Journal of Cardiothoracic and Vascular Anesthesia - Articles in Press

Postoperative N-terminal Pro–Brain Natriuretic Peptide Level in Coronary Artery Bypass Surgery With Ventricular Dysfunction After Perioperative Glucose-Insulin-Potassium Treatment - Corrected Proof

2012-01-30

Objective: The aim of this study was to clarify the efficacy of perioperative glucose-insulin-potassium (GIK) infusion on preoperative and postoperative N-terminal (NT)-pro–brain natriuretic peptide (BNP) concentrations in patients with a low ejection fraction undergoing isolated on-pump coronary artery bypass graft (CABG) surgery. Design: A double-blind, randomized, controlled study. Setting: Modarres Hospital, Tehran, Islamic Republic of Iran. Patients: Sixty-six patients with a low ejection fraction who required coronary artery surgery were selected. Intervention: Patients were allocated to a GIK (n = 36) or a control (n = 30) group. The GIK group received GIK solution (500 mL of dextrose in water (DW) 10% + 40 U of regular insulin + 40 mEq of KCl, and 2 g of MgSO4) at a rate of 1 mL/kg/h for 10 hours preoperatively and until the removal of the aortic cross-clamp. The control group received half saline solution as placebo with an equivalent infusion rate during the same interval. Measurements and Main Results: Serum NT-proBNP levels were measured before starting the GIK, at the time of anesthesia induction, and 24 hours after surgery. The primary outcome measures were preoperative and postoperative NT-proBNP level. The amount of elevation in postoperative NT-proBNP concentrations was less prominent in the GIK group than in the control group (2,601 ± 1,799 pg/mL v 4,732 ± 4,127 pg/mL; p = 0.02). The patients in the GIK group were extubated sooner (495 ± 92 minutes) than the control group (774 ± 224 minutes; p = 0.002). The overall extubation time was 606 ± 177 minutes. Delayed requirement for mechanical ventilation was significantly more in the controls compared with the GIK group (45.8% v 13.9%, p = 0.004). Conclusions: GIK is of value in the reduction of post–cardiac surgery NT-proBNP elevation. Thus, its infusion should have a protective effect in patients with low ejection fraction undergoing CABG surgery. Further studies may prove GIK infusion benefits in high-risk CABG surgery patients optimize outcome.

Should Cervical and Thoracic Osteophytes Be a Contraindication for Transesophageal Echocardiography in Cardiac Surgery? - Corrected Proof

Hany Elsayed, Michael Shackcloth — 2012-01-30

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has been used in the operating room with increasing frequency since the early 1980s, and its safety has been reported across many centers. The diagnosis of esophageal injury is rare but should be considered in the postoperative setting after cardiac surgery using TEE, with an incidence of one in 1,000 major injuries. A case of delayed presentation of esophageal injury in a patient after cardiac surgery is described. The location and shape of the tear suggested the cause to be compression of the esophagus against a thoracic vertebral osteophyte.

Response: Role of True Cardiopulmonary Bypass Time and Acute Kidney Injury After Cardiopulmonary Bypass - Corrected Proof

Avinash B. Kumar, Manish Suneja — 2012-01-30

We thank Dr Dexter for his interest in our article titled “Association Between Postoperative Acute Kidney Injury and Duration of Cardiopulmonary Bypass: A Meta-Analysis.” In a number of previously published multivariate logistic regression models, cardiopulmonary bypass (CPB) time is a known risk factor in the development of acute kidney injury (AKI) CPB. The pathophysiology of AKI CPB is linked closely to the use of extracorporeal circulation. The risk of AKI is lower when the surgical technique does not use CPB, as supported by the American Heart Association position statement. CPB time, as stated in our article, is determined by several factors, including the type of surgery, the severity of the illness, the complexity of the repair, and the experience of the surgeon. The “skin-to-skin” surgical time and the CPB times are significantly different, and the CPB times are not typically scheduled. Hence, the actual CPB time is clinically relevant to the outcome being studied.

Improvement of PaO2 During One-Lung Ventilation With Partial Left-Heart Bypass in Pediatric Patients Is Caused by Increased Blood Flow to the Dependent Lung - Corrected Proof

Koichi Yuki, Kelly Chilson, James A. DiNardo — 2012-01-30

LEFT-HEART BYPASS (LHB) removes a portion of oxygenated pulmonary venous blood from the left atrium for delivery to a distal aortic site or the femoral artery. Partial LHB is often used in thoracoabdominal aneurysm repair in adults, whereas aortic coarctation surgery is a main indication in the pediatric population. The advantages of this technique when using a centrifugal pump without a venous reservoir or an oxygenator/heat exchanger include a reduction in left ventricular afterload and continuous distal aortic perfusion, which potentially reduces renal, splanchnic, and spinal cord ischemic times. Another potential advantage of partial LHB is the improvement of arterial partial pressure of oxygen (PaO2) during one-lung ventilation (OLV) as has been shown in adults undergoing thoracoabdominal aneurysm repair. Two cases in children are described in which LHB during OLV substantially improved PaO2. The authors postulate that decompression of the left atrium during partial LHB and OLV increases the proportion of total pulmonary blood delivered to the dependent lung by increasing the gradient between the pulmonary arterial and venous pressures in the dependent lung. In addition, the mathematic modeling to explain the physiology responsible for this finding is presented.

Duration of Cardiopulmonary Bypass and Outcome - Corrected Proof

Franklin Dexter — 2012-01-30

Kumar et al performed a meta-analysis modeling the association between the duration of cardiopulmonary bypass (the dependent variable) and the presence/absence of acute kidney injury (the independent variable). Stratification was not made by the surgical procedure. To obtain an unbiased estimate for the association between duration and outcome, the procedures need to be tested for inclusion in the statistical model. The testing needs to include procedures defined in sufficient detail to differentiate between effects on the outcome of procedures of different durations versus longer durations per se. The conclusion that “longer cardiopulmonary bypass times are associated with a higher risk of developing acute kidney injury” requires additional investigation.

Evaluation of Aspirin's Effect on Platelet Function Early After Coronary Artery Bypass Grafting - Corrected Proof

2012-01-27

Objective: Aspirin therapy decreases mortality and ischemic complication rates after coronary artery bypass grafting (CABG). However, platelet inhibition after oral aspirin seems to be insufficient in the early postoperative period. There are incomplete data reporting aspirin efficacy early after CABG. The aim of this study was to assess the pharmacologic effect of aspirin on platelets in the first postoperative days using the most specific laboratory tests for the evaluation of aspirin efficacy. Design: A prospective study. Setting: A clinical study in one cardiac surgery center and measurements in two pharmacologic institutions. Participants: Thirty patients. Interventions: Postoperative aspirin efficacy (200 mg/d) was assessed by the suppression of serum thromboxane B2 (TxB2) and by arachidonic acid-induced aggregometry using the MULTIPLATE analyzer. Samples were collected before surgery and on postoperative days 1-5. Methods and Main Results: The median baseline value (range) of serum TxB2 was 1.6 ng/mL (1.4-1.9). The median TxB2 inhibition >90% (the value required for full platelet inhibition) was not achieved until day 5 (−91%, 0.13 ng/mL [0.08-0.22], p < 0.001) and in only 55% of patients. The median baseline ASPI value was 805 (640-975) aggregation units (AU)*min. A significant decrease in aspirin insufficiency was not seen before postoperative day 5 (390 [243-621], p < 0.003) and only 34% of patients reached an effective platelet inhibition on day 5 (cutoff < 300 AU*min). Conclusions: The effect of aspirin on inhibition of TxB2 production and arachidonic acid-induced platelet aggregation is impaired during the first postoperative days after CABG. A more effective antiplatelet strategy presumably could increase early graft patency and improve clinical outcomes after CABG.

