Journal of Cardiothoracic and Vascular Anesthesia

Masthead

2010-02-01

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

2010-02-01

Articles to Appear in Future Issues

2010-02-01

Esmolol Reduces Perioperative Ischemia in Noncardiac Surgery: A Meta-analysis of Randomized Controlled Studies G. Landoni, S. Turi, G. Biondi-Zoccai, E. Bignami, V. Testa, I. Belloni, G. Cornero, and A. Zangrillo; Milan, Italy

Guide for Authors

2010-02-01

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.

East Joins West

Joel A. Kaplan — 2010-02-01

THE MEMBERS OF the Editorial Board of the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) and the Journal's publisher, Elsevier, Inc, are pleased to announce a new affiliation with the Chinese Society of Cardiovascular and Thoracic Anesthesiologists (CSCVTA) of the Chinese Society of Anesthesiologists (CSA), starting with this issue of the Journal. JCVA is pleased to become the official journal of the CSCVTA at this important time of international growth and collaboration among cardiovascular specialists, educators, and researchers around the world.

The Cardiothoracic and Vascular Anesthesia Session at the 2009 Annual Meeting of the Chinese Society of Anesthesiologists

Ru-Jin Zhang, Yun Yue — 2010-02-01

THE ANNUAL MEETING is always a highlight of the Chinese Society of Anesthesiologists (CSA). The 2009 annual meeting of the CSA was held on September 4-6, at The Shanghai International Convention Center, which is located in the heart of Lujiazui, Shanghai's financial and trade zone, adjacent to the Oriental Pearl TV Tower and facing the multinational architecture along the Bund across the Huangpu River.

Ordinary Images—Extraordinary Stories: Echo Challenges and Clinical Decisions

Feroze Mahmood, Madhav Swaminathan — 2010-02-01

TRANSESOPHAGEAL echocardiography (TEE) is fast assuming the role of an essential monitor in cardiac operating rooms (ORs). Its role has evolved from an alternative to epicardial echocardiography during cardiac surgery to be classified as a category I indication during congenital and valve repair cardiac surgery. The diagnostic and therapeutic uses of TEE cross medical disciplines, and the indications are determined by the circumstances of its use (eg, cardiologists commonly use it for the evaluation of intracardiac masses and the placement of percutaneous closure devices and anesthesiologists have traditionally used TEE for intraoperative monitoring during cardiac surgery). Gradually, the use of perioperative TEE is transitioning from being exclusively a monitoring modality during cardiac surgery to use during high-risk noncardiac surgery. Despite its widespread use by anesthesiologists (cardiac and noncardiac), the degree of therapeutic impact of TEE on perioperative decision-making is controversial. This perhaps could be caused by the difficulty in defining the nature and degree of therapeutic impact. Also, it is quite possible that because of the supportive nature of information gained from TEE, the therapeutic impact is significantly underestimated.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2009

2010-02-01

The hybrid operating room is the venue for transcatheter therapy with the convergence of 3 specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Because pharmacologic conditioning and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia, and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass graft (CABG) surgery. Although off-pump CABG surgery is equivalent to on-pump CABG surgery, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel recently was approved for platelet blockade in PCI, it may be superseded by ticagrelor. Although PCI and CABG surgery appear equivalent for multivessel coronary disease, CABG surgery lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Because eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide, and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements.

Aortic Valve Replacement With or Without Coronary Artery Bypass Graft Surgery: The Risk of Surgery in Patients ≥80 Years Old

Andrew Maslow, Paula Casey, Athena Poppas, Carl Schwartz, Arun Singh — 2009-10-13

Objective: The purpose of this study was to evaluate the outcomes for elderly (≥80 years) patients undergoing aortic valve replacement (AVR) with or without coronary artery bypass graft surgery (AVR/CABG). The authors hypothesized that the mortalities of AVR and AVR/CABG are lower than that predicted by published risk scores.Design: A retrospective analysis of data from a single-hospital database.Setting: Single tertiary care, private practice.Participants: Consecutive patients undergoing AVR or AVR/CABG.Measurements: Two hundred sixty-one elderly (≥80 years) patients undergoing isolated AVR (145) or AVR/CABG (116) were evaluated. The majority (94.6%) underwent AVR for aortic valve stenosis. Outcomes were recorded and compared between the 2 surgical procedures with predicted mortalities based on published risk assessment scoring systems.Results: The overall short-term mortality for the elderly group was 6.1% (AVR 5.5% and AVR/CABG 6.9%). The median long-term survival was 6.8 years. There were no significant differences in either morbidity or mortality between the AVR and AVR/CABG groups. Although predicted mortalities were similar for each surgical procedure, they overestimated observed outcome by up to 4-fold.Conclusions: Short- and long-term mortality was low for this group of elderly patients undergoing AVR or AVR/CABG and not significantly different between the 2 surgical groups. Predicted outcomes were worse than that observed, consistent with the hypothesis, and supportive of a more aggressive surgical treatment for aortic valve disease in the elderly patient.

Effect of Aortic Valve Surgery on Left Ventricular Diastole Assessed by Echocardiography and Neuroendocrine Response: Percutaneous Versus Surgical Approach

2009-11-30

Objectives: Aortic valve implantation through peripheral vascular access is an option for high-risk patients with severe aortic valve stenosis. The authors aimed to compare the acute effect of endovascular and surgical aortic valve procedures on left ventricular diastolic function.Design: A case-matched, nonrandomized study.Setting: A university hospital.Participants: Patients with aortic stenosis.Interventions: B-natriuretic peptide was measured in 30 patients with a logistic EuroSCORE ≥20% undergoing endovascular aortic valve implantation. Patients were case matched (age, mitral flow propagation velocity, mitral annulus early diastolic velocity, and B-natriuretic peptide measurement) with 30 control patients undergoing surgical aortic valve replacement through sternotomy. Left ventricular diastole was evaluated initially and after valve procedures with echocardiography by mitral flow propagation velocity and mitral annulus early diastolic velocity.Measurements and Main Results: B-natriuretic peptide was similar preoperatively in the 2 groups (346 [188-438] v 367 [211-458] pg/mL) and higher (p = 0.006) in the surgical group postoperatively (389.5 [237-479] v 710.5 [389-822] pg/mL), with a postprocedural statistically significant increase only in the surgical group. Diastolic function was similar in the 2 groups preoperatively, improved postoperatively in the endovascular group, and worsened in the surgical group.Conclusions: B-natriuretic peptide increased after surgical but not after endovascular aortic valve replacement. Furthermore, endovascular aortic valve implantation acutely improved left ventricular diastolic function as documented by increases in mitral flow propagation velocity and mitral annulus early diastolic velocity.

