Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 2.

The right ventricle (RV) is intricately linked in the clinical presentation of critical illness; however, the basis of this is not well-understood and has not been studied as extensively as the left ventricle. There has been an increased awareness of the need to understand how the RV is affected in different critical illness states. In addition, the increased use of point-of-care echocardiography in the critical care setting has allowed for earlier identification and monitoring of the RV in a patient who is critically ill. The first part of this review describes and characterizes the RV in different perioperative states. This second part of the review discusses and analyzes the complex pathophysiologic relationships between the RV and different critical care states. There is a lack of a universal RV injury definition because it represents a range of abnormal RV biomechanics and phenotypes. The term "RV injury" (RVI) has been used to describe a spectrum of presentations, which includes diastolic dysfunction (early injury), when the RV retains the ability to compensate, to RV failure (late or advanced injury). Understanding the mechanisms leading to functional 'uncoupling' between the RV and the pulmonary circulation may enable perioperative physicians, intensivists, and researchers to identify clinical phenotypes of RVI. This, consequently, may provide the opportunity to test RV-centric hypotheses and potentially individualize therapies.

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review.

Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

Opioid-Free Anesthesia for Lung Cancer Resection: A Case-Control Study.

OBJECTIVE: To assess the feasibility and effectiveness of an opioid-free anesthesia (OFA) technique in lung cancer resection surgery versus standard opioid-based techniques. DESIGN: Retrospective, propensity-matched, case-control study. SETTING: A single, specialty cardiothoracic center between January 2018 and July 2019. PARTICIPANTS: Adult patients undergoing lung cancer resection surgery. INTERVENTIONS: A cohort of 83 patients undergoing an OFA technique (OFA group) for lung cancer resection surgery was matched with 83 patients who underwent similar surgery with a standard anesthesia technique (STD group). Outcome measures compared between the 2 groups included postoperative pain scores at 0, 1, and 24 hours; 24-hour postoperative morphine patient-controlled analgesia consumption; recovery room and hospital lengths of stay; and 30-day all-cause mortality. MEASUREMENT AND MAIN RESULTS: No difference was found in median pain scores (interquartile range [IQR]) at 0 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.48. Median pain scores (IQR) at 1 hour were statistically significantly greater in the STD group compared with the OFA group: STD 1 (0-1), OFA 0 (0-1); p = 0.03. There was no difference in median pain scores (IQR) at 24 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.49. Mean postoperative 24-hour patient-controlled analgesia morphine consumption (standard deviation) was similar between groups: STD 21.1 (±18.8) mg, OFA 16.2 (±18.1) mg; p = 0.16. There was no difference in mean time spent in the postoperative recovery (standard deviation) area between the 2 groups: STD 116 (±49) minutes, OFA 108 (±34) minutes; p = 0.27. Median hospital length of stay (IQR) was longer in the STD group compared with the OFA group: STD 4 (2-6) days, OFA 3 (2-4) days; p = 0.002. CONCLUSIONS: This case-control study demonstrated that an OFA technique in lung cancer resection surgery offers a feasible and safe approach, resulting in similar postoperative pain scores and morphine consumption compared with standard opioid-containing techniques.

Ex-vivo lung perfusion.

PURPOSE OF REVIEW: Ex-vivo lung perfusion (EVLP) has been developed to expand the donor pool for lung transplantation recipients. The role of EVLP in organ preservation, evaluation and potential reconditioning is reviewed. RECENT FINDINGS: EVLP has been shown to significantly increase the utilization of donor lungs for transplantation. Evidence suggests that patient outcomes from EVLP lungs are comparable to standard procurement technique. Novel strategies are being developed to treat and recondition injured donor lungs. EVLP may also prove to be a tool for translational research of lung diseases. SUMMARY: EVLP has been shown to be an effective system to expand donor pool for lung transplantation without detriment to recipients. Future potential ex-vivo developments may further improve patient outcomes as well as increasing availability of donor organs.

Aortic root changes before and after surgery for chronic aortic dilatation: A 3D echocardiographic study.