Heparin-Induced Thrombocytopenia After Cardiac Surgery: An Observational Study of 1,722 Patients - Corrected Proof

2012-01-24

Objectives: To assess the characteristics and prognosis of patients in whom heparin-induced thrombocytopenia (HIT) was confirmed (HIT+) among suspected HIT patients after having cardiac surgery and to assess the accuracy of two HIT scoring systems. Design: An observational prospective study. Setting: A cardiac surgery unit of a tertiary center from November 2005 to September 2007. Participants: Of the 1,722 patients who underwent cardiac surgery, 63 were suspected of HIT based on a platelet count <100 × 109/L, a decrease in platelet count of >30%, or the occurrence of a thrombotic event. Intervention: The HIT criteria were as follows: (1) the absence of another cause of thrombocytopenia, (2) positive antiplatelet factor 4 (PF4) antibodies (>0.5 optical density [OD]/mn) on enzyme-linked immunoabsorbent assay, and (3) recovery in platelet count after the discontinuation of heparin and substitution by danaparoid sodium. Measurements and Main Results: HIT was confirmed in 24 patients (1.4% [0.8%-1.9%]); 23 belonged to the 984 treated by intravenous unfractionated heparin (IVUH) (2.3% IQ [1.4%-3.3%]) and 1 to the 738 treated by low–molecularweight heparin (0.14% [0.13%-0.4%]) (OD = 17.6; 95% confidence interval, 2.4-131; p < 0.0001). In the HIT+ patients compared with the unconfirmed HIT patients, thrombocytopenia occurred 7 (range, 6-9) days after surgery versus 3 (range, 3-5) days (p < 0.0001), and kinetics of platelet count showed a biphasic pattern. Six HIT+ patients (25% [7.7-42.3]) presented with an arterial thromboembolic event. Diagnosis performances of HIT scoring systems were low. Conclusions: Confirmed HIT occurred predominantly in patients treated with IVUH. The timing of thrombocytopenia and the variation pattern of the postoperative platelet count are key factors in diagnosing HIT. The overall incidence of intracardiac thrombotic events was noted to be high.

Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation - Corrected Proof

2012-01-24

Objectives: The aim of this study was to describe anesthetic management and perioperative complications in patients undergoing pulmonary vein isolation for the treatment of atrial fibrillation under general anesthesia using high-frequency jet ventilation. The authors also identified variables associated with longer ablation times in this patient cohort. Design: A retrospective observational study. Setting: The electrophysiology laboratory in a major university hospital. Participants: One hundred eighty-eight consecutive patients undergoing pulmonary vein isolation under general anesthesia with high-frequency jet ventilation. Interventions: High-frequency jet ventilation was used as the primary mode of ventilation under general anesthesia. Measurements and Main Results: High-frequency jet ventilation was performed successfully throughout the ablation procedure in 175 cases of the study cohort. The remaining 13 patients had to be converted to conventional positive-pressure ventilation because of high PaCO2 or low PaO2 on arterial blood gas measurements. Variables associated with a shorter ablation time included a higher ejection fraction (p = 0.04) and case volume performed by each electrophysiologist in the study group (p = 0.001). Conclusions: High-frequency jet ventilation is generally a safe technique that can be used in catheter ablation treatment under general anesthesia.

The Occurrence of Injury and Black Denaturalization of the Lips, Tongue, and Pharynx Because of Phtharal Use for Disinfection of Transesophageal Echocardiographic Equipment and Establishment of a Safe Disinfection Method - Corrected Proof

2012-01-24

Transesophageal echocardiography (TEE) is useful in cardiac surgery because it can detect intraprocedural complications and provides useful information about circulatory dynamics. The TEE apparatus is classified as a semicritical apparatus by the Centers for Disease Control and Prevention and requires high-level disinfection. However, residual materials from phtharal products used for the disinfection of TEE equipment may cause injury to and black denaturalization of mucosa.

Exogenous Surfactant May Improve Oxygenation but Not Mortality in Adult Patients with Acute Lung Injury/Acute Respiratory Distress Syndrome: A Meta-Analysis of 9 Clinical Trials - Corrected Proof

Haoyu Meng, Ying Sun, Jun Lu, Shukun Fu, Zhaoyi Meng, Melanie Scott, Quan Li — 2012-01-20

Objective: To evaluate whether exogenous surfactant therapy may be useful in adult patients with acute lung injury or acute respiratory distress syndrome, using a meta-analysis of published clinical trials. Design: A comprehensive literature search was performed to identify all randomized clinical trials examining the effects of the treatment of acute lung injury/acute respiratory distress syndrome with exogenous surfactant in adults. The primary outcome measurement was mortality 28 or 30 days after randomization. Secondary outcome measurements included a change in the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen in the first 24 hours or after 120 hours, the number of ventilation-free days, and any adverse effects. The meta-analysis was performed using the Review Manager 5.0.0 system. Participants: Randomized clinical trials. Intervention: Meta-analysis of 9 trials. Measurements and Main Results: Nine trials involving 2,575 patients were included in the meta-analysis. The analysis showed that treatment with exogenous pulmonary surfactant does not decrease mortality significantly. There was a significant effect of exogenous surfactant treatment on the change in the partial pressure of arterial oxygen/fraction of inspired oxygen ratio in the first 24 hours but this was lost by 120 hours. The duration of ventilation trended lower in surfactant-treated patients but this was not significant. In addition, surfactant-treated patients had a significantly higher risk of adverse effects. Conclusions: An exogenous surfactant may improve oxygenation over the first 24 hours after administration. However, treatment does not improve mortality and oxygenation over ≥120 hours after administration and results in a high rate of adverse effects. Therefore, the present data suggest that an exogenous surfactant cannot be considered an effective adjunctive therapy in patients with acute lung injury/acute respiratory distress syndrome.

Postoperative Respiratory Failure After Cardiac Surgery: Use of Noninvasive Ventilation - Corrected Proof

Manuel García-Delgado, Inés Navarrete, Maria José García-Palma, Manuel Colmenero — 2012-01-19

Objectives: To analyze the use of noninvasive ventilation (NIV) in respiratory failure after extubation in patients after cardiac surgery, the factors associated with respiratory failure, and the need for reintubation. Design: Retrospective observational study. Setting: Intensive care unit in a university hospital. Participants: Patients (n = 63) with respiratory failure after extubation after cardiac surgery over a 3-year period. Interventions: Mechanical NIV. Measurements and Main Results: Demographic and surgical data, respiratory history, causes of postoperative respiratory failure, durations of mechanical ventilation and spontaneous breathing, gas exchange values, and the mortality rate were recorded. Of 1,225 postsurgical patients, 63 (5.1%) underwent NIV for respiratory failure after extubation. The median time from extubation to the NIV application was 40 hours (18-96 hours). The most frequent cause of respiratory failure was lobar atelectasis (25.4%). The NIV failed in 52.4% of patients (33/63) who had a lower pH at 24 hours of treatment (7.35 v 7.42, p = 0.001) and a higher hospital mortality (51.5% v 6.7%, p = 0.001) than those in whom NIV was successful. An interval <24 hours from extubation to NIV was a predictive factor for NIV failure (odds ratio, 4.6; 95% confidence interval, 1.2-17.9), whereas obesity was associated with NIV success (odds ratio, 0.22; 95% confidence interval, 0.05-0.91). Conclusions: Reintubation was required in half of the NIV-treated patients and was associated with an increased hospital mortality rate. Early respiratory failure after extubation (≤24 hours) is a predictive factor for NIV failure.

