Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Human metapneumovirus (hMPV), a ubiquitous RNA virus of the Pneumoviridae family, has been associated with respiratory tract infections for decades in various age groups and populations. Though most of the infections, especially in children, are mild and self-limited, severe infections ranging from bronchiolitis or asthma exacerbation to severe pneumonia and acute respiratory distress syndrome (ARDS) have occasionally been reported. Among patients who require hospitalization for severe infections, treatment is supportive as no current antivirals or vaccines are effective or recommended. The following is a 45-year-old Caucasian man who developed severe ARDS complicating hMPV infection, and despite maximal medical support, he developed refractory life-threatening hypoxemia that required rescue therapy with veno-venous extracorporeal membrane oxygenation (V-V ECMO). After several days of ECMO support, the patient eventually recovered and was discharged home. This case highlights the importance of recognizing hMPV as an occasional culprit for severe respiratory infections, discusses the new global definition of ARDS, and delineates the updated recommended management, including the early application of V-V ECMO as a rescue therapy in severe cases with refractory, life-threatening respiratory failure.

Thoracic aorta pathologies, especially those of the ascending aorta and aortic arch, were traditionally approached via open surgical repair. This carries risk of ischemic end-organ damage and other complications. Endovascular repair of ascending aorta and aortic arch pathologies is becoming more successful and widespread, thereby posing numerous challenges to the anesthesiologist. This article reviews the anesthesia-pertinent pathophysiology, repair techniques, preoperative evaluation, intraoperative management, and postoperative care of patients presenting for endovascular repair of thoracic aorta pathologies.

Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.

Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.

Anesthesia for cardiac surgical patients with antiphospholipid antibody syndrome (APLS) presents challenges with monitoring anticoagulation during cardiopulmonary bypass. Additionally, this condition is associated with other autoimmune diseases and comorbidities that need to be considered in caring for these patients, and there is minimal evidence for specific strategies during cardiac surgery. Separately, Jehovah's Witness (JW) patients typically do not consent to receiving blood products, presenting an additional challenge for resuscitation during cardiac surgery and especially in the context of APLS. We present our approach to the anesthetic management of a JW patient with systemic lupus erythematosus (SLE) complicated by APLS, thrombocytopenia, and renal failure with history of renal transplant who presented for coronary artery bypass surgery. Management strategies we recommend include administration of antifibrinolytics after heparinization to mitigate bleeding risk and interdisciplinary management with the perfusion, intensive care, surgical, and nephrology teams.

Though pediatric cardiomyopathy is rare in children, there is significant associated morbidity and mortality. Etiology varies from inborn errors of metabolism to familial genetic mutations and myocyte injury. Major classes include dilated, hypertrophic, restrictive, and non-compaction. Diagnosis generally involves a combination of clinical history and echocardiography. The use of cross-sectional imaging is gaining popularity. Management varies between subtype and may involve a combination of medical and surgical interventions depending on clinical status.

Background: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide.

Methods: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022.

Results: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers.

Conclusions: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Background: Transcatheter edge-to-edge repair (TEER) with MitraClip is a safe and effective alternative to surgical mitral valve repair/replacement in patients with high operative risk. Pleth Variability Index (PVI) is a non-invasive, dynamic index based on analysis of the respiratory variations in the plethysmographic waveform recorded transcutaneously by the pulse oximeter.

Objectives: The objective of the study was to evaluate if the hemodynamic effect of improved left-sided output after successful transcatheter mitral valve repair would lead to a significant change in PVI, and if it would correlate with the decrease in left atrial pressure (LAP).

Design: Prospective, observational cohort study (ClinicalTrials.gov NCT03993938).

Setting: Single academic hospital in Detroit, Michigan (USA), from October 2019 to February 2021.

Participants: The authors included adult patients with severe mitral regurgitation who underwent successful MitraClip placement.

Measurements and main results: Of 30 patients, all components of the LAP (a wave, v wave, and mean) decreased significantly after successful MitraClip placement (P < .01). The median (IQR) PVI increased from 21 (11-35) to 23 (13-38) after clip placement; however, this change was not statistically significant (P = .275). No significant correlation between change in PVI and change in LAP was observed (P = .235).

Conclusions: In patients with severe mitral regurgitation, successful MitraClip resulted in a significant reduction in LAP without a significant change in PVI. A larger sample size may provide more insight on the utility of using PVI as an indicator of LAP change in patients with mitral regurgitation.

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.