BACKGROUND: Quantitative 3D assessment of the aortic root may improve planning and success of aortic valve (AV)-sparing operations. AIMS: To use 3D transesophageal echocardiography (TEE) to assess the effect of chronic aortic dilatation on aortic root shape and aortic regurgitation (AR) severity and to examine the effects of AV-sparing operations. METHODS AND RESULTS: To determine the changes with chronic aortic dilatation, we studied 48 patients, 23 with aortic dilatation (Group 1 ≤ mild AR, n = 13; Group 2 ≥ moderate AR, n = 10) and 25 Controls. To determine the changes in AV-sparing operations, a subgroup of 15 patients were examined pre- and post surgery. 3D-TEE images were analyzed using multiplanar reconstruction (QLAB, Philips, Philips Medical Systems, Andover, MA, USA) to obtain aortic root areas, diameters, and lengths. We also calculated a novel parameter called total coaptation surface area (TCoapSA), which sums the contact surface area of all the AV cusps. Compared to Controls, Groups 1 and 2 had significantly larger aortic root areas, inter-commissural distances, and cusp heights. Compared to Group 1 and Controls, Group 2 had significantly smaller TCoapSA when adjusted for aortic annular area (P = 0.001) with shorter coaptation height (P < 0.001). In patients undergoing AV-sparing surgery, TCoapSA was significantly larger post surgery (P = 0.001) with greater coaptation height (P < 0.001) and smaller inter-commissural distances (P < 0.001). CONCLUSIONS: The aortic valve is a dynamic structure that remodels in response to aortic dilatation. Successful valve-sparing surgery corrects these changes. Quantitative modeling of the aortic valve and root could potentially improve the repair to the individual patients and modify outcomes.

Transesophageal Echocardiography in Heart and Lung Transplantation.

The number of heart and lung transplantations has risen over the years, and they remain the mainstay of treatment for end-stage heart failure and end-stage lung diseases. From the assessment of the donor's heart to intraoperative management during separation from cardiopulmonary bypass (CPB) to the postoperative follow-up of heart transplant patients, echocardiography plays a vital role throughout this process. Patients with chronic lung diseases also may have cardiovascular compromise secondary to pulmonary hypertension, pre-existing coronary artery disease, or valvular heart disease. Preoperative echocardiographic assessment allows for optimization before major surgery. An intraoperative transesophageal echocardiography (TOE) for continuous monitoring of the cardiac function is important especially in a procedure where hemodynamic instability is often encountered. Postoperative complications are common, and they can be diagnosed with the help of TOE. The authors aim to conduct a narrative review on the use of TOE mainly in the intraoperative setting during heart and lung transplantation and also to highlight some of its uses preoperatively as well as in the immediate postoperative period.

Evaluation of the Clinical Utility of Transesophageal Echocardiography and Invasive Monitoring to Assess Right Ventricular Function During and After Pulmonary Endarterectomy.

OBJECTIVE: Patients undergoing pulmonary endarterectomy (PEA) have impaired right ventricular function. The authors sought to assess the clinical utility of commonly used perioperative echocardiographic and right heart catheter measurements in patients undergoing PEA. DESIGN: A single-center prospective observational study. SETTING: The study was conducted in a quaternary care cardiac surgical center in the United Kingdom. PARTICIPANTS: Patients undergoing PEA between April 2015 and January 2016. INTERVENTIONS: Thermodilution cardiac index and echocardiography variables were measured at 3 time points: before sternotomy (T1), after pericardial incision (T2), and after sternal closure (T3). Six-month follow-up echocardiography and 6-minute walk (6-MWT) test were performed. MEASUREMENTS AND MAIN RESULTS: Fifty patients were recruited and complete data sets were available for 41 patients. Tricuspid annular plane systolic excursion declined after pericardial incision and cardiopulmonary bypass (T1: 15 ± 4 mm, T2: 13 ± 4 mm, T3: 7 ± 2 mm; p < 0.0001), returning to baseline 6 months postoperatively. Cardiac index (T1: 2.5 ± 0.7 L/min/m2, T2: 2.6 ± 0.6 L/min/m2, T3: 2.3 ± 0.5 L/min/m2; p = 0.07) and right ventricular fractional area change (T1: 36 ± 11%, T2: 40 ± 12%, T3: 40 ± 9%; p = 0.12) were preserved perioperatively. 6-MWT improved from baseline (294 ± 111 m) to follow-up (357 ± 107 m) (p < 0.001). Pulmonary vascular resistance at T3 correlated moderately with follow-up 6-MWT (R = -0.60). CONCLUSIONS: In patients undergoing PEA, invasive measurements and echocardiography assessment of right ventricular function are not interchangeable. Tricuspid annular plane systolic excursion is not a reliable measure of right ventricular function perioperatively. Pulmonary vascular resistance shows moderate correlation with postoperative functional capacity.