Mea Culpa: Scientific Misconduct - Corrected Proof

Richard I. Hall — 2012-01-19

MUCH HAS BEEN written recently in the anesthesia literature about scientific misconduct, precipitated in large part by revelations and ongoing allegations of misconduct involving Dr Joachim Boldt and that required retraction of more than 60 articles from the medical literature. The Journal of Cardiothoracic and Vascular Anesthesia has not escaped the fallout from these events. Unfortunately, the incidence of scientific misconduct appears to be increasing. I wrote this opinion from the perspective of the chair of a research ethics board (an institutional review board in the United States).

Con: Topical Head Cooling Should Not Be Used During Deep Hypothermic Circulatory Arrest - Corrected Proof

Hilary P. Grocott, Adam Andreiw — 2012-01-13

UNQUESTIONABLY, SIGNIFICANT DEGREES of hypothermia are neuroprotective. No more dramatic examples of this are the anecdotal reports of accidental near drowning in which cold-water immersion and the hypothermia that followed allowed for dramatic survival despite long periods without oxygen. In cases of aortic arch surgery requiring deep hypothermic circulatory arrest (DHCA), hypothermia is similarly clinically neuroprotective. In these situations, the circulation to the brain can be stopped for an hour or more, often with few significant long-term effects. The suspended animation afforded by DHCA allows life-saving procedures that would have otherwise been impossible.

Pro: Topical Hypothermia Should Be Used During Deep Hypothermic Circulatory Arrest - Corrected Proof

Larisa Zhurav, Troy S. Wildes — 2012-01-13

COMPLEX AORTIC REPAIR using circulatory arrest facilitated by deep hypothermia first was described in 1975. Subsequently, numerous series describing patients undergoing aortic repairs facilitated by deep hypothermic circulatory arrest (DHCA) have been reported. During these procedures, cerebral perfusion often is interrupted completely for periods well beyond the anticipated tolerable ischemic interval for the normothermic brain. When complete circulatory cessation is used, therapeutic hypothermia is the foremost protective intervention against ischemic and reperfusion injury. The surprisingly low incidence of catastrophic neurologic outcomes in these patients is a testament to the protective effects of hypothermia.

Left Ventricular Thrombus During Cardiopulmonary Bypass as the Primary Manifestation of Heparin-Induced Thrombocytopenia - Corrected Proof

Annette Ploppa, Leo Haeberle, Eckhard Schmid, Boris Nohe — 2012-01-12

HEPARIN-INDUCED THROMBOCYTOPENIA type II (HIT) is a rare but dangerous prothrombotic disorder that is caused by the formation of platelet-activating antibodies against complexes of platelet factor 4 bound to heparin (PF4/H). Because antibodies may be detectable in >20% of patients, whereas only <1% develop clinical HIT, serologic screening is discouraged unless reasonable pretest probability is suggested by different scoring models for which a time-related decrease in platelets ≥50% is paramount. In this report, a case of HIT that manifested as left ventricular (LV) thrombus during heparin-anticoagulated cardiopulmonary bypass (CPB) without a significant decrease in platelets at that time is presented. Early thrombus detection by transesophageal echocardiography (TEE), immediate serologic testing, and early anticoagulation with argatroban prevented fatal thromboembolism before the platelet count declined ≥50% two days later.

Use of Rapid “Rescue” Perioperative Echocardiography to Improve Outcomes After Hemodynamic Instability in Noncardiac Surgical Patients - Corrected Proof

Sasha K. Shillcutt, Nicholas W. Markin, Candice R. Montzingo, Tara R. Brakke — 2012-01-06

Objective: To investigate if modified “rescue” echocardiography enhanced management during perioperative hemodynamic instability in patients undergoing noncardiac surgery. Design: A retrospective analysis of the medical data. Setting: Perioperative setting at a single academic medical center. Participants: Thirty-one adult patients undergoing noncardiac surgery who experienced perioperative hemodynamic instability and were evaluated by either transthoracic echocardiography (TTE, n = 9) or transesophageal echocardiography (TEE, n = 22). Interventions: None. Measurements and Main Results: Rapid “rescue” echocardiography was performed on each patient looking for a specific cause for the patient's perioperative compromise. Echocardiography results, medical management, surgical management, and patient outcomes were all reviewed from the medical record and the department database. All patients were found to have an explainable diagnosis for the hemodynamic instability on the echocardiographic examination. The most common diagnoses were left-heart dysfunction (n = 16), right-heart dysfunction (n = 9), hypovolemia (n = 5), pulmonary embolus (n = 5), and myocardial ischemia (n = 4). Based on findings at echocardiography, 4 patients (13%) underwent and survived an emergent secondary procedure. All 31 patients recovered during their surgical procedure, and 25 (81%) progressed to hospital discharge. Conclusions: Both TTE and TEE can play a critical role in the diagnosis and management of perioperative hemodynamic instability.

Misplacement of a Guidewire into the Vertebral Vein Through the Internal Jugular Vein - Corrected Proof

Susumu Ide, Tomoyuki Kawamata, Noriko Imai, Akira Ando, Mikito Kawamata — 2012-01-06

We recently encountered a case in which a guidewire was misplaced into the vertebral vein through the internal jugular vein (IJV) despite visualization of the IJV by real-time transverse ultrasound images. This is the first report on the misplacement of a guidewire into the vertebral vein through the IJV.

Mitral Regurgitation in Acute Aortic Insufficiency - Corrected Proof

Anita L. Cave, Nikolaos J. Skubas — 2012-01-06

A53-year-old man presented to the authors' institution with acute aortic insufficiency (AI) from endocarditis and dehiscence of a bioprosthetic (bovine) aortic valve. A preoperative transthoracic echocardiogram showed an aortic root abscess, severe AI, mitral regurgitation (MR), and a left ventricular (LV) ejection fraction of 60%. Cardiac catheterization demonstrated no significant coronary artery disease. An electrocardiogram showed normal sinus rhythm. A reoperative aortic valve replacement with a possible mitral valve replacement or repair was planned.

