Journal of Cardiothoracic and Vascular Anesthesia - Articles in Press

Redo Sternotomy for Cardiac Reoperations Using Peripheral Heparin-Bonded Cardiopulmonary Bypass Circuits Without Systemic Heparinization: Technique and Results - Corrected Proof

Arun K. Singh, Gary Stearns, Andrew Maslow, William C. Feng, Carl Schwartz — 2010-08-30

Objective:: Cardiac reoperations are challenging and time-consuming and incur a high incidence of perioperative complications because of injuries to cardiac structures, bleeding, and hemodynamic instability. Some centers are using extracorporeal circulation with heparinization at the time of resternotomy, but it leads to prolonged anticoagulation, platelet dysfunction, fibrinolysis, coagulopathy, and morbidity. The authors routinely perform resternotomy in complex surgery with the support of heparinless cardiopulmonary bypass with heparin-bonded circuits (HBCs). The authors describe their technique, indication, and results.Methods:: The femoral artery or axillary artery and femoral veins are cannulated before sternotomy, and cardiopulmonary bypass is instituted using an HBC without systemic heparinization. Systemic heparin (200-300 U/kg) is administered when all structures are isolated before aortic cross-clamping (activated coagulation time >400 seconds).Results:: Between 1996 and 2008, 336 patients underwent redo sternotomy using the HBC for complex cardiac procedures, with 29 deaths (8.6% deaths within 30 days). Only 5 (1.5%) of 336 patients sustained injury to the right ventricle, aorta, bypass grafts, or ventricular fibrillation during re-entry without hemodynamic deterioration; and underwent uneventful repair and outcomes. There was no online HBC thrombosis.Conclusions:: This study shows that HBC without systemic heparinization during resternotomy can be used safely in complex redo cardiac surgery. The heart is completely decompressed during the resternotomy, allowing easy dissection, less likely injury to vital structures, and less bleeding without compromising the hemodynamics.

Direct Observation of the Human Microcirculation During Cardiopulmonary Bypass: Effects of Pulsatile Perfusion - Corrected Proof

2010-08-27

Objectives:: Possible benefits of pulsatile perfusion during cardiopulmonary bypass often are attributed to enhanced microvascular flow. However, there is no evidence to support this in humans. Therefore, the authors assessed whether pulsatile perfusion alters human microvascular flow.Design:: A prospective, randomized observational crossover study.Setting:: A tertiary cardiothoracic surgery referral center.Participants:: Sixteen patients undergoing routine cardiopulmonary bypass for cardiac surgery.Interventions:: All patients underwent both pulsatile and nonpulsatile perfusion in random order.Measurements and Main Results:: The authors used sidestream dark-field imaging to record video clips of the sublingual human microcirculation. Perfusion was started either in the pulsatile (n = 8) or the nonpulsatile mode. After 10 minutes, microvascular recordings were made. The perfusion mode was then switched, and after 10 minutes, new microvascular recordings were taken. The authors quantified pulsatile perfusion-generated surplus hemodynamic energy by calculating pulse pressure and energy-equivalent pressure. Microvascular analysis included determination of the perfused vessel density (mean ± standard deviation). This did not differ between nonpulsatile and pulsatile perfusion (6.65 ± 1.39 v 6.83 ± 1.23 mm-1, p = 0.58, and 2.16 ± 0.64 v 1.96 ± 0.48 mm-1, p = 0.20 for small and large microvessels, respectively, cutoff diameter = 20 μm). Pulse pressure and energy-equivalent pressure was higher during pulsatile perfusion. However, there was no correlation between the difference in energy-equivalent pressure or pulse pressure and perfused vessel density (r = −0.43, p = 0.13, and r = −0.09, p = 0.76, respectively).Conclusion:: Pulsatile perfusion does not alter human microvascular perfusion using standard equipment in routine cardiac surgery. Changes in pulse pressure or energy-equivalent pressure bear no obvious relationship with microcirculatory parameters.

Metabolic Syndrome Exacerbates Short-term Postoperative Cognitive Dysfunction in Patients Undergoing Cardiac Surgery: Results of a Pilot Study - Corrected Proof

2010-08-23

Objective: The authors tested the hypothesis that patients with metabolic syndrome are more likely to develop short-term cognitive dysfunction after cardiac surgery with cardiopulmonary bypass.Design: A prospective study.Setting: Veterans Affairs medical center.Participants: Fifty-six age- and education-balanced patients undergoing elective cardiac surgery with cardiopulmonary bypass (28 patients with and without metabolic syndrome in two separate groups) and 28 nonsurgical controls were enrolled.Interventions: None.Measurements and Main Results: Recent verbal and nonverbal memory and executive functions were assessed using a psychometric test battery before and 1 week after cardiac surgery or at 1-week intervals in nonsurgical controls. Neurocognitive scores under the baseline condition were at least 1 z score (1 standard deviation) worse in surgical patients with compared without metabolic syndrome in all 3 cognitive areas (nonverbal and verbal recent memory and executive functions). Neurocognitive performance further deteriorated after surgery by at least 1 z score on 3 tests in the verbal memory modality (Immediate and Delayed Story Recall and Delayed Word List Recall). Overall cognitive performance (composite z score) after surgery was significantly (p = 0.03) worse in metabolic syndrome patients compared with those who did not have the disorder.Conclusions: The results indicate that short-term cognitive functions were more profoundly impaired in patients with metabolic syndrome undergoing cardiac surgery with cardiopulmonary bypass compared with their healthier counterparts.

Levosimendan Does Not Reduce Mortality in Cardiac Surgery - Corrected Proof

Hisato Takagi, Takuya Umemoto — 2010-08-23

We read with great interest a meta-analysis by Landoni et al of 10 randomized controlled trials (representing 440 patients) of levosimendan on mortality in patients undergoing cardiac surgery. Overall analysis showed that the use of levosimendan was associated with a significant reduction in postoperative mortality (4.7% in the levosimendan group v 12.7% in the control arm; odds ratio [OR], 0.35; 95% confidence interval [CI], 0.18-0.71; p = 0.003). Data of 3 of the 10 trials, however, were not combined in the meta-analysis, resulting in 361 patients in the remaining 7 trials, because of no events (deaths) in both the groups and inestimable ORs. Furthermore, results of a number of randomized trials have been published since the meta-analysis was conducted. We herein performed an updated meta-analysis of randomized trials of levosimendan in cardiac surgery including the 3 trials not in the meta-analysis by Landoni et al.

Asleep-Awake-Asleep Technique During Carotid Endarterectomy - Corrected Proof

2010-08-23

Conscious anesthesia is widely used in Europe for various procedures including those in neurosurgery, spinal, and carotid surgery. Remifentanil has become the analgesic drug of choice in most cases; propofol is the preferred drug to achieve hypnosis. Conscious techniques appear particularly useful in those cases in which the anesthesiologist needs to take advantage of awake monitoring while maintaining the benefits of general anesthesia.

Successful Management of Potentially Fatal Vasodilator-Resistant Spasm of a Nongrafted Coronary Artery - Corrected Proof

Manender Kumar Singla, Kishore C. Mukherjee, Anupam Shrivastava, Vikas Goyal — 2010-08-23

A SPASM OF THE native coronary artery is a rare but life-threatening complication after coronary artery bypass graft (CABG) surgery. Therefore, the emphasis is placed on early postoperative coronary angiography (CAG) in patients whose condition is inexplicably unstable after the surgery. There are reports in which the coronary artery spasm was relieved with intracoronary infusions of various vasodilators, but in others the spasm could not be relieved and mortalities have occurred. The authors present a case of a postoperative spasm of a nongrafted coronary artery resistant to intracoronary vasodilator administration that needed reoperation with grafting of the affected vessel. Subsequent CAG after 6 days showed relief of the spasm.

