower-extremity perfusion during TAAA repair; this is associated with less myoglobin release most likely caused by reduced rhabdomyolysis.

Cardiac Calendar—2010 to 2012

George Silvay — 2010-04-12

Annual Meeting of the European Association of Cardiothoracic Anesthesiologists. Edinburgh, Scotland, UK. June 9-11, 2010. Contact: www.eacta.org, e-mail: eacta2010@mci-group.com.

Levosimendan and Platelet Function

Kürşad Kaptan, Cengiz Beyan — 2009-07-27

We are very interested in a recent report by Zangrillo et al's meta-analysis of 5 randomized controlled trials investigating the influence of levosimendan in patients' outcome after cardiac surgery. Their primary endpoint of the meta-analysis was postoperative cardiac troponin release. They reported that levosimendan was associated with significant reductions in cardiac troponin peak release and in time to hospital discharge. In this meta-analysis, the authors concluded that levosimendan was associated with a significant reduction in cardiac troponin release in patients undergoing cardiac surgery and had cardioprotective effects. The authors did not investigate adverse events related to treatments in this meta-analysis. However, we should take into consideration the side effects of drugs when using them. For this reason, we would like to provide the possible effect of levosimendan on platelets. Recently, the effect of levosimendan on platelet function has been investigated. The study results displayed that levosimendan significantly inhibited aggregation of platelets induced by adenosine phosphatase and collagen, and there was a relationship between the levosimendan concentration and the inhibition of platelet aggregation, although the mechanism of action of it is not known. On the other hand, the clinical significance of the antiaggregatory effect of levosimendan is also not known.

Anesthetic Management of a Patient With Giant Right Atrial Myxoma

Tsuyoshi Tagawa, Masahiro Okuda, Shigeki Sakuraba — 2009-07-30

A 68-year-old asymptomatic man presented to our hospital for excision of a right atrial mass. It was unexpectedly discovered by an abdominal computed tomography (CT) scan during evaluation for gastrointestinal bleeding. The CT scan showed an 8.9 × 6.7 × 6.7 cm large mass occupying most of the right atrial cavity ().

Failure of Action of Neuromuscular Blocking Agents in a Patient With Severe Vasoconstriction Caused by Infused Vasopressors Following a Mitral Valve Replacement

Murali Chakravarthy — 2009-07-31

A 35-year-old woman weighing 42 kg suffering from severe mitral stenosis, tricuspid regurgitation, pulmonary hypertension, and chronic atrial fibrillation underwent mitral valve replacement and Maze procedure under general anesthesia (uneventful endotracheal intubation using intravenous rocuronium). The termination of cardiopulmonary bypass required inotropic support with intravenous infusions of 10 μg/kg/min of dopamine, 0.05 μg/kg/min of epinephrine, and 0.05 μg/kg/min of norepinephrine in order to sustain a mean arterial pressure of 60 mmHg. The patient was transferred to the cardiac surgical intensive care unit for further postoperative management. Mechanical ventilation was continued with an inspired oxygen concentration of 0.8. The patient continued to have a low-cardiac-output syndrome despite continuing the vasopressor and inotropic medications. The rectal temperature was normal. On the first postoperative day, her clinical condition further deteriorated. The mean arterial pressure remained below 40 mmHg, and urine output was absent over 4 hours. The patient was unconscious. The arterial blood gas showed worsening acidosis. A decision to start intravenous infusions of 5 μg/kg/min of dobutamine and 6 U/h of vasopressin was made to produce a possible beneficial effect by the combined use of an inodilator (dobutamine) and vasoconstrictor. The mean arterial pressure increased to 60 mmHg. Anuria and acidosis persisted despite the increase in the mean arterial pressure. Peripheral arterial pulses were found to be absent.

Missing Sponge: Clinical Signs

Hemant Digambar Waikar — 2009-06-05

I read with interest an article (case conference) titled “Retrograde Sponge-Induced Homodynamic Instability After Cardiac Surgery” by Gadinglajkar et al. The authors report an incident wherein a surgical sponge placed posterior to the heart during cardiopulmonary bypass was detected by intraoperative transesophageal echocardiography (TEE) to be the cause of unstable hemodynamics in the post-CPB period. In the discussion, they extensively highlighted the role of TEE in cardiac anesthesia.

Transesophageal Echocardiography in Identifying Fungal Vegetations in the Right Cardiac Chambers in an Intensive Care Unit Patient

2009-07-31

Echocardiography is currently considered one of the main tools in the diagnosis and treatment of infective endocarditis. By using echocardiography, it is possible to localize the site of vegetations exactly and also to estimate their extent in the cardiac chambers.

Assessment of Neurocognitive Function and Neuroprotective Strategies in Cardiac Surgery

Gabor Erdoes, Reto Basciani — 2009-08-31

We read with interest the article published by Sahu et al in which the authors report the findings of 2 different rewarming strategies in patients undergoing coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The authors conclude that weaning from CPB at a nasopharyngeal temperature of 33°C (v 37°C) followed by passive rewarming in the intensive care unit (ICU) may be a useful strategy to lower postoperative neurocognitive dysfunction and to decrease morbidity.