Outcome After Implantation of Cardiac Resynchronization/Defibrillation Systems in Patients With Congestive Heart Failure and Left Bundle-Branch Block

2009-10-05

Objective: The implantation of cardiac resynchronization/defibrillation devices (CRT-Ds) increasingly is used in patients with congestive heart failure and left bundle-branch block. There are no data on the effects of anesthesia and surgery on outcome after implantation.Design: A retrospective, observational study; postoperative survey.Setting: University hospital.Participants: Three hundred forty-one patients (258 men/83 women, 63 ± 9 years) with congestive heart failure and left bundle-branch block who underwent CRT-D implantation in 1996 to 2005.Measurements and Main Results: Perioperative data were retrieved from the patients' records. Cardiologists caring for the patients were contacted to obtain information on current New York Heart Association (NYHA) status and mortality after CRT-D implantation. Preoperatively, 45 patients were classified as NYHA II, 246 as NYHA III, and 50 as NYHA IV. CRT was performed via thoracotomy in 100 and transvenously in 241 cases. General anesthesia (propofol or sevoflurane and remifentanil) was performed in 273 and local anesthesia (lidocaine) in 68 patients. Hypotension occurred mainly during general anesthesia (43% v 4%). The 30-day mortality was 0%. The postoperative survey started in 2006 and was completed by 215 patients. The mean survival time was 77 months; 151 patients survived the study period. Outcome was not influenced by local and general anesthesia. Presence of preoperative NYHA class >II (odds ratio [OR] = 1.6, confidence interval [CI] = 0.5-5.1), mitral regurgitation (OR = 2.5, CI = 1.2-5.5), and serum creatinine >1.1 mg/dL (OR = 3.0, CI = 1.5-6.2) resulted in an inferior prognosis.Conclusions: In patients with severely impaired cardiac function, general anesthesia for the implantation of a biventricular pacing device can be used with justifiable risk. The method of anesthesia did not influence outcome.

Left Ventricular Longitudinal Strain for Perioperative Cardiac Monitoring in Aortic Aneurysm Surgery Using Transthoracic 2-Dimensional Echocardiography: A Feasibility and Repeatability Study

2009-08-24

Objective: This study investigated perioperative echocardiographic image quality, the feasibility, and intra- and interobserver repeatability of left ventricular longitudinal two-dimensional strain echocardiography (2DSE) in aortic aneurysm surgery.Design: A prospective, descriptive method evaluation.Setting: A single-center study.Participants: Eighteen patients undergoing elective open infrarenal aortic aneurysm repair.Intervention: No intervention was made.Measurements and Main Results: Four echocardiographic examinations were made: E1, preoperatively; E2, within 4 hours after surgery; E3, the first postoperative day; and E4, the second postoperative day. Four-chamber, 2-chamber, and longitudinal axis apical views were achieved. Image quality was scored visually on a scale from 1 to 5 with 5 as the best, and the 2-dimensional strain echocardiography (2DSE) software was applied to measure peak systolic strain. Blinded analyses were performed twice by 1 observer and once by a second observer. Image quality decreased significantly after surgery as compared with the preoperative examination, but 72% of patients had at least 1 image scoring ≥3 through all examinations. The software was able to measure the segmental and global left ventricular peak systolic strain in 80% and 61%, respectively, for the first observer and 71% and 26%, respectively, for the second observer. The coefficients of repeatability for intra- and interobserver measurements were 5.5% and 7.3% for segmental strain and 1.6% and 3.5% for global strain. 2DSE was more feasible and repeatable when echocardiographic images were good.Conclusion: Feasibility and repeatability of 2DSE is good but affected by image quality. This study shows that 2DSE can be used in a clinical setting.

Epicardial Real-Time 3-Dimensional Echocardiography With the Use of a Pediatric Transthoracic Probe: A Technical Approach

2009-08-31

Objective: The aim of the present study was to suggest a simple and comprehensive method for performing real-time 3-dimensional (3D) epicardial echocardiography with a pediatric probe small enough for the surgical field. Intraoperative echocardiography is a necessary tool for planning and performing cardiac surgery. Although epicardial intraoperative echocardiography is intended for few patients, it is a part of an exhaustive approach to intraoperative echocardiography.Design: An observational feasibility study.Setting: A community hospital, single-institutional study.Participants: Eighty consecutive adult patients undergoing cardiac surgery.Interventions: All patients were examined with 3D epicardial echocardiography before and after cardiopulmonary bypass; x-plane, live 3D, and 3D full-volume imaging modalities were systematically recorded. Feasibility and acquisition time were assessed. The image quality was evaluated by 3 independent surgeons.Measurements and Main Results: Four sequential positions were determined to achieve a complete 3D heart examination focused on the structure of most interest. Acquisition plus elaboration did not require more than 20 minutes.Conclusions: Three-dimensional epicardial echocardiography is feasible, and in the x-plane modality it is quicker than standard epicardial 2-dimensional examination. According to the judgment of independent observers, it provides high-quality and reproducible images, which are particularly valuable for mitral valve repair.

Reducing Mortality in Cardiac Surgery With Levosimendan: A Meta-analysis of Randomized Controlled Trials

2009-08-24

Objectives: The authors performed a meta-analysis to evaluate whether levosimendan is associated with improved survival in patients undergoing cardiac surgery.Design: A meta-analysis.Setting: Hospitals.Participants: A total of 440 patients from 10 randomized controlled studies were included in the analysis.Interventions: None.Measurments and Main Results: Four investigators independently searched BioMedCentral and PubMed. Inclusion criteria were random allocation to treatment, comparison of levosimendan versus control, and cardiac surgery patients. Exclusion criteria were duplicate publications, nonhuman experimental studies, and no mortality data. The primary endpoint was postoperative mortality. Levosimendan was associated with a significant reduction in postoperative mortality (11/235 [4.7%] in the levosimendan group v 26/205 [12.7%] in the control arm, odds ratio = 0.35 [0.18-0.71], p for effect = 0.003, p for heterogeneity = 0.22, I2 = 27.4% with 440 patients included), cardiac troponin release, and atrial fibrillation. No difference was found in terms of myocardial infarction, acute renal failure, time on mechanical ventilation, intensive care unit, and hospital stay.Conclusions: Levosimendan has cardioprotective effects that could result in a reduced postoperative mortality. A large randomized controlled study is warranted in this setting.

