RESUMO
Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.
Assuntos
Oclusão com Balão , Procedimentos Cirúrgicos Cardíacos , Humanos , Porcelana Dentária , Resultado do Tratamento , Procedimentos Cirúrgicos Cardíacos/métodos , Aorta/cirurgia , Cateterismo , Valva Mitral/cirurgiaRESUMO
STUDY OBJECTIVE: Obesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/m2, is associated with adverse outcomes and challenges during surgery. Difficulties during endotracheal intubation, occur in 3-8% of procedures and are among the principal causes of anesthetic-related morbidity and mortality. Endotracheal intubation can be challenging in obese patients due to an array of anatomic and physiologic factors. Double lumen tubes (DLTs), the most commonly used airway technique to facilitate anatomic isolation of the lungs for one lung ventilation. However, DLTs can be difficult to properly position and are also more likely to cause airway injuries and bleeding when compared to conventional single lumen tubes. We investigated the association between BMI and difficult tracheal DLT intubation. DESIGN: Retrospective cohort study. SETTING: Operating room. PATIENTS: We analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021. MEASUREMENTS: BMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression. MAIN RESULTS: Among 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/m2 increase in BMI was associated with a marginal increase of difficult intubation, odds ratio (OR) 1.06 (95% Confidence Interval [CI]: 1.002, 1.11; P = 0.040). Difficult intubation was not associated with airway abnormalities, estimated OR 0.85 (95% CI: 0.62, 1.17; P = 0.321). There was no interaction between known airway abnormalities and BMI (P = 0.894). CONCLUSIONS: Difficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m2 corresponds to an increase in average absolute risk for difficult intubation from 16 to 19%, which probably is not clinically meaningful.
Assuntos
Intubação Intratraqueal , Ventilação Monopulmonar , Adulto , Humanos , Índice de Massa Corporal , Estudos Retrospectivos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Ventilação Monopulmonar/métodos , Obesidade/complicações , PulmãoRESUMO
Redo cardiac surgery can present a unique set of challenges even to the experienced surgeon. Although outcomes have steadily improved in the modern era; if an intraoperative adverse event occurs, there is a 5% incidence of mortality and 19% incidence of myocardial infarction, stroke or death. Overall, the modern incidence of mortality at reoperation varies but be segregated into low and higher risk cohorts depending on the planning computed tomography imaging and risk to substernal structures on re-entry. Patients with ascending aortic or root pseudoaneurysms represent a particularly difficult subset of high-risk patients requiring reoperative cardiac surgery due to the danger of exsanguination and air embolization. The gold standard for management of such cases remains the use of deep hypothermic circulatory arrest (DHCA) to achieve safe re-entry in such cases however this can result in unpredictable DHCA duration depending on the degree of pericardial adhesions. We report a case of aortic pseudoaneurysm in a patient with patent coronary grafts managed using an endoballoon precisely positioned relative to the proximal anastomoses resulting in a safe surgical re-entry and shorter DHCA time.
Assuntos
Falso Aneurisma , Procedimentos Cirúrgicos Cardíacos , Humanos , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Resultado do Tratamento , Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Coração , Estudos Retrospectivos , ReoperaçãoRESUMO
OBJECTIVE: Redo sternotomy in patients with arterial cardiac structures adherent to the sternum carries a risk of catastrophic bleeding. In some of those cases, particularly if they have undergone multiple previous operations, deep hypothermic circulatory arrest alone may not provide sufficient time for a controlled dissection. METHODS: We present a series of 6 cases at risk for exsanguination during sternal re-entry successfully reoperated using percutaneous cardioplegic cardiac arrest induced before completed sternal re-entry to avoid or minimize the hypothermic circulatory arrest time. RESULTS: All patients survived their complex operations. CONCLUSIONS: Percutaneous cardioplegic arrest allows safer repeat sternotomy in patients with arterial cardiac structures adherent to the sternum.
Assuntos
Aneurisma Aórtico/cirurgia , Parada Cardíaca Induzida/métodos , Reoperação/métodos , Esternotomia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esternotomia/efeitos adversos , Esternotomia/métodosAssuntos
Anestesia/métodos , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Stents , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Idoso , Ecocardiografia , Feminino , Humanos , Desenho de Prótese , Tomografia Computadorizada por Raios X , Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/diagnósticoRESUMO
Two patients in whom the bispectral index (BIS) decreased to zero following cardiac arrest during cardiothoracic surgery are described. The BIS value decreased to zero after cardiac arrest, and the value remained low for the remainder of the anesthetic despite successful cardiopulmonary resuscitation. Both patients were found to have severe brain injuries in the postoperative period.