RESUMEN
OBJECTIVE: The authors hypothesized that grading valvular aortic stenosis (AS) with dimensionless index (DI) during intraoperative pre-cardiopulmonary bypass (pre-CPB) transesophageal echocardiography (TEE) would match the grade of AS during preoperative transthoracic echocardiography (TTE) for the same patients more often than when using peak velocity (Vp), mean pressure gradient (PGm), or aortic valve area (AVA). DESIGN: Retrospective, observational. SETTING: Single university hospital. PARTICIPANTS: The participants in this study included 123 cardiac surgical patients with any degree of AS, who underwent open cardiac surgery between 2010 and 2016 at the Medical University of South Carolina and had Vp, PGm, AVA, and DI values available from reporting databases or archived imaging. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When using DI, pre-CPB TEE grading of AS severity was 1 grade higher 21.1% of the time and 1 grade lower 13.0% of the time compared with TTE, for an overall disagreement rate of 34.1%. The overall disagreement rates between pre-CPB TEE and TTE for Vp, PGm, and AVA were 39.8%, 33.3%, and 33.3%, respectively. CONCLUSIONS: The authors could not demonstrate that DI was better than Vp, PGm, or AVA at matching AS grades between intraoperative pre-CPB TEE and preoperative TTE. When DI was used, pre-CPB TEE was more likely to overestimate than underestimate the severity of AS compared with TTE. However, when Vp or PGm was used, pre-CPB TEE was more likely to underestimate the severity of AS compared with TTE. A comprehensive approach without overemphasis on 1 parameter should be used for AS assessment by intraoperative TEE.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico por imagen , Puente Cardiopulmonar/normas , Ecocardiografía Transesofágica/normas , Ecocardiografía/normas , Cuidados Preoperatorios/normas , Índice de Severidad de la Enfermedad , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Puente Cardiopulmonar/métodos , Ecocardiografía/métodos , Ecocardiografía Transesofágica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios/métodos , Estudios RetrospectivosRESUMEN
Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. CASE: A 64-year-old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three-dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.
Asunto(s)
Valvuloplastia con Balón , Ecocardiografía Tridimensional/métodos , Ecocardiografía Transesofágica/métodos , Implantación de Prótesis de Válvulas Cardíacas , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/cirugía , Femenino , Humanos , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: To describe the experience regarding the perioperative management of patients with left ventricular assist devices (LVADs) who require anesthesia while undergoing noncardiac surgery (NCS) at a single medical center. DESIGN: Retrospective chart review SETTING: Academic medical center PARTICIPANTS: Patients with LVADs INTERVENTIONS: Medical records from April 1, 2009 through January 31, 2014 were reviewed for patients who underwent Heartmate II LVAD placement at this facility. Individual records were reviewed for NCS after LVAD placement, specifically investigating perioperative and anesthetic management. MEASUREMENTS AND MAIN RESULTS: Seventy-one patients underwent LVAD placement during this time period. Thirty-five patients (49%) underwent a total of 101 NCS procedures. Arterial catheters were placed in 19 patients (19%), and 33 patients (33%) were intubated for their procedure. No complications or perioperative mortality occurred related to the NCS. CONCLUSIONS: Noncardiac surgery is becoming more common in patients with LVADs. Anesthetic management of these patients outside of the cardiac operating room is limited. Patients with Heartmate II LVADs can safely undergo noncardiac surgery.
Asunto(s)
Manejo de la Enfermedad , Corazón Auxiliar/tendencias , Atención Perioperativa/métodos , Atención Perioperativa/tendencias , Complicaciones Posoperatorias/prevención & control , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Corazón Auxiliar/efectos adversos , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , UltrasonografíaRESUMEN
Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level. Failure to attain the target ACT raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the hemostatic system. Although antithrombin deficiency has generally been thought to be the primary mechanism of heparin resistance, the reasons for heparin resistance are both complex and multifactorial. Furthermore, the ACT is not specific to heparin's anticoagulant effect and is affected by multiple variables that are commonly present during cardiac surgery. Due to these many variables, it remains unclear whether decreased heparin responsiveness as measured by the ACT represents inadequate anticoagulation. Nevertheless, many clinicians choose a target ACT to assess anticoagulation, and interventions aimed at achieving the target ACT are routinely performed in the setting of heparin resistance. Treatments for heparin resistance/alterations in heparin responsiveness include additional heparin or antithrombin supplementation. In this review, we discuss the variability of heparin potency, heparin responsiveness as measured by the ACT, and the current management of heparin resistance.