Effects of Fenoldopam Mesylate on Central Hemodynamics and Renal Flow in Patients Undergoing Cardiac Surgery: Color Doppler Echocardiographic Evaluation

Massimo Meco, Silvia Cirri — 2009-06-25

Objective: The purpose of this study was to evaluate the effect of 0.1 μg/kg/min of fenoldopam mesylate on renal flow and central hemodynamics measured by echocardiography in hemodynamically stable patients with preserved renal function undergoing cardiac surgery.Design: Experimental observational study.Setting: Single-institutional community hospital study.Participants: Thirty patients undergoing cardiac surgery.Intervention: Fenoldopam mesylate infusion (0.1 μg/kg/min) in patients undergoing cardiopulmonary bypass.Measurements and Main Results: Doppler measurements of renal blood flow and echocardiographic hemodynamic determinations after Doppler echocardiography measured flux velocities of the main, segmental, and interlobar and interlobular right renal arteries. The authors calculated the resistive index of all the renal segments studied. Moreover, the authors measured the flux of the main renal artery and its diameter as well as the main hemodynamic variables. All the measurements were performed in the intensive care unit setting at baseline and 20 minutes after the infusion of 0.1 μg/kg/min of fenoldopam mesylate. Fenoldopam mesylate infusion significantly increased blood flow in all renal compartments, thus improving the resistive index. The study showed that fenoldopam mesylate infusion does not induce any significant change of the heart rate or arterial pressure, cardiac output, preload, or wall stress.Conclusions: In hemodynamically stable cardiac surgery patients with preserved renal function, an infusion of 0.1 μg/kg/min of fenoldopam mesylate has no influence on systemic hemodynamics while increasing renal blood flow.

A Prospective, Randomized Study of the Effects of Continuous Ultrafiltration in Hepatic Patients After Cardiac Valve Surgery

2009-10-05

Objectives: The use of continuous ultrafiltration may be effective in preventing the hepatic decompensation in cirrhotic patients after valvular heart surgery with cardiopulmonary bypass (CPB). The authors aimed to evaluate the effects of continuous ultrafiltration on the need for blood transfusion, liver function tests, duration of postoperative ventilatory support, and the length of the intensive care unit (ICU) stay in cirrhotic patients undergoing valvular heart surgery.Design: A prospective, randomized double-blinded placebo study.Setting: A single university hospital.Participants: Sixty cirrhotic patients scheduled for valvular surgery.Interventions: After local ethics committee approval and informed consent, participants were divided into 2 groups. In the conventional ultrafiltration (CUF) group (n = 30), CPB was used with conventional ultrafiltration. In the continuous ultrafiltration group (n = 30), in addition to the same CUF procedure, modified ultrafiltration was used after CPB.Measurements and Main Results: Perioperative liver function tests, hematocrit, platelet count, the postoperative ventilation time, ICU and hospital length of stay, complications, and mortality were recorded. After CPB, patients receiving continuous ultrafiltration had a shorter time to extubation, postoperative ventilation time and ICU and hospital length of stay (p < 0.01), lower bleeding (p < 0.01), greater rise in hematocrit (11.3% ± 2.39% v 4.7% ± 1.22%, p = 0.001) and platelet count (7.0 ± 3.0 v 0.8 ± 0.21 104/μmL, p = 0.001), higher albumin levels (p < 0.001), and lower plasma levels of bilirubin, aminotransferase, alkaline phosphatase, and γ-glutamyl transpeptidase (p < 0.02). There was no significant difference between the 2 groups in the dosage of nitroglycerin or epinephrine, morbidity, or mortality.Conclusions: The authors concluded that continuous ultrafiltration reduced postoperative bleeding and blood transfusions, improved liver function, and shortened the hospital stay in cirrhotic patients after valvular heart surgery.

Preoperative Heparin Therapy Causes Immune-Mediated Hypotension Upon Heparin Administration for Cardiac Surgery

2010-02-01

Objective: To evaluate whether patients with positive or negative heparin antibodies who received heparin preoperatively by continuous infusion developed cardiovascular changes upon heparin administration prior to cardiopulmonary bypass.Design: Clinical trial.Setting: Single institution, academic hospital.Participants: Eighty (80) patients with good ventricular function on low-dose heparin infusion prior to surgery.Interventions: Patients were divided into 2 equal groups: group A had negative heparin antibodies (% ratio < 0.26), group B had positive heparin antibodies (% ratio > 1.2). All patients received heparin, 400 units/kg, prior to institution of cardiopulmonary bypass. Cardiovascular changes, activated coagulation time (ACT), and histamine levels were measured before and 5 minutes after administration of heparin. Platelets also were counted before and 6 hours after surgery.Measurements and Main Results: Significant hypotension and decreased cardiac index occurred in patients with positive heparin antibodies who received heparin prior to cardiac surgery. Histamine levels increased significantly 5 minutes after heparin administration. Significant thrombocytopenia occurred 6 hours after surgery in group B patients. There was a good correlation between heparin antibodies, histamine levels, thrombocytopenia and cardiovascular changes. Group B patients also had heparin resistance as manifested by a lower ACT after the loading doses of heparin.Conclusion: Patients with positive heparin antibodies pretreated with heparin prior to surgery developed a type of immune-mediated cardiovascular changes and postoperative thrombocytopenia.

Safety and Efficacy of Tranexamic Acid Compared With Aprotinin in Thoracic Aortic Surgery With Deep Hypothermic Circulatory Arrest

2009-08-31

Objectives: This study was conducted to evaluate the safety and efficacy of high-dose tranexamic acid (TA) compared with aprotinin in patients who underwent thoracic aortic surgery with deep hypothermic circulatory arrest (DHCA).Design: A retrospective study.Participants: Eighty-four patients underwent thoracic aortic surgery with DHCA arrest between July 2006 and December 2007. Antifibrinolytic efficacy and perioperative outcomes were compared between the groups by appropriate statistical tests.Measurements and Main Results: Demographic data, comorbid conditions, aortic pathology, surgical procedures, and operative data were comparable between groups. The use of blood products tended to be more in the TA group, despite the fact that the aprotinin group had longer CPB duration. Thirty-day mortality was 5 of 48 (10.4%) in the aprotinin group versus 5 of 36 (13.9%) in the TA group (p = 0.44). Neurologic, cardiac, and respiratory dysfunctions were comparable as well as intensive care unit and hospital stay. Serum creatinine increased significantly postoperatively in both groups, with more patients in the aprotinin group developing stage 1 postoperative renal dysfunction based on Acute Kidney Insufficiency Network criteria. Multivariate logistic regression analysis identified risk factors for postoperative renal dysfunction including preoperative creatinine clearance, blood transfusion, and sepsis. Throughout the study, both drugs were available for use, allowing selective bias for providers.Conclusions: Aprotinin appeared more effective in reducing blood product use after thoracic aortic surgery in this limited cohort. Aprotinin use also appeared to be associated with postoperative renal dysfunction. The choice of antifibrinolytic appeared to not be associated with cardiac, neurologic, or respiratory outcomes or survival after thoracic aortic surgery requiring DHCA.

