Multimedia Library
Temporary Epicardial Pacing After Cardiac Surgery
Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery.Acute Cardiointestinal Syndrome Resulting From Postoperative Acute Biventricular Heart Failure
ACUTELY DECOMPENSATED HEART FAILURE (HF), if left untreated, causes organ hypoperfusion that can progress to irreversible and life-threatening multiorgan dysfunction. Cardiointestinal syndrome (CIS) is the result of both persistent venous congestion and hypoperfusion of the intestines as a result of biventricular HF.1 These mechanisms contribute to perturbations in normal intestine function that ultimately result in intestinal bacteria product translocation into the bloodstream.2 This translocation causes inflammatory cytokine production and sepsis, which depress myocardial function and eventually lead to biventricular heart failure, multiorgan failure, and death.Ultrasound-Enhancing Agent Enables Transthoracic Echocardiography in Patients With Delayed Sternal Closure
DELAYED STERNAL CLOSURE (DSC) is a technique adopted to manage unstable patients after cardiac surgery, including low-cardiac-output state (LCOS), intractable bleeding, and arrhythmia.1 This cohort of patients may have extensive devices within the thorax, including metal retractors, vacuum- assisted closure systems, swabs, drains, and central venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulae, rendering cardiac visualization very challenging. Transesophageal echocardiography (TEE) is the main tool to assess cardiac function in these patients.Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation
Minimally invasive approaches for left ventricular assist device (LVAD) implantation have grown in popularity and have many potential advantages, including less bleeding, shorter recovery time, and improved postoperative right ventricular function compared with traditional implantation. Centrifugal flow LVADs are easily implanted via a minimally invasive approach. In this article, the authors review intraoperive considerations for minimally invasive LVAD implantation and hemodynamic management principles for patients with centrifugal flow LVADs.Intraoperative Transesophageal Echocardiographic Findings in Surgical Resection of a Giant Right Atrial Diverticulum That Severely Compressed the Right Ventricle
A RIGHT ATRIAL (RA) diverticulum is a rare congenital malformation characterized by extraordinary cardiac enlargement that is often incidentally diagnosed by cardiac imaging.1–5 The etiology and optimal treatment of an RA diverticulum remain unclear because patients cases are asymptomatic. Although surgical resection is indicated for symptomatic patients, there have been no reports of intraoperative transesophageal echocardiography (TEE) of an RA diverticulum.Near-Infrared Spectroscopy in Adult Cardiac Surgery Patients: A Systematic Review and Meta-Analysis
To identify the normal baseline preoperative range of cerebral tissue oxygen saturation (SctO2) derived using near-infrared spectroscopy (NIRS) and the efficacy of perioperative interventions designed to modulate SctO2 in cardiac surgical patients.Pain Measurement in Mechanically Ventilated Patients After Cardiac Surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT)
The Behavioral Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT) are behavioral pain assessment tools for sedated and unconscious critically ill patients. The aim of this study was to compare the reliability, internal consistency, and discriminant validation of the BPS and the CPOT simultaneously in mechanically ventilated patients after cardiac surgery.Left Atrium Dissection: A Rare Cardiac Surgery Complication
LEFT ATRIAL DISSECTION is a rare complication of cardiac surgeries and usually is associated with mitral valve procedures. Typically, a false chamber is created through a tear of the mitral valve annulus extending into the left atrial wall. Transesophageal echocardiography (TEE) is used for diagnosis. The authors present a case of left atrial dissection that occurred after an ascending and transverse aortic arch aneurysm repair that was managed successfully conservatively.Peripheral Near-Infrared Spectroscopy: Methodologic Aspects and a Systematic Review in Post-Cardiac Surgical Patients
LOSS OF HEMODYNAMIC coherence1 between macrocirculatory oxygen parameters and the peripheral microvasculature frequently is seen in critically ill patients,2 including postoperative cardiac surgery patients. Hemodynamic stabilization by volume expansion and pharmacologic cardiovascular support may correct systemic hemodynamic variables but not oxygenation and perfusion of the microcirculation.1,3 Persistent microcirculatory abnormalities are associated with adverse patient outcomes.4 Consequently, there is interest in minimally invasive methods to assess the microvasculature in addition to established systemic hemodynamic monitoring in patients admitted to intensive care units (ICUs).Cardiovascular Collapse in the Pregnant Patient, Rescue Transesophageal Echocardiography and Open Heart Surgery
