Intraoperative Considerations in a Patient on Intravenous Epoprostenol Undergoing Minimally Invasive Cardiac SurgeryEPOPROSTENOL IS a prostaglandin effective in treating pulmonary hypertension, and its intravenous (IV) form has become a standard treatment for improving cardiopulmonary hemodynamics and exercise capacity across various patient populations with severe pulmonary hypertension.1,2 In cardiac surgeries, inhaled epoprostenol is more commonly used and has been shown to consistently reduce pulmonary artery pressures.3,4 Although inhaled epoprostenol is frequently used in patients undergoing cardiac surgery in both the perioperative and intraoperative setting, patients presenting to surgery on the IV formulation are less common, and little literature currently exists on considerations for its management.
Intraoperative New Regional Wall Motion Abnormalities Following Aortic or Mitral Valve Surgery: A Case Series and Management AlgorithmREGIONAL WALL MOTION ABNORMALITIES (RWMAs) diagnosed by transesophageal echocardiography (TEE) may occur after valvular surgery and may be caused by various mechanisms such as air or calcium embolism, coronary spasm, poor myocardial protection, or coronary artery occlusion. Although coronary artery occlusions have been described, either after aortic or mitral valve surgery,1,2 it may be difficult to differentiate the different etiologies of new RWMAs mentioned above from coronary injuries. The purpose of this case series is to differentiate between the different etiologies of RWMAs after valvular surgery from the rare occurrence of coronary occlusion.
Porcine Orthotopic Cardiac Xenotransplantation: The Role and Perspective of AnesthesiologistsON 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.
High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional TherapyHIGH-RISK pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction, hemodynamic instability, and increased risk for early mortality that is estimated at between 25% and 65% of patients.1,2 Percutaneous catheter-directed intervention (CDI) has been recognized as a rapidly deployable, minimally invasive alternative option to surgical embolectomy when systemic thrombolytic therapy is contraindicated or ineffective.1-3 CDI techniques include fragmentation and rotational thrombectomy, suction thrombectomy, ultrasound-assisted thrombectomy, conventional catheter thrombolysis, and their combinations.
Selective Lobar Exclusion in Robot-Assisted-Thoracic Surgery Using EZ BlockerLUNG EXCLUSION AND ONE-LUNG VENTILATION are the standard for the management of thoracic parenchymal surgery, usually achieved with bronchial blockers (BB) or, more frequently, with double lumen endobronchial tubes (DLT), as recently highlighted by Langiano et al1 and Clayton-Smith et al2. However, there are situations, as in the case of patients with difficult airways, tracheostomy, or prolonged mechanical ventilation after surgery, in which the use of endobronchial blockers could be the best viable option.
A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory FailureA 19-YEAR-OLD, 96 KG, 175 cm previously healthy man with COVID-19 pneumonia, sepsis, and adult respiratory distress syndrome was transferred from a community hospital to the authors’ institution for treatment with extracorporeal membrane oxygenation (ECMO). The patient had persistent hypoxemia and hypotension despite optimal mechanical ventilation and high-dose vasoactive drug support. He was cannulated for femoral-femoral venoarterial (VA) ECMO shortly after arrival in the intensive care unit. This intervention initially improved the patient's oxygenation and reduced his vasopressor requirements, but hypoxemia and hypotension recurred concomitant with ECMO suction events and reduced flow rates that were only transiently responsive to volume resuscitation and flow adjustment.
“The Pericardial Effusion is Drained, But the Catheter Is Stuck”—Percutaneous Evacuation of Pericardial Effusion Complicated by Pigtail Catheter Entrapment in Fibrinous PericarditisPERICARDIOCENTESIS HAS been demonstrated to be a safe and valuable tool in the treatment of patients with moderate-to-large pericardial effusions or cardiac tamponade.1 Major complications are rare, but can include death, cardiac arrest, and iatrogenic perforation of the heart or vascular structures.2 Minor complications including hypotension and non-life-threatening arrhythmias are more common, but infrequent. The majority of complications are reported at the time of catheter placement; there are few reported complications during removal of the catheter.
Atrial Embolization after a Transcatheter Mitral Valve ReplacementMITRAL REGURGITATION (MR) IS the most prevalent form of valve disease, affecting about 10% of people over the age of 75 years and is associated with increased mortality.1,2 Management is dependent on the cause, pathophysiology, and predicted treatment efficacy. Although the historic gold standard for disease refractory to medical therapy is valve repair or replacement, over the last decade several transcatheter strategies have emerged, providing less invasive alternative options to elderly and frail patients at high risk for cardiac surgery.