Insulin Therapy in Divided Doses Coupled With Blood Transfusion Versus Large Bolus Doses in Patients at High Risk for Hyperkalemia During Liver Transplantation

2009-04-13

Objective: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation.Design: Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation.Setting: University-based, academic, tertiary center.Participants: Adult patients whose baseline potassium levels were ≥4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007.Interventions: Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation.Measurements and Main Results: Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001).Conclusions: The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.

Revised Cardiac Risk Index (Lee) and Perioperative Cardiac Events as Predictors of Long-term Mortality in Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair

Sylvia Archan, Christopher R. Roscher, Ronald M. Fairman, Lee A. Fleisher — 2009-06-26

Objective: To determine if the Revised Cardiac Risk Index (Lee) is useful for stratification of patients by risk of both perioperative cardiac morbidity and long-term all-cause mortality in the setting of endovascular repair of abdominal aortic aneurysms.Design: This study was designed as a retrospective review.Setting: It was conducted at a single academic medical institution.Participants: The analysis included 225 patients with abdominal aortic aneurysms admitted to the authors' institution from 1999 to 2006.Interventions: All patients underwent endovascular aortic aneurysm repair.Measurements and Main Results: Data were collected from medical records, office charts, and physician quality-assurance databases. There were no in-hospital cardiac deaths. The major adverse cardiac event rate in the perioperative period was 6.2%. Long-term all-cause mortality was 23%. Univariate analysis showed that a history of coronary artery disease (CAD) (likelihood ratio [LR] = 8.7, p = 0.023), history of congestive heart failure (LR = 4, p = 0.042), and a Revised Cardiac Risk Index (RCRI) ≥3 (LR = 8.6, p = 0.004) were significant predictors for perioperative major adverse cardiac events. A history of CAD (LR = 10.7, p = 0.002), echocardiographic evidence of myocardial infarction (LR = 8.5, p = 0.006), exercise tolerance of only 1 block (LR = 8.4, p = 0.005), RCRI ≥3 (LR = 5.6, p = 0.022), and perioperative cardiac events (LR = 15.9, p < 0.0001) were significantly associated with long-term all-cause mortality. Perioperative cardiac events remained highly significant in predicting long-term mortality within the RCRI ≥3 subgroup (LR = 6.1, p = 0.019).Conclusions: The results of this study confirm that long-term mortality remains high after endovascular repair of abdominal aortic aneurysms. The Lee index may be a useful tool for stratification of high-risk patients from both a short- and long-term perspective in the setting of endoluminal graft repair.

Time Course of Desflurane-induced Preconditioning in Rabbits

2009-05-21

Objectives: The authors tested the hypothesis that volatile anesthetic-induced preconditioning (APC) follows a similar time pattern as that described for ischemic preconditioning and that delayed APC is mediated by nitric oxide.Design: A prospective randomized vehicle-controlled study.Setting: A university research laboratory.Subjects: New Zealand white rabbits (n = 75).Methods: Rabbits were instrumented for the measurement of systemic hemodynamics and subjected to a 30-minute coronary artery occlusion (CAO) and 3 hours of reperfusion. Desflurane (1.0 minimum alveolar concentration) was administered for 30 minutes and was discontinued 0.5 hours, 2 hours, 3 hours, 12 hours, 24 hours, 48 hours, 72 hours, and 96 hours before CAO, respectively. In 2 separate experimental groups, the nitric oxide synthase inhibitor N-omega-nitro-L-arginine (L-NA) was administered 72 hours after the administration of 0.0 or 1.0 minimum alveolar concentration of desflurane. The infarct size was determined gravimetrically. Data are mean ± standard deviation.Results: Desflurane significantly (p < 0.05) reduced the infarct size compared with the control (63% ± 12%, n = 7) when administered 0.5 hours (35% ± 5%, n = 7), 2 hours (35% ± 9%, n = 7), 24 hours (31% ± 8%, n = 7), 48 hours (30% ± 11%, n = 6), and 72 hours (39% ± 5%, n = 6) before CAO. However, when desflurane was administered 3 hours (53% ± 9%, n = 7), 12 hours (71% ± 6%, n = 7), or 96 hours (66% ± 5%, n = 7) before CAO, the myocardial infarct size was not reduced. The second window (72 hours) of preconditioning was abolished by the NOS inhibitor L-NA (52% ± 16%, n = 7). L-NA alone had no effect on infarct size (64% ± 11%, n = 7).Conclusions: Desflurane induces a first (0.5-2 hours) and second window of preconditioning (24-72 hours) in the rabbit model of acute myocardial infarction. The second window of APC is mediated by nitric oxide.

Cardioprotection Afforded by St Thomas Solution Is Enhanced by Emulsified Isoflurane in an Isolated Heart Ischemia Reperfusion Injury Model in Rats

Han Huang, Wensheng Zhang, Shanling Liu, Chen Yanfang, Tao Li, Jin Liu — 2010-02-01

Objective: The purpose of this study was to investigate whether adding emulsified isoflurane to St Thomas cardioplegia solution could enhance the cardiac protection after cardioplegic arrest in rats.Design: A randomized, blind study.Setting: A university laboratory.Participants: Thirty male Sprague-Dawley rats.Interventions: Thirty isolated heart preparations were randomly divided into 3 groups (n = 10/group) according to the different cardioplegia solutions being given: St Thomas solution mixed with emulsified isoflurane (containing 2.8% of isoflurane, group EI), St Thomas solution mixed with emulsified Intralipid (Huarui Pharmacy, Wuxi, Jiangsu, China) (group EL), and St Thomas solution alone (group St). In the 35-minute normothermic ischemia period, infusion of cardioplegia solution was repeated every 15 minutes. After the 35-minute ischemia period, the heart was perfused with Krebs-Henseleit buffer for another 2 hours.Measurements and Main Results: The functional parameters of the heart were monitored throughout the experiments. The coronary effluent was collected for measuring the activity of CK-MB 30 minutes after reperfusion, and the infarct size was assessed at the end of reperfusion. The infarct size in group EI (24% ± 4%) was reduced when compared with that in group EL (31% ± 8%, p < 0.05) and group St (43% ± 9%, p < 0.001). The CK-MB activity in group EI was decreased significantly when compared with that in group EL and group St (p < 0.05). The functional recovery in group EI also was improved. Compared with standard St Thomas solution alone, adding 30% Intralipid alone also significantly reduced the infarct size and the CK-MB leakage and improved the recovery of the mechanical function.Conclusions: St Thomas cardioplegia solution supplemented with emulsified isoflurane enhanced its cardioprotection in an isolated heart ischemia reperfusion injury model in rats.