Anesthesia Apps: Overview of Current Technology and Intelligent Search Techniques - Corrected Proof

Jonathan Kraidin, Steven H. Ginsberg, Alann Solina — 2012-01-06

THERE HAS BEEN a dramatic increase in the use of handheld computing devices in medicine over the past decade. In 2003, Fisher et al noticed the increasing utility of handheld computers. At the time, personal digital assistants, such as the Palm (Palm, Inc, Sunnyvale, CA) and Pocket PC (Microsoft Corp, Redmond, WA), were being used to access medical literature, research drugs, track patients, assist with medical coding and billing, and aid in medical education. The introduction of Apple's (Cupertino, CA) iPhone in June 2007 revolutionized the industry with a multitouch interface and a superior Web browser. In the same year, the Open Handset Alliance unveiled the Android mobile device platform, which was purchased by Google (Mountain View, CA) in 2005. In 2009, Motorola (Schaumburg, IL) released the Droid, running Google's Android operating system. RIM (Waterloo, Ontario, Canada) introduced the Blackberry Storm in 2008.

Impact of Patients' Positions on the Incidence of Arrhythmias During Pulmonary Artery Catheterization - Corrected Proof

2012-01-04

Objective: The complication of cardiac arrhythmias during pulmonary artery catheterization (PAC) may be related to the position of the patient. Therefore, the purpose of this study was to determine the effects of patients' positions on incidence of arrhythmias and the time required to place the pulmonary artery catheter. Design: A prospective, double-blind, randomized, controlled study. Setting: A tertiary university hospital. Participants: One hundred forty patients undergoing elective coronary artery bypass graft surgery. Interventions: Patients were divided into 2 groups. In the study group (n = 70), patients were positioned with their head down at 10° first and then 10° up and tilted right laterally when the PACs were passed from the right atrium to the right ventricle and then the right ventricle to the pulmonary capillary wedge position, respectively. In the control group (n = 70), patients remained in a supine position during pulmonary artery catheterization. Measurement and Main Result: During the catheterization, arrhythmias were recorded and classified into benign (1-3 premature ventricular contractions) and severe (more than 3 premature ventricular contractions or nonsustained ventricular tachycardia). The time for PACs to pass from the right atrium to the right ventricle and the right ventricle to the pulmonary capillary wedge position was measured as T1 and T2, respectively. The incidence of benign arrhythmias between groups was not significantly different (49% for study and 34% for control group, p = 0.196), whereas the incidence of severe arrhythmias was significantly higher in the control group (20% v 5.8%, p = 0.036). The time used for each technique (T1 and T2) in both groups was not significantly different (p = 0.362 and 0.468, respectively). One patient in the study group was excluded because of difficulty in passing the catheter from the right atrium to the right ventricle. Conclusions: Adjusting patients in the head-up and right lateral position while passing the PAC can reduce the incidence of severe arrhythmias, but not in the time taken to place it. This position may have clinical implications, particularly in high-risk patients.

Value of Cerebral Oxygen Saturation Monitoring During Cardiopulmonary Bypass in an Adult Patient With Moyamoya Disease - Corrected Proof

2012-01-04

MOYAMOYA DISEASE (MMD) is a progressive, chronic cerebrovascular occlusive disease occurring predominantly in the Asian population. As described by Suzuki and Takaku in 1969, it affects the internal carotid arteries and anterior and middle cerebral arteries, resulting in compensatory collateral networks at the base of the brain. These networks can be observed in cerebral angiography as a “puff of smoke” (moyamoya means “cloud” in Japanese). The clinical appearance is marked by various cerebrovascular incidents, including intracranial hemorrhage, transient ischemic attack (TIA), and recurrent small strokes.

Combined Cesarean Delivery and Repair of Acute Ascending and Aortic Arch Dissection at 32 Weeks of Pregnancy - Corrected Proof

Adam D. Lichtman, Klaus Kjaer — 2012-01-04

A HEALTHY 35-YEAR-OLD gravida 2 para 1 woman at 32 + 3 weeks' gestational age was admitted to an outside hospital for an acute onset of chest pain that began that day at her baby shower. Owing to an episode of transient hypoxemia, she was worked up for pulmonary embolism. Computed tomographic examination was negative for pulmonary embolism but did show a Stanford type-A dissection. Before this admission, the pregnancy was uneventful and included a normal transthoracic echocardiogram (echocardiography was performed owing to a history suggestive of connective tissue disease). The patient was transferred to the authors' institution, where an emergency cesarean section was performed, and a healthy male infant was delivered.

Volatile Anesthetics Reduce Biochemical Markers of Brain Injury and Brain Magnesium Disorders in Patients Undergoing Coronary Artery Bypass Graft Surgery - Corrected Proof

2011-12-30

Objectives: Neuropsychological disorders are some of the most common complications of coronary artery bypass graft (CABG) surgery. The early diagnosis of postoperative brain damage is difficult and mainly based on the observation of specific brain injury markers. The aim of this study was to analyze the effects of volatile anesthesia (VA) on plasma total and ionized arteriovenous magnesium concentrations in the brain circulation (a-vtMg and a-viMg), plasma matrix metalloproteinase-9 (MMP-9), and glial fibrillary acidic protein (GFAP) in adult patients undergoing CABG surgery. Design: An observational study. Setting: The Department of Cardiac Surgery in a Medical University Hospital. Patients and Methods: Studied parameters were measured during surgery and in the early postoperative period. Patients were assigned to 3 groups: group O, patients who did not receive VA; group ISO, patients who received isoflurane; and group SEV, patients who received sevoflurane. Results: Ninety-two patients were examined. CABG surgery increased MMP-9 and GFAP. The highest MMP-9, GFAP, and the most dramatic disorders in a-vtMg and a-viMg were noted in group O. Conclusions: Cardiac surgery increased plasma MMP-9 and GFAP concentrations. Changes in MMP-9, GFAP, and arteriovenous tMg and iMg were significantly higher in group O. Volatile anesthetics, such as ISO or SEV, reduced plasma MMP-9, GFAP concentrations, and disturbances in a-vtMg and a-viMg.

Cardiopulmonary Bypass Transiently Inhibits Intraventricular Vortex Ring Formation in Patients Undergoing Coronary Artery Bypass Graft Surgery - Corrected Proof