Diagnosis of Shone's Anomaly by Intraoperative Transesophageal Echocardiography in an Adult Patient Undergoing Repair of Coarctation of the Aorta - Corrected Proof

Satyajeet Misra, Thomas Koshy, Prasanta Kumar Dash — 2010-08-23

SHONE'S ANOMALY (SA) consists primarily of 4 coexisting cardiovascular anomalies; supravalvular mitral ring, parachute mitral valve (PMV), membranous or muscular subaortic stenosis, and coarctation of the aorta (CoA). SA rarely is encountered in adults. A case in which the diagnosis of SA was made on the basis of intraoperative transesophageal echocardiography (TEE) is presented.

Reducing Post-Cardiopulmonary Bypass Delirium: More Ketamine or Less Etomidate? - Corrected Proof

Chhaya V. Sharma, Simon Stacey, Paul Yate — 2010-08-23

We read with great interest the study performed by Hudetz et al showing that a single dose of ketamine on induction of anesthesia significantly reduced the incidence of delirium after cardiac surgery with cardiopulmonary bypass (CPB). Randomly assigned patients received either 0.5 mg/kg of ketamine or placebo 1 hour before surgery. Induction was performed using fentanyl and 0.2 to 0.5 mg/kg of etomidate in all patients, followed by a muscle relaxant and inhalation and fentanyl maintenance of anesthesia.

One-Lung Ventilation for Radiofrequency Ablation of Pulmonary Lesions Out of the Surgical Area: A Secure Option - Corrected Proof

Ana B. Fernández, Oscar Rodríguez, J. Rubén Sangüesa — 2010-08-18

Radiofrequency ablation (RFA) is an emerging minimally invasive therapy that is increasingly being used for the treatment of many types of tumors. The first use of RFA for lung tumors in humans was reported in 2000. RFA uses percutaneously placed image-guided probes to destroy tissues through localized heating. Only about 15% of patients diagnosed with lung carcinoma each year are surgical candidates, either because of advanced disease or comorbidities. The effects of RFA on quality of life, particularly dyspnea and pain, as well as long-term outcome studies generally are lacking. Even so, the results regarding RF lung ablation are comparable to other therapies currently available, particularly for the conventionally unresectable or high-risk lung cancer population.

Integrating Evidence-Based Medicine Into the Perioperative Care of Cardiac Surgery Patients - Corrected Proof

Kevin W. Hatton, Jeremy D. Flynn, Christine Lallos, Brenda G. Fahy — 2010-08-16

THE BEST PRACTICE PATTERNS in modern medical care aim to integrate the evidence from the medical literature with the clinician's personal and institutional expertise (including cumulative clinical experience, education, and skills) and the individual patient's preferences and values. The integration of evidence-based medicine (EBM) into perioperative care is an important component of modern anesthesiology, surgery, pharmacy, and nursing practice, particularly in the arena of cardiac surgery (CS). Because the evidence in this area continually is evolving, the landscape of EBM for the perioperative care of CS patients is ever-changing, with optimized, patient-centered care as the impetus for progress. Additionally, various external funding and oversight organizations as well as accreditation agencies, including the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, have begun to affect physician and hospital reimbursement and accreditation by tracking hospital and physician performance on certain “core measures” and their reported incidence of so-called “never-events” (conditions or complications that should occur with a very low incidence) when providing ideal or perfect clinical care.

Temporal Changes in the Use of Blood Products for Coronary Artery Bypass Graft Surgery in North America: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Database - Corrected Proof

2010-08-16

IT IS NOT KNOWN if and to what extent transfusion in coronary artery bypass graft (CABG) surgery has changed over time in the United States, considering the publication of national guidelines and the suspension of marketing of aprotinin associated with negative publications related to its safety.

Intravascular Volume Therapy With Colloids in Cardiac Surgery - Corrected Proof

Matthias Lange, Christian Ertmer, Hugo Van Aken, Martin Westphal — 2010-08-16

IN PATIENTS UNDERGOING cardiac surgical procedures, the occurrence of hypovolemia is common, and thus the administration of considerable amounts of fluid frequently is required to maintain sufficient tissue perfusion and to prevent vital organ failure. The causes of volume deficit are multifactorial and include absolute hypovolemia secondary to bleeding or capillary leakage and relative hypovolemia derived from regional or systemic vasodilation (often linked to vasodilatory drugs, rewarming, or reperfusion). In conjunction with diuresis and insensible fluid losses, combined intravascular, interstitial, and intracellular volume deficits are frequent entities.

A Randomized, Controlled Trial on Dexmedetomidine for Providing Adequate Sedation and Hemodynamic Control for Awake, Diagnostic Transesophageal Echocardiography - Corrected Proof

2010-08-16

Objective: Transesophageal echocardiography (TEE) has become established as a sensitive and accurate diagnostic method for the rapid assessment of myocardial function. It was theorized that dexmedetomidine (Precedex; Hospira, Inc, Lake Forest, IL) might prove to be useful for sedating patients while undergoing TEE.Design: A prospective, randomized trial was designed comparing dexmedetomidine versus standard therapy (eg, midazolam and opioids) for sedation.Setting: This trial was performed in a tertiary care, single-institution university hospital.Participants: Males and females, American Society of Anesthesiologists I to IV, ages 18 to 65 years, requiring diagnostic TEE. Patients were excluded if pregnant, if they had taken benzodiazepines or opioids within 24 hours, or if they were deemed to be too unstable to receive any kind of sedation.Interventions: Patients were randomized to standard therapy or dexmedetomidine infusion groups. Sedation was assessed at 6 time points. Pulse oximetry, electrocardiogram, heart rate, noninvasive blood pressure, and respiratory rate were monitored. Additional variables measured were the amount of each drug given, the time of the TEE procedure, and the time to recovery.Measurements and Main Results: A survey about the quality of sedation, the level of comfort, and whether or not they would accept this type of sedation again was administered after recovery from sedation. Demographic data and patient questionnaire responses were reported as means and standard errors or percents and were analyzed with the t test and chi-square test. Twenty-two patients were enrolled. Hemodynamics were statistically different between the two groups at several time points. Both systolic and diastolic blood pressures (BP) were elevated in the standard therapy group, whereas the dexmedetomidine group had a lower BP. Heart rate was elevated significantly in the standard therapy group compared with the dexmedetomidine group. There was no statistical or clinical difference between the groups in terms of oxygenation or respiratory rate.Conclusions: The authors concluded that dexmedetomidine appears equivalent in achieving adequate levels of sedation without increasing the rate of respiratory depression or decreasing oxygen saturation compared with standard therapy, and it may be better in achieving desired hemodynamic results.

Post-traumatic Stress Disorder and Neuropsychologic Impairment Among Cardiac Surgery Patients - Corrected Proof

Phillip J. Tully — 2010-08-16

The article by Hudetz et al covers the exhaustively documented topic of neuropsychologic impairment after cardiac surgery among a sample of 86 male patients recruited from a Veterans Affairs hospital. The potentially novel information provided by this study is the comparison of persons supposedly with and without post-traumatic stress disorder (PTSD) undergoing cardiac surgery. A sample of nonsurgical hospital patients with coronary artery disease, as specified by medical notes, also was recruited. Whether these patients were also screened for a history of PTSD was not reported although 29% had a history of depression.

A New Technique of Peripheral Venous Access Under Surgical Drapes in Thoracic Anesthesia - Corrected Proof

Hirotoshi Kitagawa, Yasuhiko Imashuku, Toji Yamazaki — 2010-08-16

During surgery under thoracic anesthesia, occasionally there is the need for an alternative intravenous catheter for blood transfusion or sampling. However, detection of the external jugular vein can be difficult. Furthermore, in such cases, we have experienced difficulty in venous access under the surgical drapes. The dark field under the surgical drapes impedes the detection or puncture of peripheral veins. The StatVein (Technomedica, Yokohama, Japan;) also known as AccuVein AV300, AccuVein LLC, Huntington, NY is a portable and lightweight tool for helping to locate superficial veins. Herein, we describe the use of StatVein for peripheral venous access in dark-field conditions.

