Multimedia Library
Where Should We Leave the Wild “Raa Raa” During Cardiopulmonary Bypass?
THE PULMONARY artery catheter (PAC), the Raa Raa, the noisy, wild lion in a British stop-motion animated children's television program1 (Fig 1), also known as the Swan-Ganz catheter, is used frequently during cardiac surgery. The PAC might provide clinicians with important information on the preload, afterload, and contractility through the measured and derived parameters for risks stratification and guide perioperative management, particularly in patients with advanced heart failure, pulmonary hypertension, cardiogenic shock, and those who undergo heart and lung transplantation and left ventricular assist device implantation.Ascending Aortic Pseudoaneurysm Fistulating into the Right Atrium: Vital Diagnosis via Intraoperative Transesophageal Echocardiography
THORACIC AORTIC PSEUDOANEURYSM is a rare complication after cardiovascular surgery, with an incidence <0.5%.1,2 A 54-year-old man presented with a large pseudoaneurysm (7.6 cm × 6.4 cm) of the proximal ascending aorta after undergoing an aortic valve replacement for bicuspid aortic valve disease (Fig 1). The patient complained of shortness of breath and fatigue. The patient was taken to the operating room for repair. An intraoperative transesophageal echocardiogram demonstrated a contained transmural rupture of the ascending aortic wall with continuous-flow jets from the aortic lumen toward the pseudoaneurysm in the upper esophageal ascending aortic short-axis view (Fig 2A, Video 1).“Ripples in Water” Effect Detected by Ultrasound During Internal Jugular Catheterization
Herein, I describe an interesting “ripples in water” effect in the right internal jugular vein using ultrasound guidance before its catheterization. A 54-year-old male with severe mitral stenosis, tricuspid regurgitation, pulmonary artery hypertension, and atrial fibrillation, was scheduled for mitral valve replacement. After the induction of anesthesia, the patient was positioned and prepared for a right internal jugular vein catheterization under ultrasound guidance. An ultrasound assessment revealed stasis of blood in the vessel and a “ripples in water” effect in a cross-sectional view (Fig 1; Video 1).Porcine Orthotopic Cardiac Xenotransplantation: The Role and Perspective of Anesthesiologists
ON JANUARY SEVENTH, 2022, the first genetically modified porcine cardiac xenograft was transplanted into a patient at the University of Maryland Medical Center. As members of the xenotransplant team and division of cardiac anesthesiology at the University of Maryland School of Medicine, the authors here had a role in this historic event. Cardiac xenotransplantation could become a common occurrence if it proves to be a viable answer for the limited supply of donor hearts to treat end-stage heart failure.Use of the Ventrain Ventilation Device and an Airway Exchange Catheter to Manage Hypoxemia During Thoracic Surgery and One-Lung Ventilation
HYPOXEMIA is a common challenge during one-lung ventilation (OLV),1,2 and first-line approaches for its management include assessing airway device position, increasing oxygen-inspired fraction (Fio2), optimizing ventilation, and applying continuous positive airway pressure to the nonventilated lung.3,4 The Ventrain (Ventinova Medical, Eindhoven, Netherlands) allows for ventilation through smaller internal diameter endotracheal tubes or smaller bore catheters. It is a handheld device with tubing for connection to an oxygen flow meter on one end and a male Luer Lock connector on the other end.Cardiac Hydatid Cyst Diagnosed Incidentally by Transesophageal Echocardiography After Cardiac Arrest
Hydatid cyst caused by echinococcus granulosus continues to be an endemic health problem in many countries. The liver (50%-70%) and lungs (5%-30%) are the most common locations for hydatid cysts. Cardiac hydatid cysts are found in fewer than 2% of patients.1 We present an uncommon case of cardiac hydatid cyst diagnosed incidentally by transesophageal echocardiography after cardiac arrest due to anaphylaxis that developed during liver hydatid cyst aspiration.One-Lung Ventilation to Accommodate Echocardiographic Guidance of the MitraClip
WE RECENTLY PUBLISHED an article by Musuku et al.1 in which we described the use of a combination of intracardiac echocardiography (ICE) by the cardiologist and transthoracic echocardiography (TTE) by the anesthesiologist for guidance of a MitraClip (Abbott, Abbott Park, IL) procedure in which transesophageal echocardiography (TEE) was not possible because of a newly diagnosed laryngeal mass. As a follow-up to that article, we present a patient in whom a large hiatal hernia prevented adequate TEE guidance, and lung isolation was used to dramatically improve image quality and accommodate a primarily TTE-guided approach for MitraClip.Intraoperative Epicardial Pacing-Induced Dyssynchrony Leading to Severe Mitral Regurgitation and Hemodynamic Instability
Interventricular dyssynchrony from right ventricular (RV) epicardial pacing is known to cause hemodynamic derangements.1 Here, we present a case of prominent left ventricular (LV) dyssynchrony on separation from bypass causing severe mitral regurgitation (MR) that was dramatically reversed with intraoperative cardiac resynchronization.The Risk of Malposition: A Tale of Two Devices
IN THE MODERN ERA, a multitude of mechanical devices are used to temporize organ perfusion and hemodynamics in patients with heart failure, and thus “bridge” these patients to recovery, transplant, or a durable assist device. However, with increasing frequency of their placement, the rate of malposition has also increased, sometimes with serious consequences.1 Modifications to either insertion or device design also have been developed because of a desire to increase mobility, reduce cost, and optimize comfort.Novel Closed-Loop Bronchoscopy Barrier Sheath: Valuable Addition for One-Lung Ventilation During the Coronavirus Disease 2019 Pandemic