Aortic Valve Repair Using HAART 300 Geometric Annuloplasty Ring: A Review and Echocardiographic Case SeriesAortic valve repair (AVr) aims to preserve the native aortic leaflets and restore normal valve function. In doing so, AVr is a more technically challenging approach than traditional aortic valve replacement. Some of the complexity of repair techniques can be attributed to the unique structure of the functional aortic annulus (FAA), which, unlike the well-defined mitral annulus, is comprised of virtual and functional components. Though stabilizing the ventriculo-aortic junction (VAJ), a component of the FAA, is considered beneficial for patients with chronic aortic insufficiency (AI), the ideal AVr technique remains a subject of much debate.
Dyspnea Declare Yourself! Decoding DopplerAN APPRECIATION of the utility of echocardiographic Doppler spectral profile analysis in diagnosing cardiac pathology and guiding surgical intervention more than justifies an investment in obtaining proficiency in these skills. Given the relatively low incidence of significant complications associated with transesophageal echocardiographic examination, the facile use of both spectral and color Doppler principles to diagnose unusual pathology is essential. Doppler modalities are used to characterize blood flow, pressure gradients, chamber dimensions, and other anatomic and physiological parameters.
Garden-Hose Mitral Regurgitation: A Variant That Can Result in Underestimation of Severity: A Multimodality Imaging Case StudyThe quantitative assessment of mitral regurgitation (MR) by echocardiography has limitations. Cardiac magnetic resonance (CMR) imaging has an emerging role in the quantitation of MR, and preliminary studies indicate that CMR assessment may more accurately quantify MR and better correlate with postsurgical left ventricular reverse remodeling. The authors here report a case of MR in which multimodality imaging with CMR and transesophageal echocardiography was crucial in accurately diagnosing the severity of MR when transthoracic and provocative supine bike echocardiography underestimated the degree of MR in a unique variant known as “garden-hose” MR.
Right Heart Failure Management: Focus on Mechanical Support OptionsMillions of American adults suffer from right heart failure (RHF), a condition associated with high rates of hospitalization, organ failure, and death. There is a multitude of etiologies and mechanisms that lead to RHF, often in a feedforward spiral of decline. The management of advanced cases of RHF can be particularly difficult. For patients who are refractory to the medical optimization of volume status, hemodynamic and pharmacologic support, and rhythm control, mechanical therapies may be warranted.
Acute Cardiointestinal Syndrome Resulting From Postoperative Acute Biventricular Heart FailureACUTELY 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.
Prospective Observational Trial of a Nonocclusive Dilatation Balloon in the Management of Tracheal StenosisTRACHEAL STENOSIS is a debilitating condition that is difficult to treat, requires multidisciplinary management, and yet often presents with severe respiratory compromise requiring urgent intervention. Emergency tracheostomy may be life-saving but impacts future definitive management by tracheal resection and reconstruction (TRR).1,2 Although considered the gold standard for the management of tracheal stenosis, TRR requires a high level of resources and still is associated with a significant rate of failure and restenosis.
Is It a Residual Ventricular Septal Defect?A 1-YEAR-OLD BOY (weight, 7.4 kg; height, 67 cm), with Trisomy 21 and a diagnosis of complete atrioventricular septal defect with tetralogy of Fallot, presented to the author's institution for intracardiac repair. Transthoracic echocardiography reported an ostium primum atrial septal defect, a nonrestrictive inlet-type ventricular septal defect, and anterosuperior deviation of the infundibular septum with a severe right ventricular outflow tract obstruction (peak pressure gradient of 75 mmHg). Intraoperative transesophageal echocardiography confirmed the findings (Fig.
Transesophageal Echocardiographic Evaluation of the Portal Vein During Living Donor Liver Transplantation: A Report of 3 PatientsTRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has established itself as a diagnostic and monitoring tool inside the cardiac operating room.1 It is now increasingly being used in noncardiac surgical setups, such as neurologic operating rooms, other major noncardiac surgery, and intensive care units.2 The risk of esophageal variceal bleed has been a limiting factor in the use of TEE in patients undergoing liver transplant surgery.3,4 Nevertheless, it has emerged as a valuable tool in select patients undergoing liver transplant surgery, mainly due to its ability to provide real-time hemodynamic status of the patient.
Assessing Skill Acquisition in Anesthesiology Interns Practicing Central Venous Catheter Placement Through Advancements in Motion AnalysisThe study authors hypothesized that a combination of previously used (path length, translational motions, and time) and novel (rotational sum) motion metrics could be used to analyze learning curves of anesthesiology interns (postgraduate year 1) practicing central venous catheter placement in the simulation setting. They also explored the feasibility of using segmented motion recordings to inform deliberate practice.