Percutaneous Coronary Sinus Catheterization for Minimally Invasive Cardiac Surgery—More Questions Than Answers? - Corrected Proof

Gregory S. Miller, Leland G. Siwek, Nahush A. Mokadam, Andrew Bowdle — 2010-08-16

AVARIETY OF cardiac operations are being performed now through small incisions or thoracoscopic ports that may not allow for the direct placement of a coronary sinus catheter for the administration of retrograde cardioplegia. In some centers, specially designed coronary sinus catheters are being placed percutaneously by the anesthesiologist. Minimally invasive cardiac surgery is not new although the techniques and the equipment continue to evolve. In 1998, this Journal published an article titled “Coronary Sinus Catheterization Made Easy for Port-Access Minimally Invasive Cardiac Surgery.” Despite the interest in this technique in the late 90s, it is not in widespread use today. In this issue, Lebon et al reported on their experience placing 95 percutaneous coronary sinus catheters from the right internal jugular vein for minimally invasive cardiac surgery. By using transesophageal echocardiographic guidance for engaging the coronary sinus and fluoroscopy for advancing the catheter in the coronary sinus, they attained a success rate of 87%, as judged by attaining a pressure in the coronary sinus >30 mmHg during cardioplegia administration. Failure occurred for a variety of reasons; the most common reason was displacement of the catheter from the coronary sinus during surgery. The mean total procedure time was 16 ± 14 minutes. They encountered 1 complication, a small, confined disruption in the coronary sinus identified by extravasation of contrast agent, which was not clinically significant.

Transcatheter Aortic Valve Implantation: Is General Anesthesia Superior to Conscious Sedation? - Corrected Proof

Jens Fassl, Manfred D. Seeberger, John G.T. Augoustides — 2010-08-12

With great interest we read the article “Anesthesia and Perioperative Management of Patients Undergoing Transcatheter Aortic Valve Implantation: Analysis of 90 Consecutive Patients With Focus on Perioperative Complications” by Guinot et al. The authors reported their experience with the perioperative management of 90 high-risk patients with aortic stenosis who underwent transcatheter aortic valve implantation (AVI) between October 2006 and February 2009. Guinot et al described important aspects of anesthesia and perioperative care of patients undergoing minimally invasive aortic valve replacement. Their article is of utmost interest because the number of minimally invasive AVI procedures is increasing worldwide, and adequate anesthetic management plays a fundamental role for the success of these procedures.

A Mitral Valve Mass: Tumor, Thrombus, or Vegetation? - Corrected Proof

Michael Mazzeffi, David L. Reich, David H. Adams, Gregory W. Fischer — 2010-08-12

A 58-YEAR-OLD man developed transient monocular visual loss in the right lower quadrant of the left eye that fully resolved in less than 24 hours. He was afebrile and had no other symptoms. His known medical history included well-controlled arterial hypertension and dyslipidemia. He denied a history of cerebrovascular disease, atrial fibrillation, intravenous drug use, and thromboembolic disease. Medical evaluation included a carotid Doppler ultrasound that showed no abnormality, an unremarkable brain magnetic resonance imaging (MRI) examination, an unremarkable ophthalmologic examination, and a normal white blood cell count. A transesophageal echocardiographic (TEE) examination was performed and showed moderate mitral regurgitation in the setting of bileaflet prolapse. Additionally, an 8 × 7 mm mass was found to be attached to the atrial side of the anterior leaflet of the mitral valve ( and [supplementary videos are available online]). The patient was scheduled for mitral valve reconstructive surgery and mass resection 3 weeks after his medical evaluation had been completed. What is the diagnosis?

Progress in Perioperative Medicine: Focus on Statins - Corrected Proof

Nina Singh, Prakash Patel, Tygh Wyckoff, John G.T. Augoustides — 2010-08-12

Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial function, atherosclerotic plaque stability, inflammation, and thrombosis. These favorable pleiotropic effects may be the basis for their perioperative risk reduction in cardiothoracic and vascular procedures. The published evidence suggests that statins offer significant outcome benefits throughout perioperative practice. Because statin therapy significantly reduces the perioperative risk for patients undergoing cardiovascular procedures, they already are recommended in published guidelines. Beyond cardiac risk reduction, statin therapy also may protect the brain and the kidney in the perioperative setting, both in cardiac and vascular surgery. The pleiotropic effects of statins also appear to have therapeutic roles in the progression of valve disease, sepsis, and venous thrombosis. Further trials are required to provide data to drive their safe and comprehensive perioperative application for optimal patient outcome both in the short term and the long term. Because there are multiple randomized trials currently in progress throughout perioperative medicine, it is very likely that the indications for statins will be expanded significantly.

Cardiac Surgery–Associated Acute Renal Injury: New Paradigms and Innovative Therapies - Corrected Proof

Susan Garwood — 2010-08-11

PERIOPERATIVE RENAL FAILURE is not an uncommon clinical problem after major cardiovascular surgery and relentlessly continues to be associated with poor outcomes; mortality rates for new patients requiring dialysis are similar to several decades ago (http://www.usrds.org/2009/pdf/V2_06_09.PDF). Barriers that have precluded effective clinical studies are caused in part by inconsistencies in defining the entity and an incomplete understanding of the pathophysiology in the clinical setting, both of which contribute to the lack of success in prevention and treatment of this disease. In 2004, the American Society of Nephrology Renal Research Group conducted a series of retreats to address areas of renal research requiring particular attention and identified acute renal failure as a vexing and significant clinical problem. Recommendations included the need for a common terminology and definition, thus allowing better risk stratification of patients. Thus, the term acute kidney injury (AKI) was adopted to reflect the entire spectrum of the disease from minimal elevations in serum creatinine to anuric renal failure, from functional deviations to structural changes, and from prerenal azotemia to acute tubular necrosis. A consensus definition of AKI was proposed by the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) group (http://wwwADQI.net), which published a classification system for AKI based on changes in serum creatinine and/or urine output criteria. This is a 5-stage classification, the first 3 of which define grades of increasing severity of AKI (risk, injury, and failure) on the basis of changes of serum creatinine or glomerular filtration from baseline as well as a decline in urine output. The last 2 stages are outcome variables (loss and end-stage kidney disease), thus the acronym RIFLE classification. These criteria have since been modified by the Acute Kidney Injury Network (AKIN), which proposed a timeframe of 48 hours within which AKI has to occur and 3 classes describing increases in serum creatinine relative to baseline (). In recognition of findings that even minimal increments in serum creatinine adversely affect outcomes, the AKIN definition includes lesser degrees of serum creatinine elevation (≥0.3 mg/dL or ≥50% above baseline within 48 hours). The ADQI group recently proposed a consensus definition specifically aimed at AKI after cardiac surgery using these modified criteria, subdividing the AKIN diagnostic and staging criteria into “early” (within the first 7 days) and “late” (occurring between 7 and 30 days after cardiac surgery). Both RIFLE and AKIN classifications have been validated in large populations of critical care and cardiac surgery patients, with a recent prospective cohort study of almost 300 cardiopulmonary bypass patients determining that the RIFLE and AKIN definitions of AKI were essentially of similar diagnostic and prognostic value.

The Eustachian Valve as a Pitfall in Persistent Foramen Ovale and Atrial Septum Defect Closure - Corrected Proof

2010-08-11

THE EUSTACHIAN VALVE plays an important role during fetal life by directing oxygen-rich blood from the inferior vena cava (IVC) through the foramen ovale into the left atrium (LA) and the systemic circulation. After birth, the eustachian valve disappears or is reduced to a thin, nonfunctional ridge. Occasionally, it remains as an elongated and prominent structure within the right atrium (RA).