CORONAVIRUS disease 2019 (COVID-19) is a rapidly evolving pandemic, with serious implications for both patients and healthcare professionals.1 One-lung anesthesia and ventilation constitute a high-risk procedure because they entail the use of repeated flexible bronchoscopy for confirmation of lung isolation, and troubleshooting intraoperative hypoxemia and bronchial suctioning during various stages of surgery; and has the potential for aerosol generation and environmental contamination, thus endangering the safety of healthcare professionals and providers.A Rare and Unique Central Line Complication
THE following describes a rare complication that can occur when placing multiple central venous catheters into a single vessel. In this patient, upon insertion of a second central line into the internal jugular vein, an existing catheter was pierced with the new catheter going through the existing line. The complication was not fully recognized until removal of the central access was attempted in the intensive care unit (ICU) days later.Persistence of the Dilemma: Inability to Detect a Persistent Left Superior Vena Cava Using Standard Echocardiographic Criteria
Persistent left superior vena cava (PLSVC) is an anomaly commonly associated with congenital heart disease with an incidence of 3% to 8% compared with the incidence in the general population of 0.3% to 0.5%.1 The diagnosis can be missed easily unless specific preoperative testing is carried out, such as a cardiac computed tomography scan. Although often benign, unusual drainage or presence of an associated intracardiac shunt may have clinical significance, especially during the perioperative period.Isolated Left-Sided Heart Tamponade on Echocardiography in Severe Pulmonary Hypertension and Right Heart Failure
CARDIAC tamponade is a life-threatening condition related to fluid accumulation within the pericardial sac that impairs normal cardiac filling. As fluid accumulates in the pericardial space, pressure increases. This increase in pericardial pressure is transmitted across the transmural space, and when it exceeds intracavitary pressures, collapse of the chambers occurs. In circumferential pericardial effusions, bilateral tamponade typically occurs, and the sequence of chamber collapse corresponds with the lowest intracavitary pressures.Previously Undiagnosed Patent Foramen Ovale as Cause of Hypotension and Hypoxemia in a Patient With Recent TandemHeart LVAD Insertion
DETERMINATION OF the cause of hypoxia during percutaneous left ventricular assist device (LVAD) use can be a diagnostic challenge. We present an interesting case of hypotension and hypoxemia in a patient with a TandemHeart LVAD (CardiacAssist, Inc.). The patient was a 64-year-old man with a history of ischemic cardiomyopathy, pulmonary hypertension, and coronary artery disease status post previous coronary artery bypass graft surgery. He presented with left ventricular heart failure and recurrent ventricular tachycardia and underwent ventricular tachycardia ablation assisted by planned percutaneous TandemHeart LVAD.The Use of Point-of-Care Lung Ultrasound and Echocardiography in the Management of Coronavirus Disease 2019 (COVID-19)
Over the past few months, coronavirus disease 2019 (COVID-19) has provided an unprecedented challenge to critical care teams across the world. As the number of cases increases exponentially, we are seeing an unparalleled strain on intensive care resources.Successful Use of Limited Transthoracic Echocardiography to Guide Veno-venous Extracorporeal Membrane Oxygenator Placement in a Patient With Coronavirus Disease 2019
ACCORDING TO THE American Society of Echocardiography (ASE), the 2019 novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can be easily spread during echocardiographic studies, with transesophageal echo (TEE) carrying a heightened risk because it can provoke aerosolization of the virus. Therefore, it is recommended that TEE be avoided in suspected or confirmed coronavirus disease–2019 (COVID-19) patients if an alternative imaging modality, such as transthoracic echo (TTE), can provide equivalent information.Novel Coronavirus Disease 2019 (COVID-19) Aerosolization Box: Design Modifications for Patient Safety
THE NOVEL CORONAVIRUS disease 2019 (COVID-19) is an unprecedented global pandemic that has shaken the healthcare community. The transmission of COVID-19 has not yet been fully elucidated, but we do know that the virus can be spread by respiratory droplets and aerosols, resulting in a severe lower respiratory tract infection and acute respiratory distress syndrome.1 Along with other countries, the majority of the United States has issued “stay-at-home” orders to slow the spread of the disease. However, physicians and healthcare providers continue to go to work each day with great personal risk to themselves and their families.How 3D Printing Can Prevent Spread of COVID-19 Among Healthcare Professionals During Times of Critical Shortage of Protective Personal Equipment
Over the last several months, severe acute respiratory syndrome coronavirus 2 (COVID-19) has continued to spread all over the globe at an alarming rate, with total disregard for patients’ pre-existing medical conditions, age, or other demographics.1 The mortality rate is substantially higher than influenza, and the death rate in the United States seems to be surpassing that of both China and Europe.2 Although healthcare professionals report for duty each morning and evening to care for an increasing number of patients with various gradations of disease, their own safety and health remain threatened.Ultrasound Parasternal Block as a Novel Approach for Cardiac Sternal Surgery: Could it Be the Safest Strategy?
