Preventing or Minimizing Acute Kidney Injury in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is now routinely performed in patients with aortic stenosis with low mortality and complication rates. Although periprocedural risks have been substantially minimized, procedure- and contrast-induced acute kidney injury (AKI) remains a major concern. AKI remains a frequent complication of contrast-guided interventional procedures and is associated with a significantly adverse prognosis. We review the currently available clinical data related to AKI, with emphasis on contrast-induced nephropathy (CIN), and discuss a novel, integrated approach aiming to minimize AKI risk in high-risk patients. A stepwise algorithm is also proposed for the management of these complex patients.

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events.

OBJECTIVE: The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN: Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING: Single university hospital. PARTICIPANTS: A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS: Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS: TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS: Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

Paradoxical air embolus during endoscopic retrograde cholangiopancreatography: an uncommon fatal complication.

Air embolism during endoscopic retrograde cholangiopancreatography is a rare but potentially fatal complication. A 66-year-old man underwent endoscopic retrograde cholangiopancreatography and remained stable until the end of the procedure, when he was found to have mottling on his right side and became hypoxic and unresponsive. Transesophageal echocardiography showed air within the left ventricle, consistent with systemic air embolism. Mortality resulted from significant cardiac and cerebral ischemia. The literature suggests that capnography is helpful in early diagnosis of air embolus, but it could not be used in this case because the patient's trachea was not intubated.

Echocardiography-based hemodynamic management of left ventricular diastolic dysfunction: a feasibility and safety study.

BACKGROUND: Patients with left ventricular diastolic dysfunction (LVDD) are at increased risk of postoperative adverse events. The primary aim of this study was to evaluate the safety and feasibility of using echocardiography-guided hemodynamic management (EGHEM) during surgery in subjects with LVDD compared to conventional management. The feasibility of using echocardiography to direct a treatment algorithm and clinical outcomes were compared for safety between groups. METHODS: Subjects were screened for LVDD by preoperative transthoracic echocardiography (TTE) and randomized to the conventional or EGHEM group. Subjects in EGHEM received hemodynamic management based on left ventricular filling patterns on transesophageal echocardiography (TEE). Primary outcomes measured were the feasibility to obtain TEE images and follow a TEE-based treatment algorithm. Safety outcomes also compared the following clinical differences between groups: length of hospitalization, incidence of atrial fibrillation, congestive heart failure (CHF), myocardial infarction, cerebrovascular accident, transient ischemic attack and renal failure measured 30 days postoperatively. RESULTS: Population consisted of 28 surgical subjects (14 in conventional group and 14 in EGHEM group). Mean subject age was 73.4 ± 6.7 years (36% male) in conventional group and 65.9 ± 14.4 years (36% male) in EGHEM group. Procedures included orthopedic (conventional = 29%, EGHEM 36%), general (conventional = 50%, EGHEM = 36%), vascular (conventional = 7%, EGHEM = 21%), and thoracic (conventional = 14%, EGHEM = 7%). There was no statistically significant difference in adverse clinical events between the 2 groups. The EGHEM group had less CHF, atrial fibrillation, and shorter length of stay. CONCLUSIONS: Echocardiography-guided hemodynamic management of patients with LVDD during surgery is feasible and may be a safe alternative to conventional management.

Use of rapid "rescue" perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients.

OBJECTIVE: To investigate if modified "rescue" echocardiography enhanced management during perioperative hemodynamic instability in patients undergoing noncardiac surgery. DESIGN: A retrospective analysis of the medical data. SETTING: Perioperative setting at a single academic medical center. PARTICIPANTS: Thirty-one adult patients undergoing noncardiac surgery who experienced perioperative hemodynamic instability and were evaluated by either transthoracic echocardiography (TTE, n = 9) or transesophageal echocardiography (TEE, n = 22). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Rapid "rescue" echocardiography was performed on each patient looking for a specific cause for the patient's perioperative compromise. Echocardiography results, medical management, surgical management, and patient outcomes were all reviewed from the medical record and the department database. All patients were found to have an explainable diagnosis for the hemodynamic instability on the echocardiographic examination. The most common diagnoses were left-heart dysfunction (n = 16), right-heart dysfunction (n = 9), hypovolemia (n = 5), pulmonary embolus (n = 5), and myocardial ischemia (n = 4). Based on findings at echocardiography, 4 patients (13%) underwent and survived an emergent secondary procedure. All 31 patients recovered during their surgical procedure, and 25 (81%) progressed to hospital discharge. CONCLUSIONS: Both TTE and TEE can play a critical role in the diagnosis and management of perioperative hemodynamic instability.