Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Left Atrial Dissection Secondary to Retrograde Coronary Sinus Cannulation During a Stanford Acute Type-A Aortic Dissection Repair: A Case Report.

Left atrial (LA) dissections are rare phenomena, often iatrogenic, caused by blood flow into a false lumen, potentially obstructing the pulmonary veins or flow into the left ventricle. Severity can range from an incidental observation or complete circulatory collapse. While LA dissections are often associated with mitral valve repair, there are 2 reported cases of LA dissections associated with retrograde cardioplegia cannula insertion through the coronary sinus. Here, we present a large LA dissection that was directly visualized and tracked to a coronary sinus injury from the retrograde cardioplegia cannula. The clinical presentation and echocardiography findings informed our subsequent management.

The Mitral Coaptation to Ventricular Septal Space: Two- and Three-Dimensional Transesophageal Echocardiographic Assessment.

OBJECTIVES: To assess the dimensions and changes in the CSEPT (space between the ventricular septum and mitral coaptation point) before and after cardiopulmonary bypass (CPB) and to compare patients with and without aortic valve stenosis (AS) undergoing cardiac surgery. DESIGN: Retrospective review of intraoperative transesophageal echocardiographic examinations. SETTING: Single academic medical center. PARTICIPANTS: The study comprised 91 elective cardiac surgical patients-30 with AS scheduled for aortic valve replacement and 61 without AS (non-AS). INTERVENTIONS: Two- and 3-dimensional (2D and 3D) analysis of the CSEPT before and after CPB. MEASUREMENTS AND MAIN RESULTS: Assessment of the CSEPT distances and areas was performed using 2D and 3D imaging before and after CPB. Two-dimensional measures of CSEPT distances were performed using midesophageal 5-chamber and long-axis windows. Three-dimensional measures were performed offline using multiplanar reconstruction. The CSEPT space was smaller after CPB (p < 0.01). Before and after CPB, the midesophageal 5-chamber and long-axis windows were similar to each other, and both were larger than the pre-CPB 3D CSEPT distance. Patients with AS had smaller before and after CPB distances and areas compared with non-AS patients (p < 0.05). The change in CSEPT area in AS patients was 24%. CONCLUSIONS: The CSEPT space is smaller after CPB and more so for patients with AS undergoing aortic valve replacement. Two-dimensional CEPT distances vary compared with 3D CSEPT distances. Additional study using Doppler analysis will elucidate the added value of 3D assessment of the CSEPT space.

The Left Ventricular Outflow Tract Changes in Size and Shape From Pre- to Post-Cardiopulmonary Bypass: Three-Dimensional Transesophageal Echocardiography.

OBJECTIVES: To compare two-dimensional (2D) and 3D imaging of the left ventricular outflow tract (LVOT) and to evaluate geometric changes pre- to post-cardiopulmonary bypass (CPB). DESIGN: Retrospective review of intraoperative transesophageal echocardiographic examinations. SETTING: Single academic medical center. PARTICIPANTS: The study comprised 69 cardiac surgical patients-27 with aortic valve stenosis (AS) and 42 without AS. INTERVENTIONS: Two-dimensional and 3D analysis of the LVOT pre- and post-CPB. MEASUREMENTS AND MAIN RESULTS: Pre- and post-CPB 2D assessment of LVOT diameter (2D LVOTd) was compared with 3D analysis of the minor (3D LVOTd-min) and major diameters. LVOT areas (LVOTa) were calculated using LVOTd to yield 2D LVOTa and 3D LVOTa-min. These were compared with LVOTa measured by planimetry (3D LVOTa-plan). An ellipticity ratio (ER) (ER = 3D minor/major axes) was calculated. The 2D LVOTd was larger than the 3D LVOTd-min before (2.12 v 2.02 cm respectively (resp); p < 0.001) and after (1.96 v 1.85 cm resp; p = 0.04) CPB. Compared with pre-CPB, there were significant decreases in the 2D LVOTd (p = 0.003) and the 3D LVOTd-min (p < 0.001) post-CPB. Ellipticity increased after CPB (ER 0.80 v 0.75; p = 0.004), and the 2D LVOTa was larger than the 3D LVOTa-min before CPB (3.60 cm2v 3.28 cm2; p < 0.001) and less so after CPB (3.11 cm2v 2.79 cm2; p = 0.053). Compared with pre-CPB, all LVOTa measurements decreased significantly after CPB (p < 0.001). The 3D LVOTa-plan decreased after CPB by approximately 10% (4.05 cm2v 3.61 cm2; p < 0.001). The 2D LVOTa and 3D LVOTa-min underestimated the 3D LVOTa-plan before and after CPB (p < 0.001) by 11% to 14% and 19% to 23%, respectively. When compared with non-AS patients, patients with AS had a smaller LVOTa pre- and post-CPB (p < 0.05). CONCLUSIONS: The LVOT is smaller and more elliptical after CPB. Patients with AS have a smaller LVOT compared with non-AS patients. LVOTa calculated using LVOTd underestimates the 3D LVOTa-plan by as much as 23% depending on patient type and timing of measurement. Accurate assessment of the LVOT requires 3D imaging.

Selected highlights from clinical anesthesia and pain management.

STUDY OBJECTIVE: To review research highlights of manuscripts published in 2017 that pertain to all aspects of the clinical practice of anesthesiology. DESIGN: Narrative review. SETTING: N/A. MATERIALS: The major themes addressed in this review include recent studies examining airway management, obstetrical and gynecological anesthesia, pediatric anesthesia, cardiac anesthesia, regional analgesia and pain management. INTERVENTIONS: N/A. MAIN RESULTS: N/A. CONCLUSIONS: This review will highlight and inform anesthesiologists of the developing trends in clinical anesthesia and will also pose new challenges for further studies.

Selected highlights in clinical anesthesia research.

STUDY OBJECTIVE: To review research highlights of manuscripts published in 2016 that pertain to all aspects of the clinical practice of anesthesiology. DESIGN: Narrative review. SETTING: N/A. MATERIALS: The major themes address broad categories of general anesthesia including airway management, abdominal surgery, and obstetrical and gynaecological anesthesia. In addition, recent advancements in specialties of anesthesiology including regional anesthesia are reviewed. INTERVENTIONS: N/A. MAIN RESULTS: N/A. CONCLUSIONS: This recent body of evidence will both help inform anesthesiologists of the developing trends in anesthesiology and will also pose new challenges for further studies.