Ventriculoarterial decoupling in human septic shock.

INTRODUCTION: Septic shock is the most severe manifestation of sepsis. It is characterized as a hypotensive cardiovascular state associated with multiorgan dysfunction and metabolic disturbances. Management of septic shock is targeted at preserving adequate organ perfusion pressure without precipitating pulmonary edema or massive volume overload. Cardiac dysfunction often occurs in septic shock patients and can significantly affect outcomes. One physiologic approach to detect the interaction between the heart and the circulation when both are affected is to examine ventriculoarterial coupling, which is defined by the ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees). In this study, we analyzed ventriculoarterial coupling in a cohort of patients admitted to ICUs who presented with vs without septic shock. METHODS: In this retrospective cross-sectional opportunity study, we measured routine hemodynamics using indwelling arterial and pulmonary arterial catheters and transthoracic echocardiograms in 25 septic patients (group S) and 25 non-septic shock patients (group C) upon ICU admission. Ees was measured by echocardiography using a single-beat (EesSB) method. Ea was calculated as 0.9 systolic arterial pressure/stroke volume, and then the Ea/EesSB ratio was calculated (normal value <1.36). RESULTS: In group S, 21 patients had an Ea/EesSB ratio >1.36 (uncoupled). The four patients with Ea/EesSB ratios ≤1.36 had higher EesSB values than patients with Ea/EesSB ratios >1.36 (P = 0.007), although Ea measurements were similar in both groups (P = 0.4). In group C, five patients had uncoupled Ea/EesSB ratios. No correlation was found between EesSB and left ventricular ejection fraction and between Ea/EesSB ratio and mixed venous oxygen saturation in septic shock patients. CONCLUSIONS: Upon admission to the ICU, patients in septic shock often display significant ventriculoarterial decoupling that is associated with impaired left ventricular performance. Because Ea/Ees decoupling alters cardiovascular efficiency and cardiac energetic requirements independently of Ea or Ees, we speculate that septic patients with ventriculoarterial uncoupling may benefit from therapy aimed at normalizing the Ea/Ees ratio.

Transesophageal echocardiography during MitraClip® procedure.

The percutaneous mitral valve (MV) repair procedure performed with the MitraClip delivery system is increasingly used to treat severe mitral regurgitation in high-risk patients. The treatment involves percutaneous insertion and positioning of a clip between the MV leaflets. Transesophageal echocardiography (TEE) plays a key role in the procedure by providing information regarding clip navigation, clip alignment to the MV coaptation line, transmitral advancement of the system, leaflet grasping, confirmation of valve tissue catching, and assessment of the final result. Real-time 3-dimensional TEE has increasing value in percutaneous MV repair providing high-quality visualization of both the heart and the intravascular devices. Optimal visualization by 3-dimensional TEE is obtained through both the atrial and ventricular aspects. In contrast to MV surgery, where TEE is involved in the prebypass assessment phase and in evaluation of the final repair, TEE is mandatory to guide management during MitraClip repair. Cardiac anesthesiologists may provide assistance to interventional cardiologists during the procedure itself in addition to their anesthetic-related tasks.

Effect of fenoldopam on use of renal replacement therapy among patients with acute kidney injury after cardiac surgery: a randomized clinical trial.

IMPORTANCE: No effective pharmaceutical agents have yet been identified to treat acute kidney injury after cardiac surgery. OBJECTIVE: To determine whether fenoldopam reduces the need for renal replacement therapy in critically ill cardiac surgery patients with acute kidney injury. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, double-blind, placebo-controlled, parallel-group study from March 2008 to April 2013 in 19 cardiovascular intensive care units in Italy. We randomly assigned 667 patients admitted to intensive care units after cardiac surgery with early acute kidney injury (≥50% increase of serum creatinine level from baseline or oliguria for ≥6 hours) to receive fenoldopam (338 patients) or placebo (329 patients). We used a computer-generated permuted block randomization sequence for treatment allocation. All patients completed their follow-up 30 days after surgery, and data were analyzed according to the intention-to-treat principle. INTERVENTIONS: Continuous infusion of fenoldopam or placebo for up to 4 days with a starting dose of 0.1 µg/kg/min (range, 0.025-0.3 µg/kg/min). MAIN OUTCOMES AND MEASURES: The primary end point was the rate of renal replacement therapy. Secondary end points included mortality (intensive care unit and 30-day mortality) and the rate of hypotension during study drug infusion. RESULTS: The study was stopped for futility as recommended by the safety committee after a planned interim analysis. Sixty-nine of 338 patients (20%) allocated to the fenoldopam group and 60 of 329 patients (18%) allocated to the placebo group received renal replacement therapy (P = .47). Mortality at 30 days was 78 of 338 (23%) in the fenoldopam group and 74 of 329 (22%) in the placebo group (P = .86). Hypotension occurred in 85 (26%) patients in the fenoldopam group and in 49 (15%) patients in the placebo group (P = .001). CONCLUSIONS AND RELEVANCE: Among patients with acute kidney injury after cardiac surgery, fenoldopam infusion, compared with placebo, did not reduce the need for renal replacement therapy or risk of 30-day mortality but was associated with an increased rate of hypotension. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00621790.

Beta-adrenergic antagonists improve oxygen saturation in acute pulmonary edema: a case series in the prehospital setting.

The use of beta-adrenergic antagonists in acute heart failure is controversial. In this case series, we report the use of intravenous atenolol, a short-acting cardioselective beta-adrenergic antagonist, to treat acute pulmonary edema in the prehospital setting. Four patients with a documented history of cardiac disease and one patient with unknown cardiac issues experienced severe respiratory distress and presented with pulmonary edema; the local emergency medical service was utilized. In all of the patients, the saturation of peripheral oxygen (SpO2) was severely low, and the patients were rapidly treated with oxygen, diuretics, morphine, and nitrates. However, only a small increase in oxygen saturation was observed. Intravenous atenolol was administered and led to a dramatic increase in SpO2. In our case series, we observed the positive effect of early treatment with short-acting beta-adrenergic antagonists on the recovery of rapid oxygen delivery in severely hypoxemic patients.

Non invasive evaluation of cardiomechanics in patients undergoing MitrClip procedure.

BACKGROUND: In the last recent years a new percutaneous procedure, the MitraClip, has been validated for the treatment of mitral regurgitation. MitraClip procedure is a promising alternative for patients unsuitable for surgery as it reduces the risk of death related to surgery ensuring a similar result. Few data are present in literature about the variation of hemodynamic parameters and ventricular coupling after Mitraclip implantation. METHODS: Hemodynamic data of 18 patients enrolled for MitraClip procedure were retrospectively reviewed and analyzed. Echocardiographic measurements were obtained the day before the procedure (T0) and 21 ± 3 days after the procedure (T1), including evaluation of Ejection Fraction, mitral valve regurgitation severity and mechanism, forward Stroke Volume, left atrial volume, estimated systolic pulmonary pressure, non invasive echocardiographic estimation of single beat ventricular elastance (Es(sb)), arterial elastance (Ea) measured as systolic pressure • 0.9/ Stroke Volume, ventricular arterial coupling (Ea/Es(sb) ratio). Data were expressed as median and interquartile range. Measures obtained before and after the procedure were compared using Wilcoxon non parametric test for paired samples. RESULTS: Mitraclip procedure was effective in reducing regurgitation. We observed an amelioration of echocardiographic parameters with a reduction of estimated systolic pulmonary pressure (45 to 37,5 p = 0,0002) and left atrial volume (110 to 93 p = 0,0001). Despite a few cases decreasing in ejection fraction (37 to 35 p = 0,035), the maintained ventricular arterial coupling after the procedure (P = 0,67) was associated with an increasing in forward stroke volume (60,3 to 78 p = 0,05). CONCLUSION: MitraClip is effective in reducing mitral valve regurgitation and determines an amelioration of hemodynamic parameters with preservation of ventricular arterial coupling.

Transcatheter aortic valve replacement with or without anesthesiologist: results from a high-volume single center.

AIMS: Local instead of general anesthesia has become the standard approach in many centers for transfemoral transcatheter aortic valve replacement (TAVR). New generation devices and an increase in operator skills had led to a drastic reduction in periprocedural complications, bringing in the adoption of a minimalist approach. In our study, we aimed to compare patients treated with TAVR under local anesthesia with or without the presence of an anesthesiologist on site (AOS). METHODS: We compare procedural aspects and results of patients treated with TAVR with an AOS against patients treated with TAVR with an anesthesiologist on call (AOC). From January 2019 to December 2020, all consecutive patients undergoing transfemoral TAVR with either the self-expandable Evolut (Medtronic, MN, USA) or balloon-expandable SAPIEN 3 (Edwards Lifesciences, CA, USA) were collected. RESULTS: Of 332 patients collected, 96 (29%) were treated with TAVR with AOS, while 236 (71%) were treated with TAVR with AOC. No differences in procedural time, fluoroscopy time and amount of contrast medium were observed. No procedural death and conversion to open-chest surgery was reported. The rate of stroke/transient ischemic attacks and major vascular complications was similar in the two groups. No patients in both groups required conversion to general anesthesia. Two patients (0.8%) in the AOC group required urgent intervention of the anesthesiologist. In the AOC group, there was a greater use of morphine (55.9% vs. 33.3%, P  = 0.008), but with a lower dose for each patient (2.0 vs. 2.8 mg, P  = 0.006). On the other hand, there was a lower use of other painkiller drugs (3.4% vs. 20.8%, P  = 0.001). No difference in inotropic drugs use was observed. CONCLUSION: In patients at low or intermediate risk undergoing transfemoral TAVR, a safe procedure can be performed under local anesthesia without the presence of an anesthesiologist in the catheterization laboratory.

Anesthetic management of transcatheter aortic valve implantation with transaxillary approach.

OBJECTIVE: To describe the anesthetic management of transcatheter aortic valve implantation (TAVI) with the transaxillary approach. DESIGN: An observational cohort study. SETTING: Two university hospitals. PARTICIPANTS: Twenty-two patients with severe aortic stenosis (± regurgitation) at high risk for surgical valve replacement, with contraindications for transfemoral TAVI (81 ± 4.9 years; logistic EuroSCORE, 27% ± 16.9%). INTERVENTION: General anesthesia or local anesthesia plus sedation followed by postoperative care. MEASUREMENTS AND MAIN RESULTS: Local anesthesia plus sedation and general anesthesia were used in 14 and 8 patients, respectively. Two patients undergoing local anesthesia were monitored with transesophageal echocardiography and supported with noninvasive mask ventilation during the procedure. Main complications included hemodynamic instability requiring inotropes (2 patients), severe postimplant aortic regurgitation requiring immediate second valve-in-valve implantation (1 patient), valve embolization requiring open-valve surgery (1 patient), subclavian artery dissection compromising the flow to a mammary artery graft (1 patient), ascending aortic dissection (1 patient), stroke (2 patients), and atrioventricular block requiring pacemaker implantation (3 patients). Four patients experienced an increased (baseline value × 1.5) postoperative serum creatinine. Five patients required red blood cell tranfusions (2 units). Intensive care unit stay and hospital stay were 6 (4-23) hours and 8 (8-9) days, respectively. All patients were alive 30 days after the procedure. The 6-month mortality was 9%. CONCLUSIONS: Transaxillary TAVI is feasible in high-risk patients with aortic stenosis and peripheral vasculopathy. Nevertheless, severe procedural complications are possible, and anesthesiologists should be prepared to assist in the management of these conditions.

Non-invasive ventilation-aided transoesophageal echocardiography in high-risk patients: a pilot study.

AIMS: Transoesophageal echocardiography (TEE) may require patient sedation, eventually leading to respiratory depression, a risky condition in severe cardiac disease. Non-invasive ventilation (NIV) has been applied during diagnostic manoeuvres, but its use during TEE has not been reported. We describe NIV-aided continuous TEE monitoring under sedation in the supine position in three consecutive orthopnoeic patients with severe aortic valve stenosis: two of them underwent percutaneous aortic valve implantation, and one underwent aortic valvuloplasty. METHODS AND RESULTS: The TEE probe was passed through a hole performed with a surgical cutter in an NIV face-mask. Pulsoximetry, heart rate, arterial blood pressure, respiratory rate, arterial blood gases, patients' comfort, and patient's sedation were monitored throughout the procedure. Percutaneous aortic valve implantation procedures lasted almost 2 h, while the valvuloplasty procedure lasted 70 min. Non-invasive ventilation and continuous TEE were performed throughout the procedures without technical problems or respiratory or haemodynamic complications, and all patients felt always comfortable. CONCLUSION: Non-invasive ventilation through a modified face-mask allowed to perform continuous TEE examination and to avoid tracheal intubation and general anaesthesia in three high-risk patients undergoing beating heart treatment of aortic valve stenosis.

Balloon aortic valvuloplasty before noncardiac surgery in severe aortic stenosis: a single-center experience.

OBJECTIVES: The aim of this study is to investigate the role and short-term results of balloon aortic valvuloplasty (BAV) before noncardiac surgery in a high selected cohort of patients. BACKGROUND: Aortic stenosis is one of the most common valvular heart diseases and a well recognized risk factor for perioperative mortality. METHODS: Between May 2012 and July 2013 we enrolled 15 consecutive patients with severe aortic stenosis to allow urgent major noncardiac surgery. They had been excluded from surgical aortic valve replacement and transcatheter aortic valve implantation. RESULTS: Fifteen patients underwent BAV as a bridge to noncardiac surgery. They were elderly (mean age 81 ±â€Š5 years) and predominantly men (66%) with high surgery risk (mean logistic EuroSCORE: 31.1 ±â€Š18.2%). Three patients underwent vascular surgery, five underwent thoracic surgery, five were subjected to major abdominal surgery and in the last two patients orthopedic surgery and mastectomy were performed. No adverse events were observed in the perioperative period. Six patients (40%) were in New York Heart Association class III or IV. Mean aortic valve area was 0.52 ±â€Š0.1 cm/m; mean aortic pressure gradient was 55.6 ±â€Š10.8 mmHg. BAV was performed successfully in all patients. The mean peak-to-peak gradient assessed by catheterization significantly reduced after BAV (from 69.0 ±â€Š22.1 to 29.7 ±â€Š9.3 mmHg; P < 0.0001). The echocardiographic mean gradient was also significantly improved (from 55.6 ±â€Š10.8 to 33.8 ±â€Š7.9 mmHg; P < 0.0001). Survival at 30 days and at 6 months' follow-up respectively was 100%. At 6 months' follow-up clinical status according to New York Heart Association class was significantly improved (P < 0.0001). CONCLUSION: BAV is well tolerated and effective in high-risk patients with severe aortic stenosis undergoing noncardiac surgery with good short-term survival. It could represent a valid choice of treatment prior to noncardiac surgery in these high-risk patients.

The Anesthetic Management of Transcatheter Aortic Valve Implantation.

An increasing number of patients with a high risk for surgery because of advanced age and associated comorbidities that significantly increase the perioperative risk successfully undergo transcatheter aortic valve implantation (TAVI). TAVI is commonly performed under general or local anesthesia or local anesthesia plus mild sedation to achieve a conscious sedation. The anesthetic regimen generally depends on the patient's clinical profile and the procedural technical characteristics, but the center's experience and internal organization likely play an important role in anesthetic decision making. The large variation in anesthetic management among various centers and countries likely depends on the different composition of the operating team and institutional organization. Therefore, a tight interaction among the various members of the TAVI team, including the cardiac anesthetist, provides the proper anesthetic management using the chosen procedural technique.

Surgical and transcatheter aortic valve procedures. The limits of risk scores.

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in very high-risk patients with severe aortic stenosis. The present multicenter, retrospective study investigates the accuracy and calibration properties of the EuroSCORE and the age, serum creatinine, and ejection fraction (ACEF) score in selecting a population of patients to be referred to TAVI. The study includes 1053 surgical and 211 transcatheter procedures. The operative mortality rate within the surgical group was 2%. The EuroSCORE and the ACEF score had similar levels of accuracy; the ACEF score was well calibrated and the EuroSCORE overestimated the mortality risk. The observed mortality rate within the transcatheter group was 10.4%. Cut-off values corresponding to a mortality rate of 10% were 26 for the logistic EuroSCORE and 2.5 for the ACEF score: both the EuroSCORE and the ACEF score may be used to refer patients to TAVI. However, they do not consider a number of 'extreme' risk conditions that may justify a transcatheter procedure even in absence of an overall elevated risk score. These risk conditions should be included in a specific risk model for referring patients for TAVI.

Antifungal prophylaxis in liver transplant recipients: a randomized placebo-controlled study.

The aim of this study was to evaluate the efficacy of two antifungal prophylaxis regimens in liver transplant recipients. One hundred and twenty-nine consecutive recipients were randomized to receive sequential treatment with intravenous liposomal amphotericin B + oral itraconazole, intravenous fluconazole + oral itraconazole, or intravenous and oral placebo. Frequency and incidence of mycotic colonization, local and systemic infection of mycotic origin, causes of death, and possible risk factors for mycotic infection were evaluated. The incidence of mycotic colonization was higher in the placebo group ( P<0.01), but there was no significant difference in the incidence of infection between the three groups. Pre-transplant colonization, severity of liver disease, and graft rejection were all risk factors for the development of fungal infection. The routine use of antifungal prophylaxis for all liver transplant recipients does not seem to be justified.

Radiofrequency ablation of lung malignancies: where do we stand?

Percutaneous radiofrequency (RF) ablation is a minimally invasive technique used to treat solid tumors. Because of its ability to produce large volumes of coagulation necrosis in a controlled fashion, this technique has gained acceptance as a viable therapeutic option for unresectable liver malignancies. Recently, investigation has been focused on the clinical application of RF ablation in the treatment of lung malignancies. In theory, lung tumors are well suited to RF ablation because the surrounding air in adjacent normal parenchyma provides an insulating effect, thus facilitating energy concentration within the tumor tissue. Experimental studies in rabbits have confirmed that lung RF ablation can be safely and effectively performed via a percutaneous, transthoracic approach, and have prompted the start of clinical investigation. Pilot clinical studies have shown that RF ablation enables successful treatment of relatively small lung malignancies with a high rate of complete response and acceptable morbidity, and have suggested that the technique could represent a viable alternate or complementary treatment method for patients with non-small cell lung cancer or lung metastases of favorable histotypes who are not candidates for surgical resection. This article gives an overview of lung RF ablation, discussing experimental animal findings, rationale for clinical application, technique and methodology, clinical results, and complications.