ANESTHESIOLOGISTS with a practice in obstetrics must be acutely aware of the differential diagnosis of maternal cardiovascular collapse during pregnancy. The overall risk of maternal death is 6.5 in 100,000 deliveries and typically occurs in the third trimester.1 Deaths in the first and second trimesters are rare. The most common etiologies include pre-eclampsia (16%), amniotic fluid embolism (AFE) (14%), hemorrhage (12%), cardiac disease (11%), and pulmonary thromboembolism (9%). Less common etiologies include infection, medication error, and ectopic pregnancy.A Pharmacokinetic Model for Protamine Dosing After Cardiopulmonary Bypass
This study investigated postoperative hemostasis of patients subjected to conventional protamine dosing compared with protamine dosing based on a pharmacokinetic (PK) model following cardiopulmonary bypass.Predictive Value of Intraoperative Thromboelastometry for the Risk of Perioperative Excessive Blood Loss in Infants and Children Undergoing Congenital Cardiac Surgery: A Retrospective Analysis
Laboratory hemostatic variables and parameters of rotational thromboelastometry (ROTEM) were evaluated for their ability to predict perioperative excessive blood loss (PEBL) after congenital cardiac surgery.Incidental Finding of a Right Atrial Appendage Thrombus During Cardiac Surgery
RIGHT ATRIAL APPENDAGE (RAA) thrombi are encountered much less frequently than their left-sided counterparts. This difference is explained partly by dissimilarities in appendage anatomy and function. Atrial fibrillation (AF), right ventricular failure, and pulmonary hypertension are associated with RAA clots. Right atrial appendage thrombi remain a potential risk for serious embolic events and need to be addressed accordingly. The left atrial appendage (LAA) is studied routinely for the presence of thrombi in the setting of AF.Sevoflurane Versus Total Intravenous Anesthesia for Isolated Coronary Artery Bypass Surgery With Cardiopulmonary Bypass: A Randomized Trial
Several studies have suggested that the cardioprotective effects of halogenated anesthetics in cardiac surgery result in reduced cardiac biomarker release compared with total intravenous anesthesia (TIVA). These findings came from relatively small randomized clinical trials and meta-analyses. The authors of this study hypothesized that the beneficial effects of volatile anesthetics translate into a reduced length of hospital stay after coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass.Intraoperative Anemia and Single Red Blood Cell Transfusion During Cardiac Surgery: An Assessment of Postoperative Outcome Including Patients Refusing Blood Transfusion
Increasing evidence suggests benefits from restrictive red blood cell transfusion (RBC) thresholds in major surgery and critically ill patients. However, these benefits are not obvious in cardiac surgery patients with intraoperative anemia. The authors examined the association between uncorrected hemoglobin (Hb) levels and selected postoperative outcomes as well as the effects of RBCs.Intraoperative Transesophageal Echocardiography for the Evaluation and Management of Diastolic Dysfunction in Patients Undergoing Cardiac Surgery: A Survey of Current Practice
To characterize existing practice patterns for intraoperative evaluation and grading of diastolic dysfunction in patients undergoing cardiac surgery.Risk Factors and Impact on Clinical Outcome of Multidrug-Resistant Acinetobacter Baumannii Acquisition in Cardiac Surgery Patients
Acinetobacter baumannii recently has emerged as an important nosocomial pathogen. The aim of this study was to assess the impact on mortality of multidrug-resistant A. baumannii (MDR-AB) infection/colonization in patients undergoing cardiac surgery and to investigate microbiologic characteristics, epidemiologic spread of this pathogen, and the relative containment measures.Rate of Major Anesthetic-Related Outcomes in the Intraoperative and Immediate Postoperative Period After Cardiac Surgery
To examine anesthesia-centered outcomes in a large cohort of patients undergoing coronary artery bypass grafting (CABG) or valvular heart surgery.Video Fluoroscopy for Positioning of Pulmonary Artery Catheters in Patients Undergoing Cardiac Surgery
To determine whether video fluoroscopy combined with traditional pressure waveform analyses facilitates optimal pulmonary artery catheter (PAC) flotation and final positioning compared with the traditional pressure waveform flotation technique alone.CASE 12—2015: Tropheryma Whipplei Endocarditis