High Transoxygenator Pressure Gradient in a Patient With Polycythemia Vera

Matthew A. Fieldwalker, Shannon C. Jackson, Douglas Seal — 2009-04-13

POLYCYTHEMIA VERA (PV) is a chronic myeloproliferative disorder characterized by an absolute increase in red blood cell mass. In well over 90% of cases, a somatic mutation in hematopoietic precursors (JAK2V617F) is causative. This acquired mutation results in growth factor hypersensitivity and increased proliferation of erythroid, myeloid, and megakaryocyte lineages. The most common presentation is polycythemia with or without thrombocytosis, leukocytosis, splenomegaly, and arterial or venous thrombosis. Symptoms of hyperviscosity including headaches, visual disturbances, dizziness, weakness, and paresthesias can be subtle and easily overlooked. Extreme thrombocytosis (>1,000 × 109/L) also can occur and contributes, paradoxically, to an increased risk of hemorrhagic complications.

Nonfatal Intracardiac Thromboembolism During Liver Transplantation

2009-03-13

INTRACARDIAC THROMBOEMBOLISM is a severe complication that can occur during orthotopic liver transplantation (OLT). The risk for thromboembolic complications in this setting is related to several factors such as excessive activation of the coagulation system, venous stasis, activators released form the grafted liver, and massive blood transfusions. The authors report a case of a nonfatal right atrial thrombus during the native hepatectomy of a cirrhotic patient undergoing OLT in which no antifibrinolytics, anticoagulants, thrombolytics, or embolectomy were necessary.

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery in a Pregnant Woman With Preeclampsia

Daniel Lazar, Liza J. Enriquez, Tatyana Rozental — 2009-07-27

BLAND-WHITE-GARLAND SYNDROME, also known as anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA), accounts for 0.26% of all congenital heart defects, with an occurrence of 1 in 300,000 live births. The mortality of this congenital anomaly is approximately 90% without surgical correction in the first years of life. A case of a previously asymptomatic woman with ALCAPA who developed preeclampsia during pregnancy and heart failure is presented. The authors review the natural history and pathophysiology of this rare anomaly and the anesthetic principles in the management of these patients.

Intraoperative Diagnosis of Aortic Dissection in Pregnancy

Ryan Crowley, Jennifer Corniea, David Chavez, Jonathan K. Ho, Aman Mahajan — 2009-05-18

AORTIC DISSECTION in young patients is primarily associated with trauma, cocaine use, chronic hypertension, bicuspid aortic valve, congenital coarctation of the aorta, or connective tissue disorders such as Marfan, Turner, and Ehrlos-Danlos syndromes. Aortic dissection during pregnancy is rare, and reported cases are associated with underlying risk factors. However, because of the low incidence of aortic dissection in pregnant women, clinical suspicion may remain low, leading to a delayed or missed diagnosis. Furthermore, the management of acute aortic dissection in the presence of fetal distress during late pregnancy is not well described. The authors report a unique case of a pregnant patient mistakenly diagnosed with myocardial infarction (MI) secondary to acute coronary syndrome who presented to the operating room (OR) for emergent Cesarean section with heart failure and fetal distress. Although the patient had no underlying risk factors for aortic pathology, intraoperative echocardiography identified an acute ascending aortic dissection, leading to successful simultaneous repair of the dissection and operative delivery of the baby.

Use of a Transesophageal Echocardiographic Probe as a Surface Probe for Evaluating the Size, Position, and Patency of the Internal Jugular Veins

Julia Stevenson, Nil Ural, Pierre LeVan, Jayanta Mukherji — 2009-07-27

SEVERAL DEVICES ARE now commercially available to allow for direct ultrasound (US) visualization of vascular structures in order to facilitate central venous cannula (CVC) placement. The authors report a case in which the use of a transesophageal echocardiographic (TEE) probe as a surface probe altered the site of CVC placement.

Single-Ventricle Patient: Pathophysiology and Anesthetic Management

Galina Leyvi, John D. Wasnick — 2009-10-29

A VARIETY OF pathologic conditions give rise to a single-ventricle (SV) physiology. This occurs when one of the ventricles is hypoplastic or absent. These patients often require a series of procedures to provide effective palliation. Surgical therapy commits the single ventricle to the delivery of oxygenated blood to the systemic circulation. Deoxygenated blood is directed to the pulmonary circulation bypassing the ventricle. With improved surgical techniques and medical care, SV patients are living longer. However, over time, they can present with a number of comorbidities related to SV physiology. Additionally, many SV patients appear in need of anesthesia for routine general and obstetric procedures. Anesthesiologists, generalists, and subspecialists alike increasingly may encounter the patient with SV physiology. This review highlights the anatomy and physiology of the SV patient before, during, and after surgical palliation. Anesthetic challenges presented by the SV patient are reviewed.

Neuroprotection by Ketamine: A Review of the Experimental and Clinical Evidence

Judith A. Hudetz, Paul S. Pagel — 2009-07-30

NEUROPROTECTION MAY BE DEFINED AS the “prevention or amelioration of neuronal damage evidenced by abnormalities in cerebral metabolism, histopathology or neurologic function occurring after a hypoxic or an ischemic event.” Thus, the prevention of cerebral ischemia and the recovery of neural tissue that already has sustained an ischemic insult represent essential goals of neuroprotection. Neuroprotection may occur as a consequence of reduced O2 demand, enhanced O2 delivery, or attenuation of pathologic processes that contribute to cellular injury or death. For decades, the dissociative sedative-hypnotic ketamine has been considered to be relatively contraindicated in the presence of ischemic brain injury or an intracerebral mass because the drug increases cerebral metabolic rate for O2 (CMRO2), cerebral blood flow (CBF), and intracranial pressure (ICP). However, this traditionally held supposition may not be entirely correct because ketamine also may have the potential to exert important neuroprotective effects against ischemic damage. Ketamine inhibits N-methyl-D-aspartate (NMDA) receptor activation and excitotoxic signaling, reduces neuronal apoptosis (programmed cell death), attenuates the systemic inflammatory response to tissue injury, and also maintains cerebral perfusion pressure as a result of sympathetic nervous system activation. These actions of ketamine may act to offset its detrimental effect on cerebral blood flow and metabolism, especially under conditions in which arterial CO2 tension is controlled during mechanical ventilation. In the setting of cardiac surgery with or without cardiopulmonary bypass (CPB), cerebral ischemia may be characterized by global or regional dysfunction resulting from hypoperfusion and microembolization.