Paul S. Pagel, Sweeta D. Gandhi, Zafar Iqbal, Judith A. Hudetz — 2011-12-26

Objective: Transmitral blood flow during early left ventricular (LV) filling produces an intraventricular rotational body of fluid known as a “vortex ring” that enhances the hydraulic efficiency of early LV filling. The authors tested the hypothesis that exposure to cardiopulmonary bypass (CPB) attenuates intraventricular vortex formation time (VFT) in patients with normal preoperative LV systolic and diastolic function undergoing coronary artery bypass graft (CABG) surgery. Design: A prospective, observational study. Participants: Ten men (65 ± 4 years, 91 ± 11 kg, and 175 ± 8 cm) with a normal preoperative LV ejection fraction (58% ± 6%) scheduled for elective CABG surgery were studied after institutional review board approval. Interventions: None. Measurements and Main Results: Anesthesia was induced with etomidate, fentanyl, and rocuronium and maintained with isoflurane. Myocardial protection during CPB consisted of antegrade and retrograde cold blood cardioplegia administered at 15-minute intervals, systemic and topical hypothermia, and warm continuous antegrade cardioplegia before aortic cross-clamp removal. The peak early LV filling and atrial systole blood flow velocities (E and A, respectively) and corresponding velocity-time integrals (VTI-E and VTI-A, respectively) were obtained with pulse-wave Doppler echocardiography and used to determine E/A and atrial filling fraction (β, VTI-A/[VTI-E + VTI-A]), respectively. Mitral valve diameter (D) was calculated as the average of minor and major axis lengths obtained in the midesophageal bicommissural and long-axis transesophageal echocardiographic imaging planes, respectively. VFT was calculated 30 minutes before and 15, 30, and 60 minutes after CPB as 4 × (1 - β) × stroke volume (SV)/πD3, where SV is the stroke volume measured using thermodilution. All patients separated from CPB in sinus rhythm without pacing or vasoactive drug support. Systemic and pulmonary hemodynamics were similar before compared with all times after CPB. CPB significantly (p < 0.05) reduced VFT (5.3 ± 1.8 to 4.0 ± 1.5 15 minutes after CPB); the recovery of VFT (to 4.7 ± 1.6, p > 0.05 v baseline) was noted 60 minutes after CPB. A reduction in E/A (1.26 ± 0.22 to 0.96 ± 0.27) and an increase in β (0.33 ± 0.04 to 0.41 ± 0.07) occurred 15 minutes after CPB. E/A and β also recovered gradually toward control values after CPB (1.25 ± 0.22 and 0.36 ± 0.04, respectively, 60 minutes after CPB; p > 0.05 v. baseline). Conclusions: The results indicated that CPB transiently attenuate VFT in patients with normal preoperative LV systolic and diastolic function undergoing CABG surgery. These data suggest that CPB adversely affects diastolic transmitral flow efficiency by reducing intraventricular vortex ring formation in vivo.

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study - Corrected Proof

2011-12-19

Objective: The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery. Design: A randomized, controlled, prospective, double-blind study. Setting: A tertiary care teaching hospital. Participants: Thirty children scheduled for cardiac surgery with a median sternotomy. Interventions: A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure. Measurements and Main Results: The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001). Conclusions: Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy.

Intraoperative Detection of Aortic Dissection After Off-Pump Coronary Artery Bypass Grafting - Corrected Proof

Sanjay Goel, Sanjoy Majhi, Bishnu Panigrahi, Subhash Sinha — 2011-12-12

Iatrogenic acute aortic dissection is a potentially fatal complication after cardiac surgery. Its frequency is about 0.12% after cardiac surgery using extracorporeal circulation. However, its incidence has increased after a regained interest in off-pump coronary artery bypass grafting (OPCAB). This report describes a patient who underwent OPCAB and whose transesophageal echocardiographic (TEE) evaluation at the end of the procedure showed a dissection flap at the anterior wall of the ascending aorta.

Intracardiac Clots Masked by Extracorporeal Membrane Oxygenation Venous Cannula - Corrected Proof

2011-12-12

The impact of coated circuits on thrombotic complications is still controversial. As reported by Sidebotham et al, thrombus is not unusual in patients supported with a heparin-coated extracorporeal membrane oxygenation (ECMO) circuit without systemic heparinization. In the clinical setting of mechanical circulatory support, transesophageal echocardiography plays an essential role in detecting the potential periprocedural complications, such as cannulation-related injuries, thrombosis, and infections. Systemic heparinization (unfractionated heparin) during ECMO support may be challenging because of the potential bleeding. In contrast, low doses of heparin may decrease the risk of bleeding by providing a more biocompatible surface in the circuit and minimizing the surface-induced complement activation and platelet dysfunction. However, thrombus formation may occur in the ECMO circuit as a potential hazard. Therefore, a systematic search for intracardiac thrombi is strongly recommended. The authors report two patients with venoarterial ECMO support in which intracardiac clots were trapped between the venous cannula and the interatrial septum.

Transesophageal Echocardiographic Examination in the Diagnosis of Bowel Ischemia Due to Thoracic Aorta Thrombosis - Corrected Proof

Theodosios Saranteas, Georgia Kostopanagiotou, Fotios Panou — 2011-12-12

The primary source of peripheral arterial embolism is cardiac in >85% of cases. Owing to the newer sophisticated imaging techniques, including transesophageal echocardiography (TEE), noncardiac sources of peripheral embolism have been detected with increasing frequency. Among these noncardiac sources, the aorta has been reported to be the origin of peripheral arterial embolism in up to 5% of cases.

Possible Anaphylaxis Due to Recombinant Factor VIIa Administration During Thoracic Aortic Surgery - Corrected Proof

Tygh Wyckoff, Elizabeth A. Reed, Nimesh D. Desai, John G.T. Augoustides — 2011-12-12

This letter reports the possibility of an anaphylactic reaction to recombinant factor VII activated (rFVIIa; NovoSeven; Novo Nordisk, Bagsvaerd, Denmark) administered during thoracic aortic surgery for the management of severe coagulopathy. To the best of the authors' knowledge, this possibility has not been reported in patients undergoing thoracic aortic surgery.

Neuraxial Anesthesia and Timing of Heparin Administration in Patients Undergoing Surgery for Congenital Heart Disease Using Cardiopulmonary Bypass - Corrected Proof

Menachem M. Weiner, Meg A. Rosenblatt, Alexander J.C. Mittnacht — 2011-12-12

Objective: The goal of this review was to add to the existing literature documenting the safety of performing neuraxial techniques in patients who are subsequently fully heparinized, with particular emphasis on the timing of heparin administration. This will help improve risk estimation and possibly lead to a more widespread use of neuraxial anesthesia in patients undergoing cardiac surgery. Design: Retrospective chart review. Setting: Single tertiary-care university hospital. Participants: All patients undergoing surgery for congenital heart diseases during a 5-year period. Interventions: The medical records of all patients undergoing surgery for congenital heart diseases during a 5-year period were reviewed for any complications related to the use of neuraxial anesthesia. Furthermore, the interval from neuraxial anesthesia to heparinization for cardiopulmonary bypass was examined. Results: In total, 714 patients were identified who had neuraxial anesthesia administered before full heparinization for cardiopulmonary bypass. No cases of symptomatic spinal or epidural hematomas occurred. Further analysis showed that the interval from neuraxial anesthesia to full heparinization was <1 hour in 466 patients. Conclusions: No complications related to neuraxial anesthesia were found in a series of 714 patients undergoing surgery for congenital heart disease using cardiopulmonary bypass, including 466 patients in whom the interval from neuraxial anesthesia to full heparinization was <1 hour.

Vascular Surgery Patients Prescribed Preoperative β-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia - Corrected Proof

2011-12-06

Objective: To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia.Design: Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records.Setting: A tertiary-care medical center within the Veterans Health Administration.Participants: Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011.Interventions: None.Measurements and Main Results: Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non–β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = −11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration.Conclusions: Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

Timing of Preoperative Aspirin Discontinuation and Outcome After Elective Coronary Artery Bypass Graft Surgery - Corrected Proof

2011-12-05

Objective: Whether aspirin should be discontinued before coronary artery bypass grafting is controversial. The potential benefits and harms associated with late use of aspirin (no discontinuation or discontinuation <3 days before surgery) were investigated in this retrospective, multicenter study.Design: Retrospective, multicenter study.Setting: Two university hospitals and one central hospital.Participants: A consecutive series of 859 patients who underwent elective coronary artery bypass grafting from January 2008 through December 2010.Interventions: Aspirin (100 mg/day) was used <3 days before surgery in 240 patients and was discontinued >3 days before surgery in 619 patients.Results: In the overall series, similar in-hospital mortality, amount of postoperative blood loss, rate of re-exploration for excessive bleeding, and use of blood products were observed in the study groups. However, aspirin discontinuation >3 days before surgery tended to be associated with a higher postoperative stroke rate (1.9% v 0.4%, p = 0.13). Such a trend was observed after off-pump (1.9% v 0%, p = 0.58) and on-pump (2.0% v 0.6%, p = 0.46) surgery. Among 153 pairs matched by the propensity score, patients with aspirin discontinued >3 days before surgery had a significantly higher rate of postoperative stroke (5.9% v 0.7%, p = 0.02) and tended to have a higher risk of the composite adverse outcome endpoint (19.6% v 12.4%, p = 0.09). The postoperative release of troponin I was similar in the study groups.Conclusions: Late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion. These findings and the risk of cardiovascular events possibly occurring at the time of its discontinuation suggest that the use of aspirin until the day of elective coronary surgery may be beneficial.

