RESUMEN
OBJECTIVES: While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding developing this approach at Veterans Affairs (VA) medical centers (VAMCs). We implemented TAVR with minimalist approach (MA) using conscious sedation (CS) with transthoracic echocardiography (TTE) and compared safety and outcomes with general anesthesia (GA) with transesophageal echocardiography (TEE) at a university-affiliated VAMC. METHODS: A total of 258 patients underwent transfemoral TAVR at a VAMC between November 2013 and October 2019. Ninety-three patients underwent GA/TEE and 165 patients underwent CS/TTE with dexmedetomidine and remifentanil. Propensity-score matching with nearest-neighbor matching was used to account for baseline differences, yielding 227 participants (81 GA, 146 CS). RESULTS: MA-TAVR had no effect on 30-day mortality or paravalvular leakage. No differences were found in permanent pacemaker implantation, major vascular complications, or postoperative hemodynamics. In this population, MA-TAVR did not reduce procedural time, hospital length of stay, or intensive care unit length of stay. CONCLUSIONS: Unlike civilian hospitals, MA with CS/TTE did not reduce overall length of stay in the veteran population; however, it was safe and effective for transfemoral TAVR without impacting clinical outcomes of mortality, major vascular complications, and paravalvular leakage.
Asunto(s)
Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Veteranos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Hospitales , Humanos , Tiempo de Internación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
We report the case of a 60-year-old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.
Asunto(s)
Anastomosis Quirúrgica/instrumentación , Puente de Arteria Coronaria/métodos , Vasos Coronarios/cirugía , Arterias Mamarias/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Válvula Mitral/cirugía , Robótica , Anastomosis Quirúrgica/métodos , Ecocardiografía Transesofágica , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Esternón/cirugíaAsunto(s)
Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Aneurisma Cardíaco/diagnóstico por imagen , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/microbiología , Insuficiencia de la Válvula Aórtica/cirugía , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/microbiología , Aneurisma Cardíaco/microbiología , Aneurisma Cardíaco/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/microbiología , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral , Valor Predictivo de las Pruebas , Resultado del Tratamiento , Estreptococos Viridans/aislamiento & purificaciónRESUMEN
STUDY OBJECTIVE: Because fentanyl has ventilatory depressing effects, alternative methods for analgesia may be beneficial for management of bariatric surgery. We evaluated whether dexmedetomidine infusion could replace fentanyl for facilitation of open gastric bypass surgery. DESIGN: Randomized, single blinded, open label. SETTING: University teaching hospital. PATIENTS: Twenty bariatric patients with an average body mass index of 54 to 61 kg/m2 undergoing surgery for open gastric bypass. INTERVENTIONS: Patients were randomized to receive either fentanyl (0.5-microg/kg bolus, 0.5 microg.kg(-1).h(-1), n = 10) or dexmedetomidine (0.5-microg/kg bolus, 0.4 microg.kg(-1).h(-1), n = 10) for intraoperative analgesia. In both groups, end-tidal desflurane was adjusted to maintain the bispectral index at 45 to 50. MEASUREMENTS: In the operating room, blood pressure and heart rate were measured at 5-minute intervals. Bispectral index and end-tidal desflurane concentration were measured every hour. During recovery in the postanesthesia care unit, patient-evaluated pain scores and morphine use by patient-controlled analgesia pump were determined. MAIN RESULTS: During surgery, desflurane concentrations necessary to maintain the bispectral index at 45 to 50 were decreased, and blood pressure and heart rate were lower with in the dexmedetomidine compared with fentanyl group. In the postanesthesia care unit, pain scores and morphine use were decreased in the dexmedetomidine group. CONCLUSIONS: Dexmedetomidine, when used to substitute for fentanyl during gastric bypass surgery, attenuates blood pressure and provides postoperative analgesia.
Asunto(s)
Analgésicos no Narcóticos , Analgésicos Opioides , Anestésicos Combinados , Anestésicos por Inhalación , Dexmedetomidina , Fentanilo , Derivación Gástrica , Isoflurano/análogos & derivados , Obesidad Mórbida/cirugía , Agonistas alfa-Adrenérgicos , Adulto , Analgesia Controlada por el Paciente , Presión Sanguínea , Desflurano , Método Doble Ciego , Electroencefalografía , Femenino , Frecuencia Cardíaca , Humanos , Hipnóticos y Sedantes , Masculino , Persona de Mediana Edad , Obesidad Mórbida/fisiopatología , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & controlAsunto(s)
Válvula Aórtica/microbiología , Válvula Aórtica/cirugía , Endocarditis Bacteriana/microbiología , Aorta Torácica/patología , Aorta Torácica/cirugía , Angiopatías Diabéticas/complicaciones , Angiopatías Diabéticas/patología , Ecocardiografía Transesofágica , Endocarditis Bacteriana/patología , Fiebre/patología , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Pleuresia/patología , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/patologíaAsunto(s)
Seno Coronario/anomalías , Vena Cava Inferior/anomalías , Anciano , Artroplastia de Reemplazo de Rodilla , Seno Coronario/diagnóstico por imagen , Ecocardiografía Transesofágica , Atrios Cardíacos , Pruebas de Función Cardíaca , Válvulas Cardíacas/diagnóstico por imagen , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/fisiopatología , Masculino , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugíaAsunto(s)
Válvula Aórtica/diagnóstico por imagen , Calcinosis/diagnóstico por imagen , Ecocardiografía Transesofágica/métodos , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Anciano de 80 o más Años , Calcinosis/diagnóstico , Enfermedades de las Válvulas Cardíacas/diagnóstico , Humanos , MasculinoRESUMEN
The reported adverse effects of perioperative transesophageal echocardiography (TEE) are mostly associated with the insertion and manipulation of the TEE probe. Recent data suggest that blind probe insertion may be associated with greater morbidity than reported previously. Although this morbidity appears to be subclinical with unknown effects on patient outcome, evaluation of strategies for insertion is warranted. Herein, we present a novel insertion technique using a soft-tipped esophageal bougie as a guide for blind TEE probe insertion in a patient undergoing cardiac surgery. The potential advantages and related safety issues are discussed.