Comparative Feasibility of Myocardial Velocity and Strain Measurements Using 2 Different Methods With Transesophageal Echocardiography During Cardiac Surgery - Corrected Proof

Graeme MacLaren, Roman Kluger, Kim A. Connelly, Colin F. Royse — 2010-08-09

Objective: To assess the feasibility and correlation between tissue Doppler and speckle tracking imaging when measuring myocardial velocity, strain, and strain rate with transesophageal echocardiography.Design: A prospective, observational study.Setting: An academic tertiary-referral hospital.Participants: Patients undergoing elective heart surgery.Interventions: None.Measurements and Main Results: Velocity, strain, and strain rate were measured using both techniques in the inferior and anterior walls in transgastric views for radial motion and in the lateral, septal, anterior, and inferior walls in midesophageal views for longitudinal motion. Nineteen patients and 304 myocardial segments were studied. Overall, tissue Doppler was found to be more successful than speckle tracking in measuring myocardial velocity, whereas strain and strain rate measurements were achieved with comparable success using either method. Tissue Doppler was more successful than speckle tracking for radial cardiac motion, and the highest success rates were achieved with this method (93.4% v 59.2% for velocity, p < 0.001; 78.9% v 59.2% for strain, p = 0.01; and 73.7% v 59.2% for strain rate, p =0.09). Good correlation between tissue Doppler and speckle tracking was shown in 4 myocardial segments: radial midinferior, radial basal inferior, radial basal anterior, and longitudinal basal septum (R = 0.6-0.82, p < 0.05).Conclusions: The correlation between tissue Doppler and speckle tracking with transesophageal echocardiography appears valid when predominantly confined to segments moving in a radial direction adjacent to the ultrasound transducer. Tissue Doppler echocardiography of radial cardiac motion appears to be the most feasible technique of measuring myocardial velocity, strain, and strain rate during cardiac surgery.

Interaction Between Spinal Opioid and Adenosine Receptors in Remote Cardiac Preconditioning: Effect of Intrathecal Morphine - Corrected Proof

Lu Yao, Gordon Tin Chun Wong, Zhengyuan Xia, Michael Garnet Irwin — 2010-08-06

Objectives: Intrathecal morphine is cardioprotective and also triggers spinal adenosine release. This study investigated the role of spinal and peripheral adenosine receptors in intrathecal morphine cardioprotection.Design: A randomized, prospective study.Setting: A university research laboratory.Participants: Seventy-two male Sprague-Dawley rats.Interventions: Anesthetized, open-chest, male Sprague-Dawley rats were assigned to 1 of 10 treatment groups 3 days after intrathecal catheter placement. Intrathecal morphine cardioprotection was induced with 3 μg/kg of morphine. Intrathecal normal saline was used as the control. The adenosine-receptor antagonist 8-(p-sulfophenyl) theophylline (50 μg/kg or 7.5 mg/kg) was given via intrathecal or intravenous routes, respectively, either 10 minutes before or immediately after morphine or saline. Ischemia reperfusion injury then was induced by 30 minutes of left coronary artery occlusion followed by 120 minutes of reperfusion.Measurements and Main Results: Infarct size, as a percentage of the area at risk, was determined by 2,3,5-triphenyltetrazolium chloride staining. This was reduced significantly in the morphine group (25% ± 5%) compared with the control (58% ± 3%, p < 0.05). The addition of intravenous 8-SPT either before or after morphine significantly attenuated the cardioprotective effect. In comparison, intrathecal administration of 8-(p-sulfophenyl) theophylline before but not after morphine attenuated the cardioprotective effects of intrathecal morphine.Conclusions: Both central and peripheral adenosine receptors are involved in the signaling of intrathecal morphine preconditioning. Central receptors are important in the initiation of the process, whereas peripheral receptors have a role in ongoing mediation of the protective effect.

Comparison of the Endotracheal Cardiac Output Monitor to Thermodilution in Cardiac Surgery Patients - Corrected Proof

2010-08-05

Objectives: To compare cardiac output (CO) measurements from a novel endotracheal bioimpedance cardiac output monitor device (ECOM; ConMed, Irvine, CA) to simultaneous pulmonary artery thermodilution (TD) CO.Design: Prospective study.Setting: One academic hospital.Participants: Forty volunteer patients undergoing cardiac surgery.Interventions: Intraoperative CO measurements.Measurements and Main Results: Simultaneous comparative data points were collected from ECOM and TD at 4 periods: post induction, post sternotomy, post cardiopulmonary bypass, and post chest closure. The mean COTD was compared with COECOM for each operative period then assessed for agreement by linear regression, Bland-Altman analysis, and percent error methods. There were 35 men (87.5%) with a mean age of 66 ± 10.7 years in the present study population. R values (p value) for the 4 time periods were 0.50 (0.002), 0.33 (0.035), 0.42 (0.007), and 0.48 (0.002). Bias and 95% limits of agreement in L/min were −0.11 (−2.40 to 2.18), 0.04 (−2.57 to 2.65), −0.06 (−2.86 to 2.74), and 0.02 (−2.42 to 2.45). Percent errors of the 4 time periods were 51%, 53%, 50%, and 48%.Conclusions: ECOM did not adequately agree with TD in patients undergoing cardiac surgery.

Transfusion Requirements in 811 Patients During and After Cardiac Surgery: A Prospective Observational Study - Corrected Proof

Hanne B. Ravn, Christian Lindskov, Lars Folkersen, Anne-Mette Hvas — 2010-08-05

Objective: To identify patients at risk for intra- and postoperative blood product transfusion in a mixed adult cardiac surgical patient population.Design: A prospective, observational study.Setting: A single-center university hospital.Participants: Patients (n = 811) undergoing cardiac surgery from January 1, 2008, to November 30, 2008.Interventions: The outcome in terms of transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and/or pooled platelets within the first 24 hours after surgery was studied. Pre- and perioperative risk factors for bleeding and transfusion of blood products were studied.Measurements and Main Results: The majority of RBCs and FFP (>70%) were given to a minority of patients (<12%). The type of surgical procedure, previous cardiac surgery, and emergency operations were all significantly associated with the transfusion of RBCs, FFP, and platelets. Antithrombotic therapy was not significantly associated with the transfusion requirement in the mixed group of cardiac patients. However, in the low-risk procedures such as coronary artery bypass graft surgery, ongoing antithrombotic therapy at the time of the operation significantly increased the risk of transfusion in this otherwise low-risk category of surgery.Conclusions: The identification of high-risk patients is necessary to optimize the perioperative management of bleeding complications. Because of the high variability in transfusion requirements, a specifically tailored patient intervention based on the individual's risk profile appears more likely to improve patient outcome compared with general interventions given to the entire patient group.

Endotracheal Cardiac Output Monitor in a Patient With Severe Tricuspid Regurgitation - Corrected Proof

Michael S. Green, Amardeep Heyer, Parmis Green, Jay Parekh — 2010-08-05

DURING CARDIAC SURGERY, the accurate measurements: of cardiac output (CO) and intracardiac pressures can assist in guiding anesthetic management. The balloon-tipped pulmonary artery catheter (PAC) was introduced in 1970 and became the gold standard for measuring CO via thermodilution. Many hemodynamic values are obtained from this type of monitoring, including intracardiac pressures, pulmonary artery pressures, pulmonary artery occlusion pressures, CO, and mixed venous oxygen saturation. This technique is invasive, and many factors can lessen its accuracy, including disease processes that increase pulmonary vascular resistance, changes in intrathoracic and intrapleural pressures, variability in pulmonary blood flow, cardiac valvular abnormalities, and intracardiac shunting. Doppler echocardiography, which was developed in the 1970s, allows a more accurate estimation of cardiac values and has the advantage of allowing direct visualization of cardiac function. Impedance cardiography, which was first described in 1991, provides further advances over earlier modalities in that it provides continuous calculation of CO and cardiac index (CI). Impedance cardiography offers a less invasive alternative to the thermodilution technique for the determination of continuous CO in comparison with PAC, which often is criticized because of its uncertain risk-to-benefit ratio.