Cardioprotection by Noble Gases

Paul S. Pagel — 2009-05-21

THE POTENTIAL FOR noble gases to produce anesthesia was initially suggested 70 years ago by Behnke and Yarbrough, who reported the development of progressive “narcosis” in United Stated Navy divers exposed to 80% argon or krypton in 20% oxygen under hyperbaric conditions (≤10 atm). This hypothesis was subsequently verified in mice and human volunteers exposed to xenon in experiments conducted shortly after the end of World War II. However, the ability of these anesthetic and other nonanesthetic (helium and neon) monatomic gases to protect myocardium against reversible and irreversible ischemia-reperfusion injury has only been recognized recently. The majority of research conducted to date has examined the cardioprotective effects of xenon, in large part, because this noble gas, in contrast to argon and krypton, exerts anesthetic and analgesic effects under normal (as opposed to hyperbaric) atmospheric pressure conditions. Xenon has a very low blood-gas solubility coefficient (0.14), produces rapid induction of and emergence from anesthesia, does not cause teratogenic effects or undergo biotransformation, and is essentially devoid of cardiovascular effects. These physical properties and clinical characteristics suggest that xenon may be especially useful as an inhaled anesthetic; a contention has certainly been supported by several recent investigations that confirmed its safety and utility in patients with and without heart disease. All noble gases exist in modest-to-trace amounts within the atmosphere (ranging from 1:107 [0.94%] for argon to 1:11.5 million [8.7 × 10−6%] for xenon) and, with the single exception of helium, are extracted from liquefied air by sequential cryogenic fractional distillation. The production cost of these noble gases increases in proportion to their relative scarcity, and, as a result, clinical use of xenon has been quite limited to date precisely because of its atmospheric rarity. Nevertheless, interest in xenon has been rekindled in the past 2 decades because of the development of minimal gas flow and recycling technologies that may eventually reduce the relative cost of xenon and make it more competitive with volatile agents and nitrous oxide.

Extracorporeal Membrane Oxygenation for Treating Severe Cardiac and Respiratory Failure in Adults: Part 2—Technical Considerations

2009-10-29

IN THIS SECOND OF 2 articles on the use of extracorporeal membrane oxygenation (ECMO) for treating severe cardiac and respiratory failure in adults, the physiology, technical considerations, and complications of this technique are reviewed. Although ECMO remains a technically and logistically demanding undertaking, recent advances in the design of circuit components, particularly the oxygenator, have improved the ease of use and durability of the technique, such that extracorporeal support can be maintained relatively safely for several weeks.

Case 1—2010 Pulmonary Thrombectomy in an Adult With Fontan Circulation

Brantley Dollar Gaitan, Harish Ramakrishna, James A. DiNardo, Maxime Cannesson — 2010-02-01

THE ADULT POPULATION WITH congenital heart disease (CHD) is increasing due to advances in surgical and medical management, with an estimated 850,000 adults with CHD and more than 20,000 patients with CHD transitioning into adulthood annually. This heterogeneous group includes patients with various modifications of the Fontan procedure; a distinct population of particular complexity who require specialized attention and periodic follow-up with their medical care into adulthood. As the adult population who had the Fontan procedure continues to expand, causes of long-term morbidity, including arrhythmias, cyanosis due to systemic venous collateralization, ventricular failure, protein-losing enteropathy, and thrombotic complications, are recognized with increasing frequency. The authors report a thrombotic complication in an adult patient with Fontan circulation who presented with a pulmonary embolus and underwent catheterization and percutaneous intervention. Given the high rate of thromboembolic complications of Fontan patients and their increasing survival into adulthood, this is a presentation that will likely increase in frequency, and percutaneous intervention may be the most conservative option in this high-risk population. Anesthetic implications and the management of patients for this procedure, and more specifically in this clinical scenario, have not been described previously.

Pro: The General Anesthesiologist Should Be Trained and Certified in Transesophageal Echocardiography

Sheldon Goldstein — 2009-11-27

DESPITE MONITORING OF routine hemodynamic variables, many patients develop complications of cardiovascular origin while undergoing noncardiac surgery. Not only is monitoring of routine hemodynamic variables insufficient to accurately diagnose and treat hemodynamic instability, it does not even ensure maintenance of intravascular volume. Transesophageal echocardiography (TEE) allows multiplane imaging of the myocardium, heart chambers and valves, pericardium, and great vessels and the assessment of blood flow characteristics and the timing of intracardiac events. It is an excellent intraoperative hemodynamic monitor. TEE has aided in the diagnosis of numerous discrete entities and determination of the etiology of hemodynamic instability, hypoxemia, and cardiac arrest. Many published reports indicate that the problem was not diagnosed until TEE examination was performed and that TEE directly contributed to patients' survival. The question then arises: should the modern-era general anesthesiologist be trained and certified in TEE? The answer is clearly yes.

Con: General Anesthesiologists Should Not Be Trained and Certified in Basic Transesophageal Echocardiography

Michael Green, Amardeep Singh Heyer — 2009-12-14

THE DEVELOPMENT OF novel medical technology is often driven by the desire to improve patient care and outcome. During the 1960s, cardiac surgery experienced an explosive growth, and the demand for monitoring and measuring surgical interventions and cardiac parameters broadened. These demands led to the development of transesophageal echocardiography (TEE). Since its introduction, the uses for TEE have increased significantly, especially in the operating room, because it allows clinicians to continually monitor cardiac performance and evaluate surgical repairs. As TEE functionality advances, it has posed challenges on issues of training, certification, and credentialing among professional organizations, most notably within the field of anesthesia. Conventionally, in a cardiac anesthesia fellowship, TEE training is part of the curriculum. However, this is not traditionally part of a general anesthesiology residency. Although exposure to TEE in general anesthesiology residency does occur, there are limited studies on training guidelines and in-service examinations regarding TEE in academic medical centers. The following question then arises: should general anesthesiologists train and certify in basic TEE while considering the issues of certification and training, cost-benefit ratio, and, most importantly, the impact on patient care?

Rheumatic Mitral and Aortic Stenosis: To Replace or Not To Replace—That Is the Question—Part 1

Melanie Darke, John Pawloski, Kamal R. Khabbaz, Feroze Mahmood — 2010-02-01

See accompanying editorial by Feroze Mahmood and Madhav Swaminathan: “Ordinary Images—Extraordinary Stories: Echo Challenges and Clinical Decisions” on page 5 of this issue.

