Native mitral valve staphylococcus endocarditis with a very unusual complication: Ruptured posterior mitral valve leaflet aneurysm.

Infective endocarditis (IE) is a life-threatening disease associated with in-hospital mortality of nearly one in five cases. IE can destroy valvular tissue, which may rarely progress to aneurysm formation, most commonly at the anterior leaflet in instances of mitral valve involvement. We present a remarkable case of a patient with IE and a rare complication of a ruptured aneurysm of the posterior leaflet of the mitral valve. Two- and Three-dimensional transesophageal echocardiography, intra-operative videography, and histopathologic analysis revealed disruption at this unusual location-at the junction of the P2 and P3 scallops, surrounded by an annular abscess.

Transcatheter Mitral Valve Interventions for Mitral Regurgitation: A Review of Mitral Annuloplasty, Valve Replacement, and Chordal Repair Devices.

Significant mitral regurgitation (MR) is the most common valvular disease in the United States in patients older than 75. However, many patients with severe MR are at a high risk for surgical repair due to other significant comorbidities. Over the past decade, many transcatheter mitral valve devices have been studied that address the different mechanisms of MR, but only a few have received a Conformité Européene (CE) mark or United States Food and Drug Administration (FDA) approval. The Carillon, Cardioband, and Mitralign all received CE marking for percutaneous mitral annuloplasty, while the Tendyne and SAPIEN 3 received a CE mark and FDA approval, respectively, for transcatheter mitral valve replacement. Finally, the NeoChord DS 1000 received a CE mark for transcatheter chordal repair. Each of these devices is reviewed in detail, including device indications, performance in clinical trials, anesthetic management, intraprocedural imaging guidance, and postprocedural complications. Although percutaneous devices will appear and disappear from use, understanding the procedural considerations remains highly relevant, as these key principles will apply to the next generation of transcatheter valve interventions.

Functional Tricuspid Regurgitation in Patients With Chronic Mitral Regurgitation: An Evidence-Based Narrative Review.

Chronic mitral regurgitation leads to a series of downstream pathologic changes, including pulmonary hypertension, right ventricular dilation, tricuspid leaflet tethering, and tricuspid annular dilation, which can result in functional tricuspid regurgitation (FTR). The five-year survival rate for patients with severe FTR is reported to be as low as 34%. While FTR was often left uncorrected during left-heart valvular surgery, under the assumption that correction of the left-sided lesion would reverse the right-heart changes that cause FTR, recent data largely have supported concomitant tricuspid valve repair at the time of mitral surgery. In this review, the authors discuss the potentially irreversible nature of the changes leading to FTR, the likelihood of progression of FTR after mitral surgery, and the evidence for and against concomitant tricuspid valve repair at the time of mitral valve intervention. Lastly, this narrative review also examines advances in transcatheter therapies for the tricuspid valve and the evidence behind concomitant transcatheter tricuspid repair at the time of transcatheter mitral repair.

Complications of Transesophageal Echocardiography: A Review of Injuries, Risk Factors, and Management.

Transesophageal echocardiography (TEE) use has become widespread in cardiac surgical operating rooms over the last 2 decades. Surgical and medical decision-making often are guided by the findings of the TEE examination, rendering TEE an invaluable tool both inside and outside the operating room. TEE has become ubiquitous in some parts because it is considered safe and relatively noninvasive. However, it is imperative for clinicians to understand that TEE can cause severe and possibly life-threatening complications, and the risks of TEE must be balanced against its benefits as a diagnostic tool. Upper gastrointestinal (UGI) injuries are the most commonly described complications of TEE; however, the relative infrequency of injuries and lack of uniform reporting make it difficult to definitively identify potential risk factors. Some large retrospective trials suggested that patient factors (age, body mass index, anatomic abnormalities), comorbid conditions (previous stroke), and procedural variables (procedure time, cardiopulmonary bypass time, etc.) are associated with TEE-related injuries. In this narrative review of complications from TEE, the authors focus on the incidence of UGI injuries, the spectrum of injuries associated with TEE, risk factors that may contribute to UGI injuries, as well as diagnosis and management options. Lastly, the discussion focuses on the prevention of injuries as TEE use continues to become more prevalent.

Long-term outcomes after transcatheter aortic valve replacement with minimal contrast in chronic kidney disease.