Does Preoperative B-Type Natriuretic Peptide Better Predict Adverse Outcome and Prolonged Length of Stay Than the Standard European System for Cardiac Operative Risk Evaluation After Cardiac Surgery? - Corrected Proof

2010-08-05

Objectives: Although B-type natriuretic peptide (BNP) strongly predicts cardiac morbidity and mortality, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) has a modest predictive value to identify a composite operative risk after cardiac surgery. The authors tested the hypothesis that a single preoperative BNP measurement would be superior to standard EuroSCORE in predicting composite adverse outcomes after cardiac surgery.Design: A prospective observational study.Setting: A teaching university hospital.Participants: Two hundred eight adult patients.Interventions: Conventional cardiac surgery with cardiopulmonary bypass.Measurements and Main Results: The preoperative additive EuroSCORE and BNP measurement were performed in all patients. Postoperative nonfatal major adverse cardiac events (malignant ventricular arrhythmia, myocardial infarction, and cardiac dysfunction), all-cause mortality, and prolonged lengths of stay were chosen as study endpoints. Predictive abilities of both EuroSCORE and BNP were assessed using logistic regression and compared with receiver operating characteristic (ROC) curves. Thirty-six (17%, 95% confidence interval [CI], 12%-22%) patients experienced 49 events over the study period. The areas under the ROC curves assessing the utility of EuroSCORE and BNP in predicting adverse outcome and prolonged in-hospital stay were 0.59 (95% CI, 0.48-0.69) versus 0.76 (95% CI, 0.68-0.85; p < 0.001) and 0.65 (95% CI, 0.57-0.74) versus 0.71 (95% CI, 0.63-0.80; p = 0.147), respectively. Using logistic regression, BNP considered as a dichotomized variable was the only independent predictor of adverse cardiac outcome (adjusted odds ratio = 10.7; 95% CI, 4.1-27.8; p < 0.001).Conclusions: Preoperative BNP measurement is a strong, independent, and more accurate predictor of adverse outcome than EuroSCORE in patients undergoing cardiac surgery. BNP could be considered as a simple and objective tool for the detection of high-risk patients after cardiac surgery.

Cardiac Calendar—2010 to 2012 - Corrected Proof

George Silvay — 2010-08-05

Sixty-Ninth National Congress–Australian Society of Anesthesiology. Melbourne, Australia. October 2-5, 2010. Contact: www.asa2010.com. 2010 Heart Valve Summit: Medical, Surgical and Interventional Decision Making. Chicago, IL. October 7-9, 2010. Contact: AATS 900 Cummings Center, Suite 221, Beverly, MA 01915, www.aats.org.

The Relationship Between Cerebral Oxygen Saturation Changes and Postoperative Cognitive Dysfunction in Elderly Patients After Coronary Artery Bypass Graft Surgery - Corrected Proof

2010-07-23

Objective: The aim of this study was to evaluate the predictive value of cerebral regional oxygen saturation (rSO2) in the occurrence of postoperative cognitive dysfunction (POCD) in elderly patients undergoing coronary artery bypass graft (CABG) surgery.Design: A prospective study.Setting: University hospital.Participants: A total of 61 patients (84% male) with a mean age of 70.39±4.69 on a waiting list for CABG surgery were enrolled in the study.Intervention: A complete neurocognitive evaluation was performed 1 day before surgery as well as 4 to 7 days and 1 month after surgery. During surgery, rSO2 was monitored continuously.Measurements and Main Results: POCD was defined as a reduction of 1 standard deviation on 2 or more neuropsychologic indices. Forty-six patients (80.7%) developed early POCD, and 23 (38.3%) showed late POCD. Patients whose rSO2 decreased to less than 50% during the surgery experienced more POCD 4 to 7 days after surgery (p = 0.04). In addition, a decrease of more than 30% from the patient's baseline rSO2 was associated with POCD 1 month after surgery (p = 0.03).Conclusion: Intraoperative cerebral oxygen desaturation is associated with early and late POCD in elderly patients. Cerebral oximetry is a promising tool in the prediction of subtle neuropsychologic deficits and further studies are needed.

The Impact of Immediate Extubation in the Operating Room After Cardiac Surgery on Intensive Care and Hospital Lengths of Stay - Corrected Proof

2010-07-23

Objective: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery.Design: A nonrandomized, observational study with propensity score–guided case-control matching of prospectively collected data.Setting: Three interrelated, university-affiliated, community hospitals.Participants: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006.Interventions: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit.Measurements and Main Results: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A “greedy 5 to 1” propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation.Conclusions: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.

Intraoperative Assessment of Mitral Valve Area After Mitral Valve Repair for Regurgitant Valves - Corrected Proof

Andrew Maslow, Arun Singh, Feroze Mahmood, Athena Poppas — 2010-07-23

ACCURATE INTRAOPERATIVE assessment of the mitral valve (MV) after repair is important to determine the success of the repair and whether or not rerepair is necessary. Inherent in the repair of the MV is an immediate reduction in mitral valve area (MVA). Further reduction in MVA is possible during follow-up.

An Unusual Cause of Massive Gastrointestinal Bleeding After Transesophageal Echocardiography - Corrected Proof

Fred Cobey, Bryan L. Balmadrid, Daniel M. Wild, Donald Glower, Ian J. Welsby — 2010-07-23

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) performed by experienced operators has been reported to have an acceptable risk profile. In 2 large series, the overall morbidity was between 0.18% and 0.2% with only 1 mortality reported in more than 17,000 patients. The risk of gastrointestinal (GI) bleeding was small. Indeed, no difference in the incidence of blood in nasogastric aspirates could be found between cardiac patients who had TEE performed and those who did not. In this context, Spier et al recently argued in favor of using TEE in the setting of known esophageal varices caused by cirrhosis. Nonetheless, the prospect of using TEE in such high-risk patients, especially those who have been anticoagulated, increases the level of concern in most clinicians. In contrast to TEE's safety record, the authors present a very unusual case of a man with a massive GI bleed after routine TEE, originating from a gastric Dieulafoy lesion. To the authors' knowledge, this is the first such case in the literature.

Postoperative Delirium and Short-term Cognitive Dysfunction Occur More Frequently in Patients Undergoing Valve Surgery With or Without Coronary Artery Bypass Graft Surgery Compared With Coronary Artery Bypass Graft Surgery Alone: Results of a Pilot Study - Corrected Proof

2010-07-23

Objective: The authors tested the hypothesis that patients undergoing valve repair or replacement surgery with or without coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB) had a greater incidence of postoperative delirium and cognitive dysfunction compared with patients undergoing CABG surgery alone.Design: Prospective study.Setting: Veterans Affairs medical center.Participants: Forty-four age- and education-balanced male patients (≥55 years of age) undergoing elective cardiac surgery with CPB (n = 22 valve ± CABG surgery and n = 22 CABG surgery alone) and nonsurgical controls (n = 22) were recruited.Interventions: None.Measurements and Main Results: Delirium was assessed with the Intensive Care Delirium Screening Checklist before and for 5 consecutive days after surgery. Recent verbal and nonverbal memory and executive functions were assessed using a psychometric test battery before and 1 week after cardiac surgery or at 1-week intervals in nonsurgical controls. Intensive care unit stay, hospital stay, and 30-day readmission were significantly (p = 0.03, p = 0.01, and p = 0.04, respectively) longer in patients undergoing valve surgery ± CABG surgery versus CABG surgery alone. Postoperative delirium occurred more frequently (p = 0.01) in patients undergoing valve ± CABG surgery versus CABG surgery alone. Overall cognitive performance (composite z score) after surgery also was impaired significantly (p = 0.004) in patients undergoing valve ± CABG surgery compared with CABG surgery alone. The composite z score after surgery decreased by at least 1.5 standard deviations in 11 patients (50%) versus 1 patient (5%) without valve surgery compared with nonsurgical controls (p = 0.001, Fisher's exact test). The presence of delirium predicted a composite z score decrease of 1.2 points (odds ratio = 0.30; 95% confidence interval, 0.13-0.68).Conclusions: The results indicated that patients undergoing valve surgery with or without CABG surgery have a higher incidence of postoperative delirium and cognitive dysfunction 1 week after surgery compared with those undergoing CABG surgery alone.