The Many Faces of the Interatrial Septum: A Diagnostic Dilemma and Considerations for Defect Closure Device SelectionPATENT FORAMEN ovales (PFOs) and atrial septal defects (ASDs) are 2 examples of interatrial septal pathology.1 The presence of a PFO is a well-known risk factor for cryptogenic stroke.1,2 Newer evidence over the course of the last decade suggests percutaneous device closure of PFOs significantly reduces the subsequent risk of recurrent stroke.2 Among ASDs, the ostium secundum type is the most common pathology and, due to its anatomy, is most amenable to transcatheter closure.1 The tools that are available to percutaneously close these different pathologies vary, and choosing the correct device for the procedure can have significant impact on the clinical outcome.
Mitral Regurgitation in Obstructive Hypertrophic Cardiomyopathy: Systolic Anterior Motion or a More Unusual Cause?A 52-YEAR-OLD, 100-kg, 191-cm transitioned woman, receiving hormonal therapy, with a history of hypertension, hyperlipidemia, tobacco abuse, and known coronary artery disease, presented to a community hospital with recurrent chest pain and dyspnea. An electrocardiogram demonstrated new ST-segment elevation consistent with an anterior wall myocardial infarction. The patient was taken to the cardiac catheterization laboratory where drug-eluting stents were implanted in the left anterior descending and diagonal coronary arteries.
Tracheal Stent Buckling and In-stent Stenosis: A Proposed Airway Management Algorithm for Airway Obstruction for Patients With Tracheal StentsEMERGENCY AIRWAY management strategies for patients with complications due to tracheobronchial stents are of growing interest to anesthesiologists. Although tracheal stenting increasingly is used to manage tracheobronchial stenosis of both benign and malignant conditions,1-3 official guidelines for the perioperative airway management of patients with tracheobronchial stents in situ are lacking.3 Here, the authors discuss the management of airway obstruction from a tracheal stent strut protrusion and in-stent stenosis in a patient with a self-expanding nitinol tracheal stent in situ.
Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With EndocarditisA 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet.
Third Atrial ChamberA 10-MONTH-OLD BOY (weight: 5.8 kg; height: 66 cm; body mass index: 13) was taken to the cardiac catheterization laboratory before the creation of a bidirectional Glenn shunt. At 4 days of age, transthoracic echocardiography done for the evaluation of persistent cyanosis revealed heterotaxy (left atrial isomerism), situs ambiguous with levocardia, bilateral superior vena cava, atrial septal defect (9 mm), partial anomalous right pulmonary venous return to the morphologic right atrium, discordant atrioventricular connection and concordant ventriculoarterial connection, with a hypoplastic right ventricle.
A Sequential Approach for Echocardiographic Guidance of Transseptal Puncture: The PITLOC ProtocolWith advancements in technology and progress in interventional procedures, left-sided structural heart disease (SHD) interventions have become part of everyday clinical practice. One of the most important steps for a successful left-sided structural heart intervention is the transseptal puncture (TSP). Appropriate transesophageal echocardiographic (TEE) guidance of TSP requires extensive supervised hands-on experience prior to attaining proficiency. Whereas some TEE skills are acquired during cardiac anesthesia fellowships, continuous procedural guidance during SHD interventions requires substantial hands-on experience.
Dilated Coronary Sinus: The Usual Persistent Left Superior Vena Cava or a Less Common Etiology?AN 84-YEAR-OLD MAN, 70 kg, 183 cm, with hypertension and left ventricular hypertrophy, presented to the authors’ institution with a history of progressive shortness of breath and abdominal distention. A large amount of ascites was present, necessitating biweekly paracentesis. The patient's functional capacity had significantly deteriorated. He described severe dyspnea associated with bending forward and standing from a sitting position. The physical examination was notable for cachexia, a grade- 3 holosystolic murmur heard best at the lower left sternal border, and a pulsating right upper quadrant.
A Case of Transient Mitral Regurgitation: Not Everything Is Always What It SeemsMitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. MR can be broadly classified into 2 different categories: primary and secondary MR. Primary MR usually is caused by leaflet abnormalities, whereas secondary MR is a chronic disease secondary to geometric distortion of both the annulus and subvalvular apparatus because of left ventricular remodeling. Without acute changes in loading conditions, myocardial blood flow, or rhythm disturbances, functional MR typically is not transient.