Echocardiography for adult patients supported with extracorporeal membrane oxygenation.

Venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) support is increasingly being used in recent years in the adult population. Owing to the underlying disease precipitating severe respiratory or cardiac failure, echocardiography plays an important role in the management of these patients. Nevertheless, there are currently no guidelines on the use of echocardiography in the setting of ECMO support. This review describes the current state of application of echocardiography for patients supported with both VA and VV ECMO.

Transesophageal echocardiography in thoracic anesthesia: pulmonary hypertension and right ventricular function.

PURPOSE OF REVIEW: Pulmonary hypertension is associated with increased postoperative morbidity and mortality. Early diagnosis and echocardiographic detection of right ventricular (RV) dysfunction are paramount in perioperative management. The goal of this review is to provide an overview of the recent literature on this topic. RECENT FINDINGS: Doppler interrogation of pulmonary artery flow may provide an insight into the severity and mechanism of pulmonary hypertension. Established echocardiographic techniques of RV assessment have multiple limitations. Newer echocardiographic technologies (strain and three-dimensional imaging) are promising, but require further validation in the perioperative setting before they are adopted. SUMMARY: More pulmonary hypertension patients are presenting for noncardiac surgery, creating a challenge for the anesthesiologist. Echocardiographic detection of RV dysfunction can be difficult. Routine use of intraoperative transesophageal echocardiography in major thoracic surgery is not advocated yet, but the development of automated techniques may provide an objective assessment of RV function.

Beyond the self: a novel framework to enhance non-technical team skills for anesthesiologists.

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

Multimodality Quantitative Assessment of Aortic Regurgitation: A Systematic Review.

We performed a systematic review on the agreement and reproducibility of 3 advanced imaging methods, 3-dimensional echocardiography (3DE), cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR), for quantifying aortic regurgitation (AR) severity. Medline, Embase, and Cochrane databases were systematically searched using the PICO model from inception to February 4, 2022, for publications that quantified AR severity with 3DE, CCT, or CMR. Measurement agreement and intraobserver and interobserver reproducibility results were extracted from each study. Study quality was assessed using the QUADAS-2 tool. Forty-two publications with 2176 patients with AR were identified. For 3DE, vena contracta (VC) width, VC area, and effective regurgitant orifice area had higher correlations with AR volume than the 2-dimensional echocardiography (2DE)-derived VC width. CCT-derived regurgitant volume had moderate-to-good correlations with 2DE. CMR regurgitant volume measurements had lower intraobserver and interobserver variabilities because of improved endocardial definition, fewer geometric assumptions, and less angle dependence for flow measurements when compared with 2DE. 3DE color flow convergence methods used to quantify AR severity were superior to 2DE methods and could be used in patients with adequate echocardiographic windows. CCT methods also demonstrated improvements over 2DE methods. Although this method is limited due to the radiation exposure, it could play a role in patients with poor echocardiographic windows unable to tolerate CMR. CMR demonstrated the smallest intraobserver and interobserver variability in evaluating AR severity and is a reasonable option for those where the echocardiographic results are mixed and for clinical trials.

Pulmonary thromboendarterectomy and pulmonary haemorrhage.

Pulmonary thromboendarterectomy surgery is the recommended treatment for patients with chronic thromboembolic pulmonary hypertension. Massive intraoperative pulmonary haemorrhage with bleeding into the airway is a rare complication, and it typically presents as cardiopulmonary bypass flow is reduced and blood begins to flow through the pulmonary circulation. Immediate management includes maintaining extracorporeal circulation to reduce blood flow through the pulmonary circulation, isolation of the affected lung, while the surgeon identifies and repairs the site of haemorrhage.

The use of ketamine as an induction agent for anesthesia in pulmonary thromboendarterectomy surgery: A case series.

Pulmonary thromboendarterectomy (PTE) surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The induction of anesthesia in patients with severe pulmonary hypertension (PHT) can be challenging, with a risk of cardiovascular collapse. The administration of ketamine in patients with PHT is controversial, with some recommendations contraindicating its use. However, ketamine has been used safely in children with severe PHT. We present a retrospective case series of adult patients with severe PHT presenting for PTE surgery, using intravenous ketamine as a co-induction anesthetic agent.