Accessory Mitral Valve Associated With Coarctation of the Aorta and Bicuspid Aortic Valve Without Left Ventricular Outflow Tract Obstruction - Corrected Proof

Christopher K. Gilbertson, Paul W. Weldner, Christopher W. Connors — 2011-11-30

ACCESSORY MITRAL VALVE (AMV) is a rare congenital cardiac anomaly that most frequently presents as heart failure secondary to left ventricular outflow tract (LVOT) obstruction. AMV is diagnosed most commonly in youth; however, much less frequently, it may present in the older population. It almost always occurs in concert with other congenital cardiac anomalies. An uncommon presentation of AMV without LVOT obstruction in an elderly patient with a history of aortic coarctation and congenital biscuspid aortic valve is described.

The Dual Modality Use of Epiaortic Ultrasound and Transesophageal Echocardiography in the Diagnosis of Intraoperative Iatrogenic Type-A Aortic Dissection - Corrected Proof

Sherif Assaad, Arnar Geirsson, Laki Rousou, Benjamin Sherman, Albert Perrino — 2011-11-30

IATROGENIC INTRAOPERATIVE aortic dissection is a potentially fatal complication of cardiac surgery. Early diagnosis and treatment are vital to good outcome. Transesophageal echocardiography (TEE) is the modality of choice for diagnosis of aortic dissection, but the ability of TEE to detect localized aortic dissection at the distal ascending aorta and proximal aortic arch is compromised by shadowing from the air-filled interface of the trachea and bronchus. A case of acute intraoperative type-A aortic dissection after aortic cannulation that initially was not visualized by TEE but by epiaortic ultrasound is presented. This technique allowed early diagnosis of dissection surrounding the cannulation site, prompting successful replacement of the ascending aorta, with optimal clinical results.

Characterization of Pulmonary and Systemic Inflammatory Responses Produced by Lung Re-expansion After One-Lung Ventilation - Corrected Proof

2011-11-30

Objectives: To characterize the pulmonary and systemic inflammatory responses of rats undergoing 1-hour or 3-hour one-lung ventilation (OLV) with subsequent 1-hour lung re-expansion.Design: A prospective, randomized, controlled animal experiment.Setting: University laboratory.Participants: Thirty male Wistar rats were used.Interventions: Rats were subjected to 1- or 3-hour OLV followed or not by 1-hour lung re-expansion. Control rats received no ventilation.Measurements and Main Results: Pulmonary protein extravasation, pulmonary myeloperoxidase (MPO) activity, cytokine levels in serum and bronchoalveolar lavage (BAL), counts of total and differential cells in BAL fluid, gasometric data, and mean arterial blood pressure (MABP) were all evaluated. Bronchial occlusion for 1 or 3 hours with no lung re-expansion did not significantly change the protein extravasation in the right and left lungs compared with the control group. However, rats submitted to 1- or 3-hour OLV followed by lung re-expansion exhibited pulmonary edema formation and neutrophil recruitment as well as a higher MPO activity in comparison with control rats. Increased levels of interleukin (IL)-6, IL-1β, and tumor necrosis factor-α in BAL fluid were observed. Increased levels of IL-6 and IL-10 in serum also were detected. Blood gas and MABP did not differ between groups.Conclusions: Lung re-expansion after bronchial occlusion evokes an acute lung inflammatory response, which has been shown to be more pronounced in long periods of bronchial occlusion in terms of cytokine inflammatory response. In addition, the magnitude of this inflammatory response also can be detected systemically.

The EuroSCORE in Western Denmark: A Population-Based Study - Corrected Proof

2011-11-21

Objective: The present study aimed to examine the predictive performance of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) in a large cohort of patients undergoing cardiac surgery from 1999 through 2010 because methodologic shortcomings have hampered many previous studies questioning its predictive performance.Design: Population-based prospectively registered data.Setting: The Western Denmark Heart Registry, a multi-institutional registry.Participants: Twenty-one thousand six hundred sixty-four patients.Interventions: On-pump cardiac surgery.Measurements and Main Results: The predictive ability of the logistic EuroSCORE was assessed using the area under the curve (AUC) for the discrimination test, the Hosmer-Lemeshow (HL) calibration test, and the mean estimated-to-observed mortality ratio (E/O). The overall AUC was 0.79 (95% confidence interval [CI] 0.77-0.81; HL test, p < 0.01; E/O 1.9). For coronary artery bypass grafting, the AUC was 0.78 (95% CI 0.75-0.81; HL test, p < 0.01; E/O 2.3). For coronary artery bypass grafting plus valve replacement, the AUC was 0.69 (95% CI 0.65-0.73; HL test, p = 0.02; E/O 1.5). For aortic valve replacement, the AUC was 0.76 (95% CI 0.72-0.80; HL test, p < 0.01; E/O 2.5). The overall and procedural specific E/O ratios tended to increase from 1999 to 2010. Mortality was overestimated across all levels of estimated risk, and in low-to-medium-risk patients, this overestimation increased most notably with time.Conclusions: The EuroSCORE provides moderate-to-good discrimination and poor calibration. Despite substantial changes in risk factors during the study period, the EuroSCORE consistently overestimated 30-day mortality independent of the preoperative risk level and surgical procedure performed, indicating improved quality of surgery and patient care.

Monitoring the Variation in Myocardial Function With the Doppler-Derived Myocardial Performance Index During Aortic Cross-Clamping - Corrected Proof

2011-11-21

Objectives: To investigate the effects of acute elevation in afterload on global (systolic and diastolic) myocardial function by performing serial intraoperative transesophageal echocardiograms during and after cross-clamp application on patients undergoing elective abdominal aortic aneurysm (AAA) surgery.Design: A prospective observational study.Setting: A tertiary care university hospital.Participants: Patients undergoing elective AAA repair under general anesthesia (GA).Intervention: The use of perioperative transesophageal echocardiography to calculate a tissue Doppler–derived myocardial performance index (MPI) during different stages of the surgery.Measurement and Results: Twenty consecutive patients scheduled for suprarenal AAA repair under GA were included in the study. Perioperative transesophageal echocardiography was performed after the induction of GA. MPI was calculated with Doppler tissue imaging as the sum of isovolumetric contraction and relaxation times divided by the ejection time before cross-clamping of the aorta and then 2, 10, and 20 minutes after cross-clamp application. A final MPI was measured after unclamping of the aorta. As compared with baseline, cross-clamp application initially worsened MPI within 2 minutes and then MPI improved to baseline after 10 minutes of cross-clamp application. The MPI improved significantly after unclamping of the aorta.Conclusions: The authors observed a temporal variation in global myocardial function after the application of a cross-clamp in the suprarenal position. There was transient deterioration of global myocardial function (the prolongation of MPI) 2 minutes after cross-clamp application, which improved within 10 minutes. Myocardial function returned to baseline after unclamping the aorta.