Brain Natriuretic Peptide (BNP) as a Biomarker of Myocardial Ischemia-Reperfusion Injury in Cardiac Transplantation - Corrected Proof

David R. McIlroy, Sophie Wallace, Nicholas Roubos — 2010-07-23

Objectives: To evaluate brain natriuretic peptide (BNP) as a biomarker of ischemia-reperfusion injury in cardiac transplantationDesign: A prospective cohort study.Setting: A single academic medical center.Participants: Adult patients undergoing orthotopic cardiac transplantation (n = 25).Interventions: None.Measurements and Main Results: The authors performed serial measurements of BNP and troponin-I in cardiac allograft donors and recipients, determining the relationship between these biomarkers and established risk factors for and measures of early graft dysfunction. Postoperative BNP correlated moderately with allograft ischemic time (ρ = 0.52, p = 0.01), donor BNP (ρ = 0.45, p = 0.03), and donor troponin-I (ρ = 0.49, p = 0.01). Postoperative BNP was higher in patients with persistently elevated inotrope requirements and enabled the early identification of such patients. In contrast, there was no association between postoperative troponin-I and these same parameters.Conclusions: Postoperative BNP is associated with preimplantation and clinical performance parameters related to allograft ischemia-reperfusion injury at the time of cardiac transplantation, providing preliminary evidence to support its potential use as an ischemia-reperfusion injury biomarker in this context.

Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing One-Lung Ventilation - Corrected Proof

Koichi Suehiro, Ryu Okutani — 2010-07-20

Objectives: To investigate the ability of stroke volume variation (SVV) calculated by the Vigileo-FloTrac system (Edwards Lifescience, Irvine, CA) to predict fluid responsiveness in patients undergoing one-lung ventilation (OLV).Design: Prospective, observational study.Setting: Clinical hospital.Participants: Thirty patients scheduled for a pulmonary lobectomy requiring OLV for at least 1 hour under combined epidural/general anesthesia.Interventions: After starting OLV, hydroxyethyl starch, 500 mL, was administered for 30 minutes.Measurements and Main Results: Hemodynamic variables including heart rate, mean arterial pressure, cardiac index, stroke volume index (SVI), and SVV were measured before and after volume loading. SVV before volume loading was significantly correlated with the absolute changes in SVV (ΔSVV) and percentage changes in stroke volume index (ΔSVI) after volume loading (ΔSVV: p < 0.05, r = −0.893; ΔSVI: p < 0.05, r = 0.866). Of the 30 patients, 15 (50%) were responders to intravascular volume expansion (an increase in SVI ≥25%), and 15 (50%) were nonresponders (an increase in SVI <25%). The area under the ROC curve was 0.900 for SVV (95% confidence interval, 0.809-0.991), whereas the optimal threshold value of SVV to discriminate between responders and nonresponders was 10.5% (sensitivity: 82.4%, specificity: 92.3%).Conclusions: The authors found that SVV measured by the Vigileo-FloTrac system was able to predict fluid responsiveness in patients undergoing surgery with OLV with acceptable levels of sensitivity and specificity.

Preoperative Statin Treatment Is Associated With Reduced Postoperative Mortality After Isolated Cardiac Valve Surgery in High-Risk Patients - Corrected Proof

2010-07-20

Objective: The aim of the present study was to assess the influence of preoperative statin therapy on postoperative mortality in high-risk patients after isolated valve surgery.Design: An observational cohort study.Setting: A 1,200-bed university hospital.Participants: All consecutive patients undergoing isolated nonemergent valve surgery with cardiopulmonary bypass between November 2005 and December 2007 were included.Intervention: None.Measurements and Main Results: During the period, 772 consecutive patients underwent nonemergent isolated valve surgery. Among them, 430 were high cardiovascular risk (defined by patients with 2 or more cardiovascular risk factors). In the high-risk cardiovascular patients, statin pretreatment was administered in 222 patients (52%). In multivariate analysis, after adjustment with a propensity score analysis, preoperative statin therapy was associated with a significant reduction of postoperative mortality in patients with high risk (odds ratio = 0.41; 95% confidence interval, 0.17-0.97; p = 0.04). Low left ventricular ejection fraction and elevated pulmonary artery pressure also were independently associated with increased postoperative mortality. By contrast, in the low-risk patient group, few patients received preoperative statin therapy (7%).Conclusions: This study suggests that preoperative statin therapy may have a potential beneficial effect on postoperative mortality after isolated cardiac valve surgery in high-risk cardiovascular patients.

The Endovascular Coronary Sinus Catheter in Minimally Invasive Mitral and Tricuspid Valve Surgery: A Case Series - Corrected Proof

2010-07-20

Objectives: To determine the safety and efficacy of a standardized approach to the use of an endovascular coronary sinus (CS) catheter during minimally invasive cardiac surgery.Design: Case series.Setting: University hospital.Participants: Patients undergoing mitral and/or tricuspid valve surgery using a minimally invasive cardiac surgery approach.Interventions: An endovascular CS catheter was placed to enable the administration of retrograde cardioplegia using transesophageal echocardiography (TEE), fluoroscopy, and CS pressure measurements.Measurements and Main Results: Data were collected from 96 patient records. A total of 95 (99.0%) endovascular coronary sinus catheters were positioned. The mean time to insert the catheter into the sinus ostium under TEE guidance was 6.3 ± 8.4 minutes. Confirmation of adequate positioning with fluoroscopy took an average of 9.1 ± 10.6 minutes for a mean total procedure time of 16.1 ± 14.1 minutes. Successful positioning, as defined by the ability to generate a perfusion pressure in the CS greater than 30 mmHg during surgery, was achieved in 87.5% of cases. During positioning, ventricularization of the CS pressure curve was observed in 86.0% of cases. The presence of ventricularization was associated with an increase in positioning success (odds ratio = 15.8; 95% confidence interval, 3.713-67.239). One patient developed extravasation of contrast agent after CS catheter placement, without evidence of CS rupture.Conclusions: Endovascular CS catheter insertion can be performed with a high rate of success for positioning and a low complication rate. During positioning, obtaining ventricularization is associated with an increased success rate.

Feeling the Pressure? Anterior Mitral Leaflet Immobility in a Patient With Bicuspid Aortic Valve Disease - Corrected Proof

Kishan Dwarakanath, Christopher J. Plambeck, Sandeep Markan, Paul S. Pagel — 2010-07-20

A 32-YEAR-OLD, 87-kg, 173-cm man with a past medical history of a congenital bicuspid aortic valve was admitted to the authors' hospital for evaluation of dyspnea on exertion. The patient had been a frequent participant in strenuous athletic activities including full-court basketball. He reported that his stamina during these activities had declined substantially in recent months. The patient also described unusual episodes of fatigue while performing his job as a biomedical engineer. He denied a history of angina pectoris, syncope, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. The physical examination was notable for a grade III of VI holodiastolic murmur heard best along the left sternal border. An Austin Flint murmur was not appreciated. The remainder of the physical examination was noncontributory. Noninvasive measurements of arterial blood pressure indicated the presence of a widened pulse pressure (75-80 mmHg). A plasma brain natriuretic peptide concentration was normal. Transesophageal echocardiography (TEE) was performed as part of the evaluation and confirmed the presence of a bicuspid aortic valve with thickened anterior-lateral (left and right coronary cusp fusion; type A) and posterior-medial leaflets of approximately equal size. The TEE examination also revealed that the middle scallop of the anterior mitral leaflet (A2) was essentially immobile throughout the cardiac cycle ( and [supplementary videos are available online]). What is the cause of this anterior mitral leaflet immobility?