Respiratory complications are a major factor contributing to postoperative morbidity and mortality, especially in patients with chronic obstructive pulmonary disease (COPD). To minimize respiratory complications, minimally invasive approaches to cardiac surgery in addition to regional anesthesia are being used.1 Cardiac surgery most commonly is performed via median sternotomy, which results in significant intraoperative and postoperative pain and a high incidence of chronic pain. When sternal dehiscence occurs, sternal resynthesis most commonly is performed with general anesthesia and intravenous opioid administration, which can result in pulmonary complications such as respiratory depression or infections.Intrathoracic Pressure Waveform Transduced From Central Venous Catheter Tip: To Remove or Reposition the Catheter?
Malpositioning of the central venous catheter (CVC) tip is a common complication of CVC placement. Undiagnosed CVC tip malpositioning can lead to significant morbidity and mortality. The management in cases of CVC tip malpositioning is to remove and relocate the catheter.1 In everyday practice, the correct placement of the CVC tip within the superior vena cava (SVC) usually is confirmed by aspiration of blood from the distal port, transduction of waveform consistent with intravenous placement, and careful interpretation of chest radiograph.Intraoperative Transvalvular Regurgitation Immediately After Mitral Bioprosthetic Valve Implantation
BIOPROSTHETIC VALVES are being used increasingly1 because of their excellent durability2,3 and lesser need for anticoagulation.4 Bioprosthetic valve dysfunction, such as pannus formation, thrombosis, calcification, and endocarditis, may occur in the months or years after valve replacement.5 However, intraoperative issues regarding newly implanted bioprosthetic valves themselves are extremely rare, and only a few cases have been reported.6-9 Here, we present 2 cases of significant mitral bioprosthetic valve regurgitation that occurred immediately after valve implantation while the patients were on cardiopulmonary bypass (CPB).Temporary Apprehension Over an Artefactual Appearance of a Paraprosthetic Leak
A 63-YEAR-OLD male (weight 51 kg, height 155 cm) underwent mitral valve repair for mitral regurgitation using a 28 mm Carpentier-Edwards Physio annuloplasty ring (Edwards Lifesciences, Irvine, CA). Bicaval cannulation was performed, and a transseptal approach was adopted. A left atrial vent (16 French) was inserted through the right pulmonary vein. A repeat transesophageal echocardiography (TEE) examination was performed before separation from cardiopulmonary bypass. At this juncture, a 4-chamber midesophageal TEE interrogation identified a “paravalvular” leak at what would be the normal location of the P1 scallop of the posterior mitral leaflet in the native mitral valve (Fig 1, Video 1).Aberrant Band in the Right Atrium Simulating Central Venous Catheter—A Rare Echocardiographic Pitfall
The authors present a new echocardiographic pitfall of an aberrant band in the right atrium that mimicked a central venous catheter on intraoperative transesophageal echocardiography (TEE) examination.Benefits of Myocardial Deformation Analysis in Cardiac Surgery
We read with interest the article by Donauer et al. accepted for publication in the Journal of Cardiothoracic and Vascular Anesthesia.1 Their study is of particular value, because it provides evidence that myocardial deformation analysis can improve substantially the diagnostic performance of echocardiography in cardiac surgery patients. By focusing their study mainly on the right ventricle (RV) and the interventricular septum (IVS), the authors also investigated an up-to-date topic, which in the past received less attention.Ultrasound-Guided Internal Jugular Catheter Insertion in Prone Position
OBTAINING vascular access is a vital component of patient care both in anesthesia and intensive care practice. Ultrasound-assisted vascular access can provide a safer and more efficient means of obtaining both peripheral and central venous access by reducing complications.1-3