A Rare Cause of Mitral Regurgitation in an Elderly Man Undergoing Aortic Valve Replacement

Jaymin R. Shah, Christopher N. Deyo, Paul S. Pagel — 2008-12-22

AN 81-YEAR-OLD, 65-kg, 164-cm man was admitted to the authors' institution for the evaluation of progressive dyspnea and fatigue. The patient denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, and peripheral edema. His past medical history was notable for tobacco abuse, essential hypertension, and hyperlipidemia. The physical examination was remarkable for a grade 3 of 6 crescendo-decrescendo systolic murmur that was loudest at the right upper sternal border and radiated throughout the chest. Transthoracic echocardiography showed a heavily calcified aortic valve with profoundly restricted motion. The peak transvalvular gradient and estimated aortic valve area were 78.7 mmHg and 0.58 cm2, respectively, estimated by continuous-wave Doppler echocardiography. These findings were consistent with severe aortic stenosis. There was no evidence of subaortic valvular stenosis or left ventricular (LV) outflow tract obstruction. Mitral and aortic insufficiency of mild and moderate severity, respectively, were also noted. The LV ejection fraction was estimated to be 60%. LV concentric hypertrophy was present, but no regional wall motion abnormalities were observed. A cardiac catheterization confirmed these echocardiographic findings and also showed the presence of hemodynamically significant stenoses in the left anterior descending and left circumflex coronary arteries. The patient was transported to the operating room for aortic valve replacement and coronary artery bypass graft surgery. After anesthetic induction and endotracheal intubation, transesophageal echocardiography (TEE) was performed that revealed the following images ( and ). What is the diagnosis?

A Missing Left Ventricular Mass

Cortessa Russell, Daniel G. Swistel, Diane Anca, Zak Hillel, John D. Wasnick — 2009-03-06

A 61-YEAR-OLD man with a history of coronary artery disease presented with a syncopal episode and a history of dizziness. A computed tomography scan showed a right occipital and posterior parietal infarction. The initial transesophageal echocardiogram (TEE) is presented in and (supplementary videos accompanying this article are available online). Cardiac catheterization showed 3-vessel coronary artery disease with mildly depressed ventricular function.

Innovations in Aortic Disease: The Ascending Aorta and Aortic Arch

John G.T. Augoustides, Michael Andritsos — 2009-12-14

Significant innovations have defined the approach to the proximal thoracic aorta. Aortic proteolysis predisposes to dissection and aneurysm. Losartan may prevent aortic root dilation in Marfan syndrome. The Loeys-Dietz syndrome mandates early aortic intervention. Because genetic aortopathies have a multicenter registry, further aortic molecular advances are likely. Acute intramural hematoma (IMH) may be due to aortic dissection with unrecognized microintimal tears. Type-A IMH is often a surgical emergency, whereas type-B IMH often requires medical management. Because preoperative ischemia predicts mortality in type-A dissection, it is logical to classify this disease by ischemic presentation. Because advanced age worsens the outcome in type-A dissection, transcatheter interventions should be urgently developed for this high-risk subgroup. Aortic arch repairs shorter than 45 minutes in duration are safely performed under deep hypothermic circulatory arrest with/without perfusion adjuncts. Bilateral antegrade cerebral perfusion (ACP) offers the best neuroprotection for complex repairs longer than 45 minutes. Axillary artery cannulation improves outcomes in proximal thoracic aortic procedures. Contralateral hemispheric ischemia is possible with unilateral ACP because cross-cerebral perfusion may be inadequate. Arch repair with ACP and moderate HCA is safe and effective and represents a research opportunity for pharmacologic ischemic preconditioning. Antegrade thoracic aortic stenting for DeBakey 1 dissection thromboses the distal false lumen to improve long-term aortic outcomes. Endovascular arch repair is feasible and may soon be done off-pump. These described innovations have collectively ushered in a paradigm shift in diseases affecting the ascending aorta and aortic arch.

Cardiac Calendar—2010 to 2012

George Silvay — 2010-02-01

30th Annual Cardiothoracic Surgery Symposium. Newport Beach, CA. March 4-7, 2010. Contact: e-mail: kmorgan@amainc.com, www.amainc.com. 30th International Symposium on Intensive Care and Emergency Medicine. Brussels, Belgium. March 23-26, 2010. Contact: Erasmus University Hospital, Route de Lennik 808, B-1070 Brussels, Belgium, e-mail: veronique.de.vlaeminck@nlb.ac.be.

Levosimendan and Cardiac Surgery

Vincenzo De Santis, Domenico Vitale, Luigi Tritapepe — 2009-03-06

We appreciated the article by De Hert et al recently published in the Journal. The authors showed that the initiation of levosimendan treatment before cardiopulmonary bypass was associated with better postoperative outcome. They also showed a higher postoperative stroke volume and a significant reduction in inotropic use in the pretreated patients. However, the authors did not find any benefit with levosimendan pretreatment in terms of troponin I release. They ascribed this difference from previous studies both to the different patient population and to the volatile anesthetic regimen.

A Novel Technique for Easy Identification of the Subclavian Vein During Ultrasound-Guided Cannulation

Tanguturu Muralikrishna, Thomas Koshy, Satyajeet Misra, Prabhat Kumar Sinha — 2009-03-13

Ultrasound (US) is used increasingly as an aid in the cannulation of the subclavian vein (SCV), which is the preferred site for long-term central venous catheter placement. Several methods are described for the differentiation of the SCV from the subclavian artery; they include nonpulsatility, position of the vein in relation to the artery, variation of lumen size with respiration, identification of confluence of the SCV and internal jugular vein, valves in the lumen of the vein, and Doppler interrogation of the flows. However, imaging of the SCV can be difficult after multiple attempts (because of hematoma and compression of the lumen) and in patients who are obese with a short neck. Thus, the inability to properly identify subclavian vessels can be a major limitation to the usage of US. We describe a simple technique to immediately distinguish the SCV from the subclavian artery during US-guided cannulation.

Transesophageal Echocardiography in Detecting Tricuspid Valve Pathology in an Intensive Care Unit Patient

2009-03-13

The tricuspid valve (TV) is composed of 3 leaflets (anterior, posterior, and septal), chordae tendinae, papillary muscles, annulus, and right ventricular (RV) walls. The role of transesophageal echocardiography (TEE) in detecting anomalies of the TV is well established. Transgastric (TG) views of TEE are used to achieve a more detailed visualization of the complex geometry of the TV; furthermore, TG views usually provide the best images of the tricuspid chordae tendinae because they are perpendicular to the ultrasound beam. We report a modified TG view here that may add further insight into the anatomic evaluation of the TV in the intensive care unit setting.

