Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review.

Iatrogenic aortic dissection (iAD) is a relatively rare but a life-threatening complication associated with cardiac surgery. All members of the team caring for cardiac surgical patients (surgeons, perfusionists, and anesthesiologists) must be familiar with this complication to minimize its incidence and improve outcome. The present narrative review focuses on iAD occurring intraoperatively and during the early postoperative period (within 1 month) of cardiac surgery. The review also addresses iAD that occurs late (beyond 1 month) after cardiac surgery and iAD associated with other procedures. iAD occurs in about 0.06% of cases when the ascending aorta is the site of arterial cannulation, in about 0.6% when the femoral or iliac arteries are used, and in about 0.5% when the axillary or subclavian arteries are used. Mortality is estimated to be 30% but is more than double if not recognized until the postoperative period. Site of origin of dissection is most commonly the arterial inflow cannula (∼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (∼29%) and the proximal saphenous vein anastomosis site (14%). Sixty percent of cases occur during coronary artery bypass graft (CABG) surgery and 17% during aortic valve surgery with or without CABG. iAD may be somewhat less common in off-pump versus on-pump CABG but is still not very rare. Risk factors, presentation, diagnosis, and management are reviewed in detail as is the key role of the use of echocardiography in the early diagnosis of iAD and for guiding its management.

Mentoring Fellows in Adult Cardiothoracic Anