Infective Endocarditis-Update for the Perioperative Clinician.

Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considerations for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.

Preoperative Pulmonary Artery-to-Aorta Diameter Ratio as a Predictor of Postoperative Severe Right Ventricular Failure and 1-Year Mortality After Left Ventricular Assist Device Implantation.

OBJECTIVES: To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation. DESIGN: This was a retrospective observational study between March 2013 and July 2019. SETTING: The study was conducted at a single, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD. INTERVENTIONS: A left ventricular assist device was used for intervention. MEASUREMENTS AND MAIN RESULTS: A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005). CONCLUSIONS: The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation.

The Intraoperative Assessment of Right Ventricular Function During Cardiac Surgery.

The importance of right ventricular (RV) dysfunction in patients undergoing cardiac surgery is well recognized. There is extensive literature regarding the accurate assessment of RV dysfunction with both echocardiography and hemodynamic data, but the majority of these studies are with transthoracic echocardiography (TTE) and in awake patients. Many of the tools used to assess the RV with TTE are angle-dependent and, therefore, may be inaccurate with transesophageal echocardiography (TEE). Very few of these modalities have been validated either with TEE or in patients under general anesthesia. The purpose of this review is to discuss the intraoperative tools available to the cardiac anesthesiologist for the assessment of RV function. The authors review the available literature surrounding intraoperative RV assessment, from subjective assessment to traditional objective tools that were developed for TTE and newer technology that can be adapted to both TTE and TEE. Future work should focus on whether or not these intraoperative RV assessment tools predict outcome after cardiac surgery.

Imaging for Temporary Mechanical Circulatory Support Devices.

Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.

Intraoperative Hemodynamic and Echocardiographic Measurements Associated With Severe Right Ventricular Failure After Left Ventricular Assist Device Implantation.

BACKGROUND: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF. METHODS: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics. RESULTS: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86). CONCLUSIONS: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.

Image-based multichannel vaginal cylinder brachytherapy for the definitive treatment of gynecologic malignancies in the vagina.

PURPOSE: Brachytherapy is integral to vaginal cancer treatment and is typically delivered using an intracavitary single-channel vaginal cylinder (SCVC) or an interstitial brachytherapy (ISBT) applicator. Multi-channel vaginal cylinder (MCVC) applicators allow for improved organ-at-risk (OAR) sparing compared to SCVC while maintaining target coverage. We present clinical outcomes of patients treated with image-based high dose-rate (HDR) brachytherapy using a MCVC. METHODS AND MATERIALS: Sixty patients with vaginal cancer (27% primary vaginal and 73% recurrence from other primaries) were treated with combination external beam radiotherapy (EBRT) and image-based HDR brachytherapy utilizing a MCVC if residual disease thickness was 7 mm or less after EBRT. All pts received 3D image-based BT to a total equivalent dose of 70-80 Gy. RESULTS: The median high-risk clinical target volume was 24.4 cm3 (interquartile range [IQR], 14.1), with a median dose to 90% of 77.2 Gy (IQR, 2.8). After a median follow-up of 45 months (range, 11-78), the 4-year local-regional control, distant control, DFS, and OS rates were 92.6%, 76.1%, 64.0%, and 67.2%, respectively. The 4-year LRC rates were similar between the primary vaginal (92%) and recurrent (93%) groups (p = 0.290). Pts with lymph node positive disease had a lower rate of distant control at 4 years (22.7% vs. 89.0%, p < 0.001). There were no Grade 3 or higher acute complications. The 4-year rate of late Grade 3 or higher toxicity was 2.7%. CONCLUSIONS: Clinical outcomes of pts with primary and recurrent vaginal cancer treated definitively in a systematic manner with combination EBRT with image-guided HDR BT utilizing a MCVC applicator demonstrate high rates of local control and low rates of severe morbidity. The MCVC technique allows interstitial implantation to be avoided in select pts with ≤7 mm residual disease thickness following EBRT while maintaining excellent clinical outcomes with extended 4-year follow-up in this rare malignancy.

Image-guided tandem and cylinder brachytherapy as monotherapy for definitive treatment of inoperable endometrial carcinoma.

OBJECTIVES: Management of endometrial cancer consists of surgical staging with adjuvant therapy guided by risk factors, though some women cannot undergo surgery due to comorbidities. We present a series of women treated with definitive high-dose rate image-guided tandem and cylinder brachytherapy (HDR-IGBT) alone. METHODS: Patients with grade 1-2, clinical stage I endometrial adenocarcinoma, <50% myometrial invasion, and tumor≤2cm were reviewed. Definitive treatment consisted of 5-6 fractions HDR-IGBT alone with CT- or MRI-based planning. Local-regional control (LRC) was defined as complete imaging response and/or cessation of vaginal bleeding. RESULTS: From 2007 to 2016, 45 patients were treated to a median dose of 37.5Gy. The median gross tumor volume (GTV) and clinical target volume (CTV) were 5.9cm3 (range, 0.7-18.7) and 80.9cm3 (17.2-159.0), respectively. The median cumulative dose to 90% (D90) of the GTV was 132.8Gy (76.5-295.6) equivalent 2Gy dose, and the median CTV D90 was 49.7Gy (34.5-57.2). Median follow-up among living patients was 18.6months (3.0-64.3). Cessation of vaginal bleeding occurred in 98%. Among those with post-treatment MRI (64%), complete radiographic response was demonstrated in 90%. The 2-year LRC, cancer-specific survival, and overall survival rates were 90%, 86%, and 97%, respectively. No grade 3+ acute or late toxicity was observed. CONCLUSIONS: HDR-IGBT alone for treatment of early-stage, medically inoperable endometrial cancer is feasible with excellent response rates and clinical results. This approach also allows sparing of critical organs and ensures target coverage, which contributed to the low toxicity rate and high LRC in comparison with 2D point-based series.

Left Ventricular Assist Device Thrombosis Is Associated With an Increase in the Systolic-to-Diastolic Velocity Ratio Measured at the Inflow and Outflow Cannulae.

OBJECTIVE: To determine whether the ratio of peak systolic-to-nadir diastolic velocity (S/D ratio) measured using Doppler at the left ventricular assist device (LVAD) inflow and outflow cannulae is associated with pump thrombosis and to determine whether there is an absolute decrease in the diastolic cannula velocities in LVAD thrombosis. DESIGN: Retrospective chart review. SETTING: University hospital. PARTICIPANTS: Patients who underwent LVAD exchange. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiograms were reviewed from all patients with the HeartMate II device (Thoratec Corporation, Pleasanton, CA) over a 6-year period and who underwent LVAD exchange for pump thrombosis. The following 3 time points were evaluated: (1) initial LVAD placement (prethrombosis), (2) thrombosis, and (3) exchanged LVAD placement (postthrombosis). Systolic and diastolic flow velocities were examined using pulse-wave spectral Doppler at the inflow and outflow cannulae, and the S/D ratio for each was determined. Statistical analysis was performed with SAS, version 9.4 (SAS Institute, Cary, NC), using 2-tailed tests and alpha = 0.05. Thirteen patients were included in the study. Significant differences were observed in S/D ratios among the 3 phases at both the inflow (p = 0.0234) and outflow (p = 0.0047) cannulae. Pairwise tests of the inflow cannulae showed that the mean S/D ratio at the time of thrombosis (mean ± standard deviation [SD], 4.29 ± 1.74) was significantly greater than the prethrombosis ratio (2.49 ± 0.65; p = 0.0069). Among outflow measurements, the mean S/D ratio at thrombosis (3.94 ± 1.34) was significantly higher than both the prethrombosis (2.63 ± 0.56; p = 0.0025) and postthrombosis (2.74 ± 0.83) (p = 0.0093) ratios. Decreases in diastolic velocities were not statistically significant at the inflow cannula. At the outflow cannula, there was a significant difference in diastolic velocity among the phases (p = 0.0233). Specifically, the postthrombosis diastolic measurements (41.50 ± 9.94) were significantly higher than both the prethrombosis (26.85 ± 10.13; p = 0.0140) and thrombosis (26.7 ± 15.35; p = 0.0151) values. CONCLUSIONS: An increased S/D ratio measured with Doppler at the LVAD inflow and outflow cannulas may be associated with pump thrombosis. Decreased diastolic cannula velocities were not observed in LVAD thrombosis.