Unusual Variance at the Main Carina During Bronchoscopy - Corrected Proof

Mruthunjaya Danappa Hulgur, Vincent Hong, Mohhamed Loubani — 2010-07-20

An 84-year-old man came for resection of a right lower-lobe tumor for squamous cell carcinoma staged at T2 N0 M0. Apart from having had TIA 20 years previously, he did not have any significant past medical history. Bronchoscopy revealed the main carina being divided into 3; the right upper lobe was arising from the distal end of the trachea (). The rest of the bronchoscopy was normal.

Linear Object in the Ascending Aorta Discovered on Routine Transesophageal Echocardiography for Coronary Artery Bypass Graft Surgery - Corrected Proof

Peter Frank Mueting-Nelsen, Henry Tannous, Andrey Apinis — 2010-07-20

A 71-YEAR-OLD man with a medical history of hypertension, non–insulin-dependent diabetes and coronary artery disease presented with unstable angina. The patient previously had undergone percutaneous coronary interventions (PCI), and bare metal stents had been placed in the right coronary (RCA) and left circumflex arteries. Upon presentation, the patient underwent coronary angiography, revealing 3-vessel disease with in-stent restenoses. The patient was referred for 3-vessel coronary artery bypass grafting (CABG).

Routine Extraluminal Use of the 5F Arndt Endobronchial Blocker for One-Lung Ventilation in Children up to 24 Months of Age - Corrected Proof

Lianne L. Stephenson, Christian Seefelder — 2010-07-20

THORACIC SURGERY in neonates, infants, and small children increasingly is performed with minimally invasive techniques including thoracoscopy. One-lung ventilation (OLV) optimizes exposure during thoracoscopic surgery. The pediatric size 5F Arndt Endobronchial Blocker (AEB) (Cook Medical Inc, Bloomington, IN) has been used successfully for lung isolation in children. A removable loop protruding through its central lumen is used to guide it with a fiberoptic bronchoscope (FOB) into the mainstem bronchus. Because a 4.5-mm inner-diameter (ID) endotracheal tube (ETT) or larger is required to accommodate the blocker concomitant with a pediatric FOB for blocker placement, its endoluminal use is limited to children 2 years and older. The authors performed a retrospective review of their practice of placing the blocker outside the ETT (extraluminal) and to position the blocker with guidance by a bronchoscope inserted through the ETT (endoluminal) in children up to 24 months of age.

Hemodynamic Stability During Biventricular Pacing After Cardiopulmonary Bypass - Corrected Proof

2010-07-20

Objective: To assess the stability of cardiac output, mean arterial pressure, and systemic vascular resistance during biventricular pacing (BiVP) optimization.Design: Substudy analysis of data collected as part of a randomized controlled study examining the effects of optimized temporary BiVP after cardiopulmonary bypass (CPB).Setting: A single-center study at a university-affiliated tertiary care hospital.Participants: Cardiac surgery patients at risk of left ventricular failure after CPB.Interventions: BiVP was optimized immediately after CPB. Atrioventricular delay (7 unique settings) was optimized first, followed by the left ventricular pacing site (3 unique settings) and then the interventricular delay (9 unique settings). Each setting was tested twice for 10 seconds each time. Vasoactive medication and fluid infusion rates were held constant.Measurements and Main Results: Aortic flow velocity and radial artery pressure were digitized, recorded, and averaged over single respiratory cycles. Least squares and linear regression/Wilcoxon analyses were applied to the first 7 patients studied. Subsequently, curvilinear analysis was applied to 15 patients. Changes in mean arterial pressure and systemic vascular resistance were statistically insignificant or too small to be meaningful by least squares analysis. During interventricular synchrony optimization, cardiac output and mean arterial pressure decreased (mean changes −5.7% and −2.5%, respectively; with standard errors 2.3% and 1.5%, respectively), whereas SVR increased (mean change 3.1% with standard error 3.4%). Only the change in cardiac output was statistically significant (p = 0.043). Curvilinear fits to data for 15 patients demonstrated progressive hemodynamic stability over the total testing period.Conclusion: BiVP optimization may be done safely in patients after CPB. With continuous monitoring of mean arterial pressure and cardiac output, the procedure results in no harmful hemodynamic perturbation.

N-acetylcysteine in Cardiac Surgery: Do the Benefits Outweigh the Risks? A Meta-Analytic Reappraisal - Corrected Proof

Guyan Wang, Daniel Bainbridge, Janet Martin, Davy Cheng — 2010-07-20

Objective: N-acetylcysteine (NAC) reduces proinflammatory cytokines, oxygen free-radical production, and ameliorates ischemia reperfusion injury; therefore, it may theoretically reduce postoperative complications in cardiac surgery. The aim of this study was to determine, through systematic review and meta-analysis of all relevant randomized trials, whether NAC reduces mortality, morbidity, or resource utilization in cardiac surgery.Design: Meta-analysis.Setting: University hospitals.Participants: A total of 1,407 patients from 15 randomized studies were included in the analysis.Interventions: None.Measurements and Main Results: All randomized trials searched up to May 2009 comparing the use of NAC versus placebo during cardiac surgery in any language and reporting at least 1 predefined outcome were included. The random effect model was used to calculate odds ratios (ORs, 95% confidence intervals [CIs]) and weighted mean differences (WMD, 95% CI) for dichotomous and continuous variables, respectively. During cardiac surgery, the use of NAC did not significantly decrease acute renal failure requiring renal replacement therapy (OR = 1.05; 95% CI, 0.52-2.11; p = 0.90), new atrial fibrillation (OR = 0.67; 95% CI, 0.37-1.22; p = 0.19), or mortality (OR = 0.81; 95% CI, 0.39-1.68; p = 0.57). There were no differences in the incidence of incremental increase in serum creatinine concentration greater than 25% above baseline (OR = 0.86; 95% CI, 0.66-1.12; p = 0.26), acute myocardial infarction (OR = 0.69; 95% CI, 0.29-1.61, p =0.39), stroke (OR = 0.78; 95% CI, 0.30-2.03; p = 0.61), red blood cell transfusion requirement (OR = 0.77; 95% CI, 0.45-1.31; p = 0.33), re-exploration (OR = 1.33; 95% CI, 0.70-2.26; p = 0.29), or postoperative drainage (WMD = 33 mL; 95% CI,−125 to 191 mL; p = 0.69) between NAC and placebo.Conclusion: Current evidence shows that the perioperative use of NAC has no proven benefit or risk on clinically important outcomes in patients undergoing cardiac surgery.

Clostridium difficile–Associated Disease Acquired in the Cardiothoracic Intensive Care Unit - Corrected Proof

2010-07-20

Objectives: To determine the prevalence, severity, and outcome associated with Clostridium difficile–associated disease (CDAD) acquired while in the cardiothoracic intensive care unit (CTICU).Design: A 5-year retrospective study.Setting: The CTICU.Participants: All CTICU patients with a positive C difficile stool toxin assay 48 hours after admission.Interventions: None.Measurements and Main Results: The results of all CTICU patients with a positive C difficile stool toxin assay were obtained from the Microbiology Department. Each patient's medical notes and charts then were reviewed in turn. A total of 27 of 5,199 (0.5%) CTICU patients acquired CDAD. The median age was 74 years (IQR 68-77), and 17 (63%) patients were male. There were 21 (78%) surgical patients; 13 (62%) were elective admissions. The most frequent diagnosis on admission was valvular heart disease (10 [37%] patients). Sixteen (59%) patients underwent coronary artery bypass graft (CABG) surgery and/or valvular heart surgery. The median interval between CTICU admission and CDAD diagnosis was 10 days (IQR 5-18). Previously identified risk factors for ICU-acquired CDAD included age >65 years (23), antibiotic use (26), and medical device requirements (27). At the time of diagnosis, 14 (52%) patients had moderate CDAD. After treatment initiation, 8 (30%) patients developed worsening CDAD. The 30-day in-hospital mortality rate for CTICU-acquired CDAD was 26% (7 patients).Conclusions: C difficile–associated disease rarely is acquired in the CTICU. Approximately one third of patients may experience disease progression, and just over a quarter may die within 30 days of diagnosis. The implementation of recommended severity definitions and treatment algorithms may reduce complication rates and merits prospective evaluation.