Pulse Pressure Variation Predicts Fluid Responsiveness in Elderly Patients After Coronary Artery Bypass Graft Surgery - Corrected Proof

2011-11-18

Objective: To assess the ability of pulse pressure variation to predict fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.Design: A prospective, interventional study.Setting: An academic, tertiary referral hospital.Participants: Sixty patients >70 years old and mechanically ventilated after coronary artery bypass graft surgery.Interventions: Intravascular volume expansion using 6% hydroxyethyl starch solution, 7 mL/kg over 20 minutes.Measurements and Main Results: Heart rate, arterial blood pressure, pulse pressure variation, central venous pressure, pulmonary artery occlusion pressure, and stroke volume index were measured immediately before and after volume expansion. Fluid responsiveness was defined as an increase in stroke volume index ≥15% after volume expansion. Forty-one patients were fluid responders and 19 patients were nonresponders. In contrast to central venous pressure or pulmonary artery occlusion pressure, pulse pressure variation was higher in the responders than in the nonresponders (22 ± 6% v 9.3 ± 3%, p = 0.001) and correlated with the percent changes in the stroke volume index after volume expansion (r = 0.47, p = 0.001). The area under the receiver operating characteristic curve for pulse pressure variation was 0.85 (95% confidence interval 0.75–0.94). The threshold value of 11.5% allowed the discrimination between responders and nonresponders with a sensitivity of 80% and a specificity of 74%.Conclusions: Pulse pressure variation is a reliable predictor of fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

Complications of Percutaneous Mitral Balloon Valvotomy: Usefulness of Real-Time 3-Dimensional Technology - Corrected Proof

Joyce J. Shin, Andrej Alfirevic, Jose L. Navia — 2011-11-17

IN ADDITION TO 2-dimensional (2D) echocardiography, 3-dimensional (3D) transesophageal echocardiography (TEE) is becoming a valuable complementary tool in providing accurate diagnosis, guiding different percutaneous procedures, and accurately managing and diagnosing possible complications. This report describes the case of a patient with symptoms of rheumatic mitral stenosis (MS) who developed acute severe mitral regurgitation (MR) after percutaneous mitral balloon valvotomy (PMBV).

“Surprise Visitor” - Corrected Proof

Eapen Thomas, Kinnari Bhatt, Salim Nasser Al-Maskari — 2011-11-17

A 5-MONTH-OLD girl with Down's syndrome presented for the repair of a complete atrioventricular septal defect (). After anesthetic induction and endotracheal intubation, a transesophageal echocardiographic (TEE) probe was inserted, and a TEE examination confirmed the preoperative diagnosis. A median sternotomy was performed, and cardiopulmonary bypass was instituted using aortic and bicaval cannulation. The ventricular and atrial septal defects were closed using Gortex and pericardial patches, respectively. Immediately before separating from cardiopulmonary bypass, a repeat transesophageal echocardiogram was performed to assess the adequacy of the repair. Transesophageal echocardiography revealed an unexpected “mass” in the left atrium (LA, ). What is the diagnosis?

Spontaneous Echocardiographic Contrast in an Obstructed Coronary Sinus Because of a Perforated Membrane - Corrected Proof

Parag Gharde, Vikram Aggarwal, Sandeep Chauhan, Milind Hote — 2011-11-17

CORONARY SINUS (CS) obstruction impedes the drainage of coronary veins, thereby increasing the coronary venous pressure and decreasing the coronary perfusion pressure, leading to possible myocardial dysfunction. The authors report intraoperative transesophageal echocardiographic (TEE) detection of CS obstruction caused by a perforated membrane (attached to the Thebesian valve), covering its ostium, resulting in a dilated CS with spontaneous echocardiographic contrast.

Removal of a Foreign Body From the Heart Under Transesophageal Echocardiographic Guidance - Corrected Proof

Arya Rajesh Chand, Ralhan Sarju, Sharma Vijay Kumar, Wander Gurpreet Singh — 2011-11-07

THE REMOVAL of an intrathoracic foreign body is a surgical challenge. The patient was a young man who stabbed himself with a needle into the precordium. The removal of this needle from the heart was a challenge because of the continuous movement of the heart. This report describes how transesophageal echocardiography (TEE) helped guide the removal of the needle from the heart, thus avoiding the use of cardiopulmonary bypass (CPB).

Extracorporeal Membrane Oxygenation Implantation via Median Sternotomy for Fulminant Pulmonary Edema After Cold Water Submersion with Cardiac Arrest - Corrected Proof

2011-11-07

SEVERE HYPOTHERMIA with core temperatures <28°C secondary to environmental exposure (eg, drowning in cold water) has an estimated mortality rate of 30% to 80%. The most important and detrimental consequence of drowning is hypoxia. In the pediatric population ≤5 years of age, submersion injuries rank as the second most frequent cause of death. Children who survive drowning are at an increased risk of developing an acute respiratory distress syndrome (ARDS).

Levosimendan Versus an Intra-Aortic Balloon Pump in High-Risk Cardiac Patients - Corrected Proof

2011-11-04

Objective: To test the hypothesis that levosimendan is more effective than preventive intra-aortic balloon pump (IABP) support in cardiac surgical patients with low left ventricular ejection fraction to decrease cardiac troponin I levels (primary endpoint) and improvement in hemodynamics.Design: Prospective randomized trial.Setting: Tertiary cardiothoracic referral center.Participants: Ninety patients with coronary artery disease and left ventricular ejection fraction <35% who underwent surgery with cardiopulmonary bypass.Intervention: Patients were assigned randomly to 1 of 3 groups. Group A received a prophylactic IABP one day before surgery. Group B received a prophylactic IABP one day before surgery and a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Group C received a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Hemodynamic and biochemical data and rate of complications were analyzed.Measurements and Main Results: The cardiac troponin I level in group C 6 hours after surgery was lower than in group A (p = 0.048). The cardiac index in group A was significantly lower than in groups B and C. The intensive care unit stay was significantly shorter in group C than in groups A and B (p = 0.001). The need for inotropic support, the rate of complications, and mortality among groups did not differ.Conclusions: The infusion of levosimendan after anesthesia induction in cardiac surgical patients contributes to lower cardiac troponin I levels and improved hemodynamics compared with a preoperative IABP.

