Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Central airway obstruction due to tracheal tumors presents unique challenges to the anesthesiologist. We present the case of a 44-year-old male taken to the OR for biopsy and resection of an undiagnosed tracheal mass. Intraoperative management was complicated by bleeding and significant hemodynamic instability, necessitating rapid surgical and anesthetic intervention. This ultimately led to abortion of surgical resection. Pathologic examination revealed a primary tracheal plasmacytoma, a rare type of tracheal tumor. Here, we describe anesthetic and hemodynamic considerations for a tracheal plasmacytoma. We discuss the approach to airway management in variable intrathoracic tracheal obstruction and the unpredictability of tracheal tumors.

Lung transplantation (LTx) historically was performed with cardiopulmonary bypass (CPB) or Off-pump. Recent data suggest an increased interest in extracorporeal membrane oxygenation (ECMO) as perioperative circulatory support by many lung transplantation centers worldwide. However, there are no established guidelines for anesthetic management for LTx. We present a patient with a history of systemic sclerosis and interstitial lung disease complicated by acute onset of systemic pulmonary hypertension and right heart failure undergoing LTx. We aim to discuss perioperative circulatory support, including ECMO bridge to LTx, and how best to consider the varied intraoperative strategies of CPB vs ECMO vs off-pump during LTx, intraoperative maintenance, and coagulation management.

Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.

The management of children with a borderline ventricle has been debated for many years. The pursuit of a biventricular repair in these children aims to avoid the long-term sequelae of single ventricle palliation. There is a lack of anesthesia literature relating to the care of this complex heterogenous patient population. Anesthesiologists caring for these patients should have an understanding on the many different forms of physiology and the impact on provision of anesthesia and hemodynamic parameters, the goals of biventricular staging and completion as well as the pre-operative, intra-operative, and post-operative considerations relating to this high-risk group of patients.

Introduction. We examined whether intraoperative assessment of left ventricular (LV) twist mechanics is feasible with transesophageal echocardiography (TEE). We then explored whether twist mechanics were altered by hemodynamic conditions or patient comorbidities. Methods. In this sub-analysis of clinical trial data, transgastric short-axis echocardiographic images of the LV base and apex were collected in patients having aortic valve replacement (AVR) at baseline and end of surgery. Transvalvular gradients and LV systolic and diastolic function were assessed using two-dimensional (2D) and Doppler echocardiography. 2D speckle-tracking echocardiography was used for off-line analysis of LV twist, twisting rate, and untwisting rate. We examined the intraoperative change in twist mechanics before and after AVR. LV twist mechanics were also explored by diabetic status, need for coronary artery bypass grafting (CABG), and use of epinephrine/norepinephrine. Results. Of 40 patients, 16 patients had acceptable TEE images for off-line LV twist analysis. Baseline median [Q1, Q3] LV twist was 12 [7, 16]°, twisting rate was 72 [41, 97]°/sec, and untwisting rate was -91 [-154, -56]°/s. Median [Q1, Q3] change in LV twist at end of surgery was -2 [-5, 3]°, twisting rate was 7 [-33, 31]°/s, and untwisting rate was 0 [-11, 43]°/s. No difference was noted between diabetic and non-diabetic patients or AVR and AVR-CABG patients. Conclusion. LV twist was augmented in patients with aortic stenosis, though twist indices were not affected by reduced afterload, diabetes, or coronary artery disease. Intraoperative assessment of twist mechanics may provide unique information on LV systolic and diastolic function, though fewer than 50% of TEE examinations successfully assessed twist. Clinical Trial Registry. This work is a sub-analysis of a clinical trial, registered on ClinicalTrials.gov on August 19, 2010 (NCT01187329), Andra Duncan, Principal Investigator.

In 2021, progress in clinical science related to Cardiac Anesthesiology continued, but at a slower rate due to the ongoing pandemic and disruptions to clinical research. Most progress was incremental and addressed persistent questions related to our field. To identify articles for this review, we completed a structured review using our previously reported methods (1). Specifically, we used the search terms: "cardiac anesthesiology and outcomes" (n = 177), "cardiothoracic anesthesiology" (n = 34), "cardiac anesthesia," and "clinical outcomes" (n = 42) filtered on clinical trials and the year 2021 in PubMed. We also reviewed clinical trials from the most prominent clinical journals to identify additional studies for a narrative review. We then selected the most noteworthy publications for inclusion in this review and identified key themes.