Prosthetic Valve Malfunction Caused by Chordal Entrapment Detected by Transesophageal Echocardiography - Corrected Proof

2010-07-20

PROSTHETIC MALFUNCTION after mitral valve replacement (MVR) is a medical emergency. In particular, pathologic transvalvular regurgitation caused by a prosthetic malfunction immediately after cardiopulmonary bypass is a problem. The authors present a case in which increasing pathologic transvalvular regurgitation after MVR was diagnosed with transesophageal echocardiography (TEE), prompting re-exploration and resection of the subvalvular apparatus.

Evaluation of the Internal Jugular Vein With Transesophageal Echocardiography as a Surface Probe: A Real Alternative to Current Practice? - Corrected Proof

Gabor Erdoes, Reto Basciani — 2010-07-12

We read with interest the article by Stevenson et al about a proposed novel use of the transesophageal echocardiographic (TEE) probe. Placing the tip of the TEE probe over the patient's anterior triangle of the neck, both internal jugular veins (IJVs) were evaluated; the authors opted to use the left-sided one for the placement of the central venous catheter (CVC) because of its greater diameter. On the basis of the presented case, the authors concluded that the surface use of TEE is a favorable screening method for IJV cannulation resulting in an increased use of ultrasound for CVC placement in cardiac anesthesia departments. Although it is an interesting report, we believe that the presented use of the TEE probe does not provide any advantage under clinical conditions.

An Indwelling Nasogastric Tube Interferes With Intubation Assisted by the Pentax Airway Scope - Corrected Proof

Hirotoshi Kitagawa, Yasuhiko Imashuku, Toji Yamazaki — 2010-07-12

The Pentax Airway Scope (AWS; Hoya Co, Tokyo, Japan) integrates a wide view of the glottis and tube guidance function by elevating the epiglottis. Therefore, the Pentax AWS is used routinely for tracheal intubation, including double-lumen tube (DLT) and tube exchange from a DLT to a single endotracheal tube (ETT). In patients undergoing general anesthesia, a nasogastric tube (NG) is routinely placed to prevent postoperative nausea and vomiting in the operating room. In such cases, we occasionally have experienced difficulty with the Pentax AWS–assisted tube exchange from DLT to ETT. Herein, we describe interference of the indwelling NG tube with intubation.

Sectional Wall Motion Detected by Epiaortic Echocardiography - Corrected Proof

2010-07-09

Objective: To evaluate in vivo cross-sectional conformational changes of ascending aortic wall excursion in patients undergoing resection for aortic aneurysm with those undergoing elective coronary artery bypass grafting (CABG) using epi-aortic echocardiography.Design: A prospective observational investigation.Setting: A single tertiary care university hospital.Participants: Thirty-four patients undergoing elective ascending aorta resection and 23 elective CABG patients.Intervention: In an open-chest model and with use of an epi-aortic echocardiographic probe, measurements of aortic wall excursion were made on the ascending aortic aneurysms. Control measurements were made on the transitional neck portions of the aneurysmal aortas (internal control) and CABG aortas (external control).Measurements and Main Results: The aortic aneurysm measurements exhibited no difference (2.8%, p < 0.62) between the excursion of the anterior and posterior walls. In contrast, under similar hemodynamic conditions, the anterior wall of the aneurysm neck moved 48.2% (p < 0.0004) more than the posterior wall. Similarly, in the CABG control group, the anterior wall moved 24% (p < 0.027) more than the posterior wall.Conclusion: This in vivo study documented a lack of asymmetric aortic wall motion in ascending aortic aneurysms. In contrast, both the internal and external control groups (aneurysm neck and CABG) demonstrated asymmetric wall motion. The lack of asymmetric wall motion may be an important aspect of aneurysm pathophysiology and key to the development of management strategies for timing of surgical intervention.

Effects of a Novel Benzodiazepine Derivative, JM-1232(-), on Human Gastroepiploic Artery In Vitro - Corrected Proof

Takahiro Moriyama, Isao Tsuneyoshi, Yuichi Kanmura — 2010-07-05

Objective: To investigate the effects of JM-1232(-) on norepinephrine (10−6 mol/L)- and high K+ (40 mmol/L)-induced contractions in isolated human gastroepiploic arteries (GEA), and to compare them with the effects of midazolam and propofol. In addition, to investigate whether the benzodiazepine-receptor antagonist, flumazenil, or μ-opioid-receptor antagonist, naloxone, influenced the vascular effects of JM-1232(-).Design: An in vitro experimental study.Setting: University laboratory.Participants: GEA segments were used from 69 patients undergoing coronary artery bypass graft surgery.Measurements and Main Results: JM-1232(-) produced dose-dependent relaxation effects in the rings. Although these effects of JM-1232(-) were greater than those of midazolam and propofol at high concentrations (10−5-10−4 mol/L), there were no significantly different relaxation effects at the clinical concentrations of 3 × 10−6 mol/L JM-1232(-), 3 × 10−6 mol/L midazolam, and 1 × 10−5 mol/L propofol. In addition, all these effects were independent of the presence of a functional endothelium. Vasorelaxation induced by JM-1232(-) on norepinephrine-preconstricted GEA was inhibited by flumazenil, but not by naloxone.Conclusions: These results indicate that JM-1232(-) dose-dependently relaxes smooth muscle in human GEA, this effect being independent of the endothelium. Within the ranges of plasma concentrations achieved in clinical practice, JM-1232(-) had similar vasorelaxation effects to midazolam and propofol. JM-1232(-)-induced vasorelaxation was inhibited by flumazenil, indicating that JM-1232(-)-induced vasorelaxation occurred via peripheral benzodiazepine receptor activation in the GEA.

Outcome in Patients Who Require Venoarterial Extracorporeal Membrane Oxygenation Support After Cardiac Surgery - Corrected Proof

2010-07-05

Objective: The authors analyzed hospital mortality in adult cardiac surgery patients who required postoperative venoarterial extracorporeal membrane oxygenation (ECMO) support for circulatory failure and identified perioperative patient variables associated with hospital mortality in these patients.Design: A retrospective study.Setting: A single institution, tertiary academic center.Participants: Adult patients requiring venoarterial ECMO support after cardiac surgery from January 1995 to December 2005 were identified from the Anesthesiology Institute Patient Registry. Twenty-two preselected patient variables were entered into a logistic regression model of hospital death.Interventions: None.Results: Two hundred thirty-three of 40,116 (0.58%) adult cardiac surgery patients required postoperative venoarterial ECMO, and among these, 149 (64%) died in the hospital. In an unadjusted analysis, older age, higher preoperative albumin, diabetes history, coronary artery bypass graft surgery, and longer total cardiopulmonary bypass (CPB) time were associated with increased hospital mortality, and a history of cardiogenic shock was associated with decreased mortality. In an adjusted logistic regression analysis, a history of cardiogenic shock and younger age were associated with decreased hospital mortality. The overall use of postoperative venoarterial ECMO in this patient population decreased since its peak in 1996.Conclusion: Venoarterial ECMO support after cardiac surgery was required in a small fraction of patients and was associated with very high hospital mortality; but among those requiring ECMO, mortality in these patients was lower in younger, nondiabetic patients with cardiogenic shock who had shorter CPB times. The mortality associated patient variables identified are not easily modifiable and do not appear sufficiently robust to define which patients should be selected for this potentially life-saving therapy.