A 50−60-YEAR-OLD MAN with ongoing alcohol and methamphetamine abuse and a suspected history of intravenous drug use presented to the emergency department with a 1-month history of bilateral leg pain. Physical examination was significant for a cold left foot and absent left dorsalis pedis and tibialis posterior pulses. Auscultation revealed a 4/6 crescendo-decrescendo systolic murmur heard loudest over the right upper sternal boarder, and a 3/6 diastolic decrescendo murmur heard loudest over the right lower sternal boarder.Air in the Moustache Can Choke the Left Ventricle
AORTIC ROOT PATHOLOGIES often require complex surgical repair techniques due to the involvement and manipulation of the coronary arteries. In 1981, Cabrol et al described a technique to reimplant the coronary arteries into the aortic conduit using a Dacron tube graft.1 In the 1980s and 1990s, the Cabrol technique and its modifications commonly were performed during aortic root surgery, but now are used less frequently due to the development of improved coronary ostial button mobilization techniques.Preliminary Experience With Combined Inhaled Milrinone and Prostacyclin in Cardiac Surgical Patients With Pulmonary Hypertension
To retrospectively evaluate the effects of combined inhaled prostacyclin and milrinone to reduce the severity of pulmonary hypertension when administered prior to cardiopulmonary bypass.Echocardiography-Based Hemodynamic Management in the Cardiac Surgical Intensive Care Unit
INTRAOPERATIVE TRANSESOPHAGEAL echocardiography (TEE) is well established within the cardiac operating room. Confirmation of the preoperative diagnosis is sought and additional relevant information is communicated to the surgeon. Following the procedure, the results of surgery are examined together with any complications, and information from echocardiography is used to optimize hemodynamic status. As the patient moves to the cardiac critical care unit and the TEE probe is removed, this information is no longer available.Impairment of Venous Drainage Due to Atrial Septal Aneurysm During Open-Heart Surgery
IT IS NOT UNCOMMON to encounter inadequate venous drainage during cardiopulmonary bypass. Some common causes include poor positioning and obstruction of the venous cannula, increased resistance due to the small diameter of the venous cannula, and kinks in the tubing that connects the venous cannula to the venous reservoir. We report a case of atrial septal aneurysm (ASA) impairing venous drainage from a 2-stage venous cannula in right atrium during a routine cardiac surgery case requiring cardiopulmonary bypass (CPB).Impact of the Anesthesiologist and Surgeon on Cardiac Surgical Outcomes
To determine the impact of anesthesiologists, surgeons, and their monthly caseload volume on mortality after cardiac surgery.Survey of the Clinical Assessment and Utility of Near-Infrared Cerebral Oximetry in Cardiac Surgery
Near-infrared cerebral oximetry increasingly is used for monitoring during cardiac surgery. Nonetheless, the scientific basis for incorporating this technology into clinical practice, the indications for when to do so, and standard diagnostic and treatment algorithms for defining abnormal values are yet to be rigorously defined. The authors hypothesized that there would be (1) variation in clinical use and practices for near-infrared spectroscopy (NIRS), and (2) variation in management of patients when clinicians are provided with NIRS information.Anesthetic Management of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Surgery (TECAB)
TOTALLY ENDOSCOPIC coronary artery bypass (TECAB) performed with robotic technology is an innovative procedure that allows coronary revascularization in the closed chest. Experience with TECAB surgery first was reported in 1999,1 and subsequent results have demonstrated the general application of this technique.2-4 Early and midterm patient outcomes are comparable to the conventional approach,2-6 but these initial cohorts of patients are still under observation for long-term outcomes.Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Pediatric Patients Undergoing Cardiac Surgery
To evaluate the feasibility of measuring renal blood flow (RBF) using transesophageal echocardiography (TEE) in pediatric patients undergoing cardiac surgery.Robot-Assisted Mitral Valve Repair
BASED LARGELY ON THE success of laparoscopic surgery in the 1990s, minimally invasive surgical approaches have gained widespread acceptance among many surgical specialties; cardiac surgery is no exception. In addition, the lay press and Internet are replete with reports of cardiac valve repair or replacement through small incisions with reportedly improved recovery times and cosmesis. Perhaps the most dramatic change to the surgical approach of valvular repair is with the use of robotic assistance (Fig 1).Acute Left Atrial Intramural Wall Dissection After Mitral Valve Replacement