Mitral Annular Nonplanarity: Correlation Between Annular Height/Commissural Width Ratio and the Nonplanarity Angle - Corrected Proof

2011-11-04

Objective: To compare two methods of mitral annular nonplanarity: the mathematically calculated annular height-to-commissural width ratio (AHCWR) and the echocardiographically derived nonplanarity angle.Design: Prospective.Setting: Tertiary care university hospital.Interventions: Three-dimensional transesophageal echocardiography.Participants: Patients undergoing mitral valve surgery.Measurements and Main Results: Using 3-dimensional transesophageal echocardiography, volumetric datasets were acquired from 22 patients undergoing mitral valve surgery. The intraoperative nonplanarity angle was calculated with Mitral Valve Assessment software (Tomtec GmbH, Munich, Germany). Furthermore, the datasets acquired during 3-dimensional transesophageal echocardiography were exported to Matlab software (MathWorks, Natick, MA), which was used to calculate the AHCWR. The nonplanarity angle was seen to correlate favorably with the AHCWR (r = 0.70).Conclusions: A favorable correlation was found between the nonplanarity angle and the AHCWR. This suggests that the nonplanarity angle can be used to assess mitral annular nonplanarity in a clinically feasible fashion.

Treatment with β-Blockers and Incidence of Post-Traumatic Stress Disorder After Cardiac Surgery: A Prospective Observational Study - Corrected Proof

2011-11-04

Objective: The aim was to investigate perioperative factors associated with the development of post-traumatic stress disorder (PTSD) in patients who underwent cardiac surgery.Design: Prospective observational study.Setting: Single academic center.Participants: One hundred twenty-eight consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass.Interventions: Patients were interviewed within the surgical unit 1 to 3 days before cardiac surgery.Measurements and Main Results: Six months after surgery, participants were mailed the modified version of the Posttraumatic Stress Symptom Inventory 10. Of the 71 patients who completed the questionnaire and mailed it back at follow-up, 14 (19.7%) received a diagnosis of PTSD. Seven of 13 female patients who were not treated with β-blockers received a diagnosis of PTSD compared with 0 of 12 who were treated with β-blockers (p = 0.005, Fisher exact test). In a general linear model, including sex and β-blocker treatment as predictors, the Posttraumatic Stress Symptom Inventory 10 score was significantly predicted by β-blockade (F = 4.74, p = 0.033), with a significant interaction between sex and β-blockade (F = 9.72, p = 0.003).Conclusions: These findings suggest that the use of β-blockers might be protective against the development of PTSD in women after cardiac surgery.

Cardiac Tamponade Secondary to Left Ventricular Wall Rupture During an Urgent Thoracolumbar Spinal Decompression and Fusion Surgery - Corrected Proof

Jing Song, Lora Leonardo, Yanhua Wang, Vilma Joseph — 2011-10-28

LEFT VENTRICULAR FREE WALL rupture has been associated with high mortality because of cardiac tamponade. The authors present a case in which the presumed cause of a cardiac tamponade was bronchogenic carcinoma with metatasis to the myocardium, which caused myocardial free wall rupture during spinal decompression and fusion surgery. This is rarer than pericardial involvement with metastatic disease, which would progress more slowly and likely have compensatory changes. This case highlights the importance of the prompt diagnosis of left ventricular free wall rupture using rescue intraoperative transesophageal echocardiography (TEE).

Socioeconomic Position Is Not Associated With 30-Day or 1-Year Mortality in Demographically Diverse Vascular Surgery Patients - Corrected Proof

Michael Mazzeffi, Hung-Mo Lin, Brigid C. Flynn — 2011-10-28

Objectives: Disparities in outcomes after surgical procedures have been attributed to race, sex, use of private insurance, and socioeconomic position (SEP). The purpose of this study was to determine the impact of SEP on mortality after lower-extremity bypass (LEB) surgery in a diverse patient population with extremes of SEP.Design: Analysis of an electronic medical database.Setting: A tertiary care hospital in a demographically diverse section of a large metropolitan area.Participants: Six hundred nine (158 white men, 156 nonwhite men, 100 white women, and 195 non-white women) patients undergoing infrarenal lower-extremity arterial bypass surgery from July 1, 2002, to December 31, 2007.Measurements and Results: SEP was estimated using data from the 2000 US Census. The effects of race, sex, various comorbidities, the Revised Cardiac Risk Index, American Society of Anesthesiologists physical status, use of private insurance, indication for bypass surgery, and SEP on all-cause mortality was analyzed. SEP differed significantly among the 4 race-sex groups, with white men having the highest position (mean = 2.38) and non-white men having the lowest position (mean = −3.02). There was no statistically significant association in 30-day mortality among race-sex groups or with SEP. One-year mortality differed significantly between men and women for the entire cohort (13.7% and 24.1%, respectively; p < 0.01) but not among race groups or SEP.Conclusions: Disparities in SEP are not associated with short- or long-term mortality after LEB surgery. Other comorbid risk factors are more important when determining outcomes and should be the focus of interventions to improve outcomes.

Transesophageal Echocardiographic Image of a Retained Fibrin Sleeve After Removal of a Venous Extracorporeal Membrane Oxygenation Cannula - Corrected Proof

2011-10-24

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) has gained widespread acceptance and success in improving the outcome of patients in cardiogenic shock and/or respiratory failure. Technologic advances in ECMO have decreased overall morbidity and mortality, but the risks of thrombogenic complications and bleeding are still present. The role of echocardiography in the evaluation of thrombus formation on large venous cannulae in the setting of ECMO is poorly described. Transesophageal echocardiographic (TEE) characteristics of a retained fibrin sheath after removal of a right atrial venous cannula are reported.

Nafamostat Mesilate, as a Treatment for Heparin Resistance, Is Not Associated With Perioperative Ischemic Stroke in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass - Corrected Proof

Mutsuhito Kikura, Keizo Tanaka, Takane Hiraiwa, Kuniyoshi Tanaka — 2011-10-24

Objective: Nafamostat mesilate, a short-acting protease inhibitor, treats heparin resistance during cardiopulmonary bypass. This study tested whether nafamostat mesilate is associated with perioperative ischemic stroke.Design: A retrospective observational study.Participants: A total of 870 adult cardiac surgery patients.Intervention: The authors retrospectively identified the patients who received nafamostat mesilate and who suffered symptomatic ischemic stroke within 30 postoperative days.Measurements and Main Results: The authors evaluated perioperative patient characteristics in association with perioperative ischemic stroke and death. The patients were identified as heparin resistant if they had an activated coagulation time of <480 seconds after the administration of heparin at 400 to 500 U/kg. Heparin-resistant patients received a 10- to 20-mg bolus plus 25 to 50 mg/h of nafamostat mesilate and heparin at 100 U/kg intravenously every 1.5 to 2.0 hours to maintain an activated coagulation time over 480 seconds. Of the 870 patients, 11 (1.3%) suffered a perioperative ischemic stroke. Of the 190 (21.8%) patients who received nafamostat mesilate, 1 (0.5%) suffered ischemic stroke compared with 10 (1.5%) in 680 patients without nafamostat mesilate (Fisher exact test; p = 0.47; regression analysis; odds ratio, 0.35; 95% confidence interval, 0.45-2.8; p = 0.32); 3 (1.6%) patients with nafamostat mesilate died postoperatively within 30 days compared with 11 (1.6%) without nafamostat mesilate (Fisher exact test; p > 0.99, regression analysis; odds ratio, 0.98; 95% confidence interval, 0.27-3.5; p = 0.97).Conclusions: No evidence was found that nafamostat mesilate was associated with perioperative ischemic stroke in heparin-resistant patients undergoing cardiac surgery with cardiopulmonary bypass.