BACKGROUND: Patients with renal insufficiency have poor short-term outcomes after transcatheter aortic valve replacement (TAVR). METHODS: Retrospective chart review identified 575 consecutive patients not on hemodialysis who underwent TAVR between September 2014 and January 2017. Outcomes were defined by VARC-2 criteria. Primary outcome of all-cause mortality was evaluated at a median follow-up of 811 days (interquartile range 125-1,151). RESULTS: Preprocedural glomerular filtration rate (GFR) was ≥60 ml/min in 51.7%, 30-60 ml/min in 42.1%, and < 30 ml/min in 6.3%. Use of transfemoral access (98.8%) and achieved device success (91.0%) did not differ among groups, but less contrast was used with lower GFR (23 ml [15-33], 24 ml [14-33], 13 ml [8-20]; p < .001). Peri-procedural stroke (0.7%, 2.1%, 11.1%; p < .001) was higher with lower GFR. Core lab analysis of preprocedural computed tomography scans of patients who developed a peri-procedural stroke identified potential anatomic substrate for stroke in three out of four patients with GFR 30-60 ml/min and all three with GFR <30 ml/min (severe atheroma was the most common subtype of anatomical substrate present). Compared to GFR ≥60 ml/min, all-cause mortality was higher with GFR 30-60 ml/min (HR 1.61 [1.00-2.59]; aHR 1.61 [0.91-2.83]) and GFR <30 ml/min (HR 2.41 [1.06-5.48]; aHR 2.34 [0.90-6.09]) but not significant after multivariable adjustment. Follow-up echocardiographic data, available in 63%, demonstrated no difference in structural heart valve deterioration over time among groups. CONCLUSIONS: Patients with baseline renal insufficiency remain a challenging population with poor long-term outcomes despite procedural optimization with a transfemoral-first and an extremely low-contrast approach.

Two- or 3-Dimensional Echocardiography-Derived Cardiac Output Cannot Replace the Pulmonary Artery Catheter in Cardiac Surgery.

OBJECTIVES: Three-dimensional (3D) transesophageal echocardiography (TEE) has been shown to be more accurate than 2D TEE for the evaluation of the left ventricular outflow tract area. The aim of the present study was to compare the agreement of 3D echocardiography-derived cardiac output (CO) with thermodilution-derived CO (TDCO) before and after cardiopulmonary bypass (CPB). DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2018. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 78 patients undergoing elective cardiac surgery. INTERVENTIONS: CPB, TEE, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Two-dimensional CO, 3D CO-diameter, and 3D CO-area values pre-CPB were strongly correlated with one another both pre-CPB and post-CPB. The 3D CO-diameter and the 3D CO-area were mildly correlated, with TDCO measurements pre-CPB (r = 0.46 and 0.39, respectively) and post-CBP (r = 0.43 and 0.47, respectively). Pre-CPB 3D CO-diameter had the most agreement with TDCO in terms of bias (-0.13 L/min); however, the limits of agreement (LOA) were wide (-2.2- to- 2.45 L/min). Post-CPB, 3D CO-diameter had the most agreement with TDCO in terms of bias (0.41) but with wide LOA (-3.29 to 2.47). All pre-CPB echocardiography-derived CO (2D CO, 3D CO-diameter, 3D CO-area) had more agreement with TDCO than did post-CPB measurements. CONCLUSIONS: Three-dimensional CO measurements were only modestly correlated with pulmonary artery catheter-derived CO pre-bypass and post-bypass. Despite low bias, the wide LOA from 2D CO, 3D CO-diameter, and 3D-area compared with TDCO suggested that the 2 methods are not interchangeable.

Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery.

OBJECTIVE: This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population. DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 119 patients undergoing elective cardiac surgery. INTERVENTIONS: Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]). CONCLUSIONS: PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

Operational and Institutional Recommendations and Requirements for TAVR: A Review of Expert Consensus and the Impact on Health Care Policy.

When transcatheter aortic valve replacement (TAVR) was first approved for use in the United States in 2012, multiple leading surgical and cardiology societies were tasked with creating recommendations and requirements for operators and institutions starting and maintaining TAVR programs. Creation of this consensus document was challenging due to limited experience with this new technology, and a lack of robust centralized data that could be used to validate outcome measures and create benchmarks for self-assessment and improvement. Despite these limitations, this document provided government agencies a framework for regulation that ultimately determined requirements for Medicare payment for TAVR and therefore greatly determined how and where care was delivered for patients with aortic stenosis. After the proliferation of TAVR institutions throughout the US and with data from more than 100,000 cases in the STS/ACC Transcatheter Valve Therapies TM Registry, leaders of the same societies reconvened in 2018 to update their consensus document. The new recommendations include suggested personnel, facilities, training, and assessment of outcomes and competencies required to run a safe and efficient TAVR program. This article seeks to detail the changes from the original consensus document with a particular focus on issues relevant to cardiac anesthesiologists as well as important healthcare policy ramifications for patients and providers in the United States.

Perioperative Care of the Obese Cardiac Surgical Patient.

Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient.

Anesthetic Techniques in Transcatheter Aortic Valve Replacement and the Evolving Role of the Anesthesiologist.

The development of transcatheter aortic valve replacement (TAVR) has transformed the treatment of patients with aortic valve disease. This procedure now is used widely for patients at high and intermediate risk for surgical aortic valve replacement. The rapid acceptance and popularity of TAVR most clearly was enabled by advancements in device technology and procedural experience. Such a dramatic change to the standard medical practice is not without consequence to fields of medicine beyond cardiology and cardiac surgery. Anesthesiologists have witnessed this movement first hand, and while improved anesthetic techniques have contributed to the success of the procedure, in return these improved outcomes likely will result in further changes to perioperative anesthetic management. In this review the authors sought to evaluate the role and responsibility of the cardiac anesthesiologist in the development of TAVR. Future advancements in device technology and considerations of how the anesthetic technique for TAVR may continue to evolve in future years are discussed.