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has been used routinely in the diagnosis and follow-up of cardiac pathology. Left atrial (LA) dissection is a rare complication after mitral valve surgery. A case of LA dissection is presented, and the pathology was accurately defined and immediately diagnosed by using intraoperative TEE; the dissection was repaired at the time of surgery. This case highlights the importance of prompt diagnosis of LA dissection using intraoperative TEE, and a second cardiac surgery was avoided.An Unusual Shadow in the Left Atrium After Mitral Valve Replacement
A 55-YEAR-OLD male patient with increasing dyspnea on exertion and valvular heart disease was referred for surgery. A transthoracic echocardiogram revealed moderate mitral stenosis and mild mitral regurgitation with moderate pulmonary hypertension. In addition, thrombi were identified in the left atrium (LA) and left atrial appendage. In the operating room, transesophageal echocardiography (TEE) confirmed the preoperative findings. A 27-mm internal-diameter, ATS prosthetic valve (ATS Medical Inc, Minneapolis, MN) was placed in the mitral position, and LA and left atrial appendage thrombi were removed.Air Lock and Embolism Upon Attempted Initiation of Cardiopulmonary Bypass While Using Vacuum-Assisted Venous Drainage
VACUUM-ASSISTED VENOUS DRAINAGE (VAVD) for cardiopulmonary bypass (CPB) improves venous drainage via small cannulae.1 Complications specific to VAVD are important to anticipate and recognize. A case of air lock and air embolus upon initiation of CPB caused by overpressurization of the venous catheter is described. A description of indications and potential complications of VAVD is presented.Use of a Miniaturized Transesophageal Echocardiographic Probe in the Intensive Care Unit for Diagnosis and Treatment of a Hemodynamically Unstable Patient After Aortic Valve Replacement
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has shown the ability to identify treatable causes of shock in patients after cardiac surgery.1,2 Unfortunately, the use of TEE in unstable patients after cardiac surgery is limited by the availability of trained echocardiographers, equipment and resource availability, and physician bias that a diagnosis can be established by other means. Some but not all of these limitations may be overcome through technologic innovation.Early Diagnosis of Superior Vena Cava Obstruction Facilitated by the Use of Cerebral Oximetry
OCCLUSION OR SIGNIFICANT narrowing of the superior vena cava (SVC) leading to SVC syndrome is an uncommon event after cardiac surgery. Unrecognized SVC syndrome may progress to catastrophic airway swelling and cerebral injury. This case describes the occurrence of cerebral venous hypertension and congestion as a consequence of SVC narrowing after an aortic valve replacement (AVR), mitral valve repair, and coronary artery bypass graft (CABG) surgery, which was rapidly recognized and subsequently repaired because of an acute bilateral significant decrease in cerebral oxygen saturation detected by cerebral oximetry (Invos 5100; Somanetics Corp, Troy, MI).Intraoperative Classification of Mitral Valve Dysfunction: The Role of the Anesthesiologist in Mitral Valve Reconstruction
ANESTHESIOLOGISTS cannot concentrate solely on advances made within the specialty, but must also keep up with developments occurring within the field of surgery because the surgical management of the patients partly determines the anesthetic management. Mitral valve disease and its surgical therapy represent a very dynamic area within the field of cardiac surgery. Thanks to better understanding of the anatomy of the mitral valve apparatus, pathophysiology of underlying disease processes, and improvements in surgical technique, a shift has taken place clearly favoring mitral valve repair over mitral valve replacement for regurgitant lesions.CASE 1—2009 Retrocardiac Sponge-Induced Hemodynamic Instability After Cardiac Surgery
UNINTENTIONAL FOREIGN BODIES, like surgical sponges, left within the pericardial cavity during cardiac surgery may be associated with morbidity and mortality. A surgical sponge placed posterior to the heart may remain undetected and be the source of persistent hemodynamic instability. The authors report an incident wherein a surgical sponge placed posterior to the heart during cardiopulmonary bypass (CPB) was detected by intraoperative transesophageal echocardiography (TEE) to be the cause of unstable hemodynamics in the post-CPB period.