Decreased Nitric Oxide Products in the Urine of Patients Undergoing Cardiac Surgery

Miguel Ángel Palomero Rodríguez, Luis María Cacharro Moras, Luis Suárez Gonzalo — 2009-06-26

We read with interest the study by Lema et al. In this interesting article, the authors established whether the release of the endothelial vasodilator nitric oxide (NO) or NO products is altered in patients undergoing surgery with cardiopulmonary bypass (CPB) in 3 different clinical conditions. They took samples for NO products (NOx) before and during hypo- and normothermic CPB and 1 hour postoperatively in 30 patients assigned to 3 groups: elective coronary artery surgery, elective coronary artery surgery randomized to 2 hematocrit values during CPB, and pediatric patients undergoing surgical repair of noncyanotic cardiac defects. They found a significant decrease of NO products, which they attributed to the physiologic response to CPB.

In Response: Decreased Nitric Oxide Products in the Urine of Patients Undergoing Cardiac Surgery

Guillermo Lema, Jorge Urzúa, Roberto Jalil — 2009-06-25

We thank Dr Palomero Rodríguez and colleagues for their comments and review regarding nitric oxide (NO) changes in the postoperative period of cardiac surgery. We agree that in the context of inflammatory conditions and trauma, changes in NO production may indicate some form of endothelial dysfunction. However, correct interpretations of those changes are still lacking. The correlation between NO changes and postoperative condition is, at the most, speculative.

Use of the Proseal Laryngeal Mask Airway and Arndt Bronchial Blocker for Lung Separation in a Patient With a Tracheal Mass and Aspiration Risk

Sivan Wexler, Ju-Mei Ng — 2009-07-27

In the December 2008 issue of JCVA, Robinson et al reported on the combined use of a laryngeal mask airway (LMA) and a bronchial blocker (BB) to provide lung isolation in a patient with a recent tracheostomy in whom options for single-lung ventilation were limited. We report the novel use of a Proseal LMA (PLMA; LMA North America, Inc, San Diego, CA) with the Arndt BB (Cook Critical Care, Bloomington, IN) for lung separation in a patient at aspiration risk in whom a tracheal mass prevented the safe placement of a tracheal tube.

Journal of Cardiothoracic and Vascular Anesthesia

Masthead

Editorial Board

Contents

Articles to Appear in Future Issues

Guide for Authors

East Joins West

The Cardiothoracic and Vascular Anesthesia Session at the 2009 Annual Meeting of the Chinese Society of Anesthesiologists

Ordinary Images—Extraordinary Stories: Echo Challenges and Clinical Decisions

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2009

Aortic Valve Replacement With or Without Coronary Artery Bypass Graft Surgery: The Risk of Surgery in Patients ≥80 Years Old

Effect of Aortic Valve Surgery on Left Ventricular Diastole Assessed by Echocardiography and Neuroendocrine Response: Percutaneous Versus Surgical Approach

Outcome After Implantation of Cardiac Resynchronization/Defibrillation Systems in Patients With Congestive Heart Failure and Left Bundle-Branch Block

Left Ventricular Longitudinal Strain for Perioperative Cardiac Monitoring in Aortic Aneurysm Surgery Using Transthoracic 2-Dimensional Echocardiography: A Feasibility and Repeatability Study

Epicardial Real-Time 3-Dimensional Echocardiography With the Use of a Pediatric Transthoracic Probe: A Technical Approach

Reducing Mortality in Cardiac Surgery With Levosimendan: A Meta-analysis of Randomized Controlled Trials

Effects of Fenoldopam Mesylate on Central Hemodynamics and Renal Flow in Patients Undergoing Cardiac Surgery: Color Doppler Echocardiographic Evaluation

A Prospective, Randomized Study of the Effects of Continuous Ultrafiltration in Hepatic Patients After Cardiac Valve Surgery

Preoperative Heparin Therapy Causes Immune-Mediated Hypotension Upon Heparin Administration for Cardiac Surgery

Safety and Efficacy of Tranexamic Acid Compared With Aprotinin in Thoracic Aortic Surgery With Deep Hypothermic Circulatory Arrest

Insulin Therapy in Divided Doses Coupled With Blood Transfusion Versus Large Bolus Doses in Patients at High Risk for Hyperkalemia During Liver Transplantation

Revised Cardiac Risk Index (Lee) and Perioperative Cardiac Events as Predictors of Long-term Mortality in Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair

Time Course of Desflurane-induced Preconditioning in Rabbits

Cardioprotection Afforded by St Thomas Solution Is Enhanced by Emulsified Isoflurane in an Isolated Heart Ischemia Reperfusion Injury Model in Rats

High Transoxygenator Pressure Gradient in a Patient With Polycythemia Vera

Nonfatal Intracardiac Thromboembolism During Liver Transplantation

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery in a Pregnant Woman With Preeclampsia

Intraoperative Diagnosis of Aortic Dissection in Pregnancy

Use of a Transesophageal Echocardiographic Probe as a Surface Probe for Evaluating the Size, Position, and Patency of the Internal Jugular Veins

Single-Ventricle Patient: Pathophysiology and Anesthetic Management

Neuroprotection by Ketamine: A Review of the Experimental and Clinical Evidence

Cardioprotection by Noble Gases

Extracorporeal Membrane Oxygenation for Treating Severe Cardiac and Respiratory Failure in Adults: Part 2—Technical Considerations

Case 1—2010 Pulmonary Thrombectomy in an Adult With Fontan Circulation

Pro: The General Anesthesiologist Should Be Trained and Certified in Transesophageal Echocardiography

Con: General Anesthesiologists Should Not Be Trained and Certified in Basic Transesophageal Echocardiography

Rheumatic Mitral and Aortic Stenosis: To Replace or Not To Replace—That Is the Question—Part 1

A Rare Cause of Mitral Regurgitation in an Elderly Man Undergoing Aortic Valve Replacement

A Missing Left Ventricular Mass

Innovations in Aortic Disease: The Ascending Aorta and Aortic Arch

Cardiac Calendar—2010 to 2012

Levosimendan and Cardiac Surgery

A Novel Technique for Easy Identification of the Subclavian Vein During Ultrasound-Guided Cannulation

Transesophageal Echocardiography in Detecting Tricuspid Valve Pathology in an Intensive Care Unit Patient

Decreased Nitric Oxide Products in the Urine of Patients Undergoing Cardiac Surgery

In Response: Decreased Nitric Oxide Products in the Urine of Patients Undergoing Cardiac Surgery

Use of the Proseal Laryngeal Mask Airway and Arndt Bronchial Blocker for Lung Separation in a Patient With a Tracheal Mass and Aspiration Risk