A Simple Method for Obtaining a “Ramped” Laryngoscopy Position After Anesthetic Induction

Marek Brzezinski, Alex Lee, Elena J. Holak, Paul S. Pagel — 2009-07-30

Establishing optimal patient position before direct laryngoscopy is essential for ensuring the best possible view of the vocal cords. The head-elevated (“ramped”) laryngoscopy position may be superior to the “sniff” position in patients with obesity. This “ramped” position may be achieved before anesthetic induction by arranging blankets, pillows, or solution bags beneath the patient's shoulders and head or using a progressively sloped positioning cushion with or without placing the operating table in a reverse Trendelenburg position. These maneuvers may facilitate visualization of glottic structures during direct laryngoscopy by horizontally aligning the external auditory meatus and the sternal notch. However, performing such major adjustments in the patient's position to achieve a more ideal “ramped” position after anesthetic induction (eg, when confronted by an unanticipated difficult airway) may risk injury to the patient and operating room personnel and may also cause inadvertent disconnection of monitoring devices, hemodynamic instability, or transient interruptions in effective bag-mask ventilation.

Journal of Cardiothoracic and Vascular Anesthesia

Masthead

Editorial Board

Contents

Articles to Appear in Future Issues

Guide for Authors

The New-Generation Hydroxyethyl Starch Solutions: The Holy Grail of Fluid Therapy or Just Another Starch?

A New Plasma-Adapted Hydroxyethyl Starch Preparation: In Vitro Coagulation Studies

Volume Replacement With a Balanced Hydroxyethyl Starch (HES) Preparation in Cardiac Surgery Patients

In Vitro Comparative Study of Hemostatic Components in Warfarin-Treated and Fibrinogen-Deficient Plasma

Risk Factors for Red Blood Cell Transfusion After Coronary Artery Bypass Graft Surgery

The Effect of the Suspension of the License for Aprotinin on the Care of Patients Undergoing Cardiac Surgery: A Survey of Cardiac Anesthesiologists' and Surgeons' Opinions in the United Kingdom

Profound Effects of Cardiopulmonary Bypass Priming Solutions on the Fibrin Part of Clot Formation: An Ex Vivo Evaluation Using Rotation Thromboelastometry

Association of the 98T ELAM-1 Polymorphism With Increased Bleeding After Cardiac Surgery

A Comparison of Central and Mixed Venous Oxygen Saturation in Circulatory Failure

Intensive Care Unit Utilization and Outcome After Esophagectomy

A Propensity-Matched Comparison of the Incidence of New-Onset Postoperative Atrial Arrhythmias in Cardiac and Noncardiac Thoracic Surgery Patients

Weaning Mechanical Ventilation After Off-Pump Coronary Artery Bypass Graft Procedures Directed by Noninvasive Gas Measurements

The Effect of Thoracic Epidural Anesthesia on Pulmonary Shunt Fraction and Arterial Oxygenation During One-Lung Ventilation

Methylene Blue for Vasopressor-Resistant Vasoplegia Syndrome During Liver Transplantation

Treatment of Refractory Hypotension With Low-Dose Vasopressin in a Patient Receiving Clozapine

Anticoagulation Management in a Patient With Antiphospholipid Antibodies Requiring Repeat Sternotomy

Undiagnosed Type IIIc Gaucher Disease in a Child With Aortic and Mitral Valve Calcification: Perioperative Complications After Cardiac Surgery

Real-Time Three-Dimensional Transesophageal Echocardiography and a Congenital Bilobar Left Atrial Appendage

Percutaneous Left Ventricular Assist Devices: Clinical Uses, Future Applications, and Anesthetic Considerations

Arterial Pressure Variation and Goal-Directed Fluid Therapy

Transcatheter Aortic Valve Implantation—Part 1: Development and Status of the Procedure

CASE 3—2010 Dynamic Partial Obstruction of the Tricuspid Valve Inlet Produced by Anterior Mediastinal Aspergillosis Invading the Right Atrium

A Cavity in the Left Ventricular Outflow Tract: A Disastrous Consequence of Tooth Decay?

Echocardiography in Acute Native Aortic Valve Endocarditis

Anterior Chest Discomfort and Right Neck Pain in a Young Woman 2 Days After an Appendectomy

Innovations in Aortic Disease Management: The Descending Aorta

Cardiac Calendar—2010 to 2012

Levosimendan and Platelet Function

Anesthetic Management of a Patient With Giant Right Atrial Myxoma

Failure of Action of Neuromuscular Blocking Agents in a Patient With Severe Vasoconstriction Caused by Infused Vasopressors Following a Mitral Valve Replacement

Missing Sponge: Clinical Signs

Transesophageal Echocardiography in Identifying Fungal Vegetations in the Right Cardiac Chambers in an Intensive Care Unit Patient

Assessment of Neurocognitive Function and Neuroprotective Strategies in Cardiac Surgery

A Simple Method for Obtaining a “Ramped” Laryngoscopy Position After Anesthetic Induction