Asunto(s)
Anticoagulantes/farmacología , Puente Cardiopulmonar , Heparina/uso terapéutico , Antitrombinas/análisis , Antitrombinas/fisiología , Relación Dosis-Respuesta a Droga , Resistencia a Medicamentos , Heparina/farmacocinética , Humanos , Tiempo de Coagulación de la Sangre TotalAsunto(s)
Desfibriladores Implantables/efectos adversos , Ecocardiografía Transesofágica , Endocarditis Bacteriana/diagnóstico por imagen , Remoción de Dispositivos , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/cirugía , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , ReoperaciónRESUMEN
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
Asunto(s)
Ecocardiografía Transesofágica , Cirujanos , Anestesiólogos , Ecocardiografía , Humanos , Quirófanos , Estados UnidosAsunto(s)
Anestesiología/normas , Ecocardiografía Transesofágica/normas , Anestesia , Consenso , Embolia Aérea/diagnóstico por imagen , Corazón/fisiología , Cardiopatías Congénitas/cirugía , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Procedimientos Neuroquirúrgicos , Atención Perioperativa , Embolia Pulmonar/diagnóstico por imagen , Garantía de la Calidad de Atención de Salud , Sociedades Médicas , Estados Unidos , Función Ventricular Izquierda , Función Ventricular DerechaAsunto(s)
Válvula Aórtica/diagnóstico por imagen , Bioprótesis/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias/diagnóstico por imagen , Animales , Válvula Aórtica/cirugía , Manejo de la Enfermedad , Falla de Equipo , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/cirugía , Porcinos , UltrasonografíaRESUMEN
We present a rare case of multiple focal nodular hyperplasia (FNH) with greater than 20 FNH lesions and coexistent liver hemangiomata. Particular attention is paid to the MRI characteristics of this disease process and the features of "multiple FNH syndrome" are discussed.
Asunto(s)
Hiperplasia Nodular Focal/diagnóstico , Imagen por Resonancia Magnética/métodos , Adulto , Medios de Contraste , Diagnóstico Diferencial , Femenino , Gadolinio DTPA , Humanos , SíndromeAsunto(s)
Enfermedades de la Aorta/cirugía , Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Calcinosis/cirugía , Ecocardiografía Transesofágica , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Ultrasonografía Intervencional , Anciano , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Calcinosis/diagnóstico por imagen , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Diseño de Prótesis , Resultado del TratamientoRESUMEN
We present a rare case of diffuse abdominal angiomatosis occurring in a 19-year-old male; particular attention is paid to the MR imaging features of this disease process.
Asunto(s)
Neoplasias Abdominales/diagnóstico , Angiomatosis/diagnóstico , Hemangioma/diagnóstico , Neoplasias Abdominales/diagnóstico por imagen , Adulto , Angiomatosis/diagnóstico por imagen , Diagnóstico Diferencial , Hemangioma/diagnóstico por imagen , Humanos , Imagen por Resonancia Magnética , Masculino , Arteria Mesentérica Superior/patología , Páncreas/patología , Vena Porta/patología , Arteria Esplénica/patología , Trombosis/diagnóstico , Tomografía Computarizada por Rayos XRESUMEN
As ultrasound technology improves and ultrasound availability increases, echocardiography utilization is growing within intensive care units. Although not replacing the often-needed comprehensive echocardiographic evaluation, limited bedside echocardiography promises to provide intensivists with enhanced diagnostic ability and improved hemodynamic understanding of individual patients. Routine and emergency echocardiography within the intensive care unit focuses on identifying and optimizing medically treatable conditions in a timely manner. Methods for such goal-directed assessments are presented.