Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Surgical repair of the proximal aorta is a complex endeavor, requiring cardiopulmonary bypass (CPB) and often the use of hypothermic circulatory arrest (HCA). In addition to the normal considerations for patients undergoing cardiopulmonary bypass, additional challenges include cerebral and end-organ protection during periods of circulatory arrest. This review aims to provide an up-to-date, evidence-based review on anesthetic management for proximal aortic repair.

Background: While several studies have summarised the clinical effectiveness evidence for extracorporeal membrane oxygenation (ECMO), there are no evidence syntheses of the impact of centres' ECMO patient volume on patient outcomes or the impact of bedside ECMO care being delivered by either a perfusionist or a nurse. There is also limited information on the cost-effectiveness of ECMO.

Purpose: This review was carried out to evaluate the clinical effectiveness and cost of different service delivery models of pulmonary ECMO to inform NHS Wales commissioning policy.

Research design: The study utilised rapid review methodology, consisting of a systematic literature search and the inclusion of the highest quality of evidence available.

Data collection: Out of 1997 records identified via literature searches, 12 studies fell within the scope. The 2 meta-analyses comparing ECMO with lung-protective ventilation favoured ECMO.

Results: Five studies looking at the clinical impact of centre patient volume had large heterogeneity. Three studies estimated that with sufficient patient volume, nurse-delivered ECMO was cost-saving, with thresholds varying between 92 and 155 patient days per year. Three studies looked at the cost impact of ECMO delivery, with ECMO being cost incurring, but potentially cost-effective, with costs per patient being lower at higher volume centres.

Conclusions: The available evidence supports the use of ECMO in adult respiratory failure patients, despite it being cost-incurring. ECMO can be nurse-delivered without a significant negative impact on patient care. Yet decision-makers need to consider their local circumstances when making commissioning decisions.

This case report describes the successful use of an intraoperative modified Valsalva maneuver to reverse atrial flutter in a pediatric patient with complex congenital heart disease undergoing systemic-to-pulmonary shunt surgery. The technique involved manipulating the Adjustable Pressure Limiting (APL) valve on the anesthesia machine to simulate the hemodynamic effects of the modified Valsalva maneuver, allowing for non-invasive management of supraventricular tachycardia without pharmacological intervention or electrical cardioversion. This intervention stabilized the patient's arrhythmia, maintaining hemodynamic stability throughout the procedure. The case highlights the potential of the maneuver as a safe, effective, and non-invasive alternative for arrhythmia management in pediatric cardiac surgeries, advocating for further research to validate this approach and possibly integrate it into standard practice for similar clinical scenarios.

Background: Pediatric cardiac transplant recipients undergo elective cardiac catheterization and endomyocardial biopsy (CC/EMB) for graft dysfunction surveillance often facilitated by general anesthesia (GA). GA and positive pressure ventilation (PPV) also depress cardiac function confounding the graft's functional assessment. We aimed to evaluate the frequency of cardiac function decline, going from the awake to the anesthetized state, and determine its association with anesthetic and patient-related factors.

Methods: Electronic medical records of pediatric heart transplant recipients undergoing CC/EMB under GA/PPV were retrospectively reviewed. Patients with awake normal cardiac function, assessed by same-day preoperative echocardiographic left ventricular shortening fraction (LVSF) ≥28% were included. A priori, groups were: (1) cardiac function decline (post- catheterization under GA, LVSF< 28%), and (2) no cardiac function decline. Univariate and logistic regression analysis accounting for repeated encounters per patient were performed.

Results: 225 eligible encounters occurred in 102 patients. Cardiac function declined in 17.3% (39/225) encounters, and in 25% (26/102) of patients. Logistic regression identified independent predictors as: older age (OR 1.4, 95% CI: 1.1-1.7, P = 0.002), angiotensin-converting enzyme inhibitor (ACEI) use (OR 2.5, 95% CI: 1.2-4.3, P = 0.018), and elevated right ventricular end diastolic pressure (RVEDP) (OR 2.4, 95% CI: 1.1-5.4, P = 0.039), with AUC 0.75. Older age and ACEI use (P = 0.001) and, older age and elevated RVEDP (P = 0.037) were correlated.

Conclusions: One in 4 patients demonstrated cardiac function decline from the awake to the anesthetized state, occurring most commonly in older children with elevated RVEDP using ACEI. Most cardiac function declines are unrelated to rejection.

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Central venous catheter (CVC) tip migration is a well reported delayed complication of these vascular access devices with left-sided internal jugular or subclavian vein placement being the primary risk factor for this complication. We report a case of left internal jugular CVC migration and its diagnosis made by the heretofore unreported use of intraoperative transesophageal echocardiography in this context. Moreover, we describe risk factors for CVC migration along with its diagnosis and management.

Background. Intracardiac echocardiography (ICE) is routinely used in cardiac electrophysiology and catheterization labs. It plays a vital role in understanding cardiac anatomy, procedural planning, and early identification of complications. In this review, we describe the utility of ICE for procedures in the electrophysiology lab, including atrial fibrillation ablation, left atrial appendage occlusion device implantation, and cardiac implantable electronic device (CIED) extraction. Intracardiac echocardiography also helps in the identification of complications such as pericardial effusion, pulmonary vein stenosis, and left atrial appendage thrombus. Compared with traditional echocardiographic modalities such as transesophageal echocardiogram (TEE), ICE has equivalent image quality, requires less sedation, and possesses no risk of esophageal injury. The disadvantages of ICE include a learning curve and necessity for central vascular access.

Objectives: To examine whether estimates of peak global systolic (S') and diastolic (E') left ventricular (LV) flow rates based on 3D echocardiographic volumes are feasible and match physiology.

Methods: In this retrospective feasibility study, we included patients undergoing major cardiac surgery. S' and E' were derived from 190 patients by taking the first derivative of the volume-time relationship of 3D ecg-gated transesophageal echocardiography (TEE) images. To examine the quality of images upon which the estimates of flow were based we correlated intraoperative 3D TEE and preoperative 2D transthoracic echocardiography (TTE) volumes. As a proof-of-concept, we then correlated S' flow with stroke volume and S' and E' were compared by valve pathology.

Results: In each of the 190 images, S' and E' were derived. There was good correlation between 1) the ejection fraction (EF) of 3D LV images obtained intraoperatively by TEE and preoperatively by TTE (Pearson's r = 0.65) and also 2) S' and stroke volume (Pearson's r = 0.73). Patients with aortic or mitral regurgitation showed higher S' than patients without valve pathologies (-315 mL/s [95% CI -388 mL/s to -264 mL/s]P = 0.001, -319 mL/s [95% CI -397 mL/s to -246 mL/s]P = 0.001 vs -242 mL/s [95% CI -300 mL/s to -196 mL/s]). These patients also showed higher E' than patients without valve pathologies (302 mL/s [95% CI 237 mL/s to 384 mL/s]P = 0.006, 341 mL/s [95%CI 227 mL/s to 442 mL/s]P = 0.001 vs 240 mL/s [95%CI 185 mL/s to 315 mL/s]). Patients with aortic stenosis showed no difference in S' or E' (-263 mL/s [95%CI -300 mL/s to -212 mL/s]P = 0.793, 255 mL/s [95%CI 188 mL/s to 344 mL/s]P = 0.400).

Conclusions: Estimates of global peak systolic and diastolic LV flow based on 3D TEE are feasible, promising, and match valve pathologies.

Anesthetic management of open thoracoabdominal aneurysm (TAAA) repair poses a number of challenges for even the most experienced of cardiovascular anesthesiologists. This procedure encompasses a large number of unique anesthetic techniques, including one-lung ventilation, invasive hemodynamic monitoring, left-heart bypass, massive transfusion, selective renal and visceral perfusion, and central nervous system monitoring with CSF drainage. In this article, we aim to describe the anesthetic management for thoracoabdominal aortic aneurysm repair, including preoperative workup, intraoperative management, as well as postoperative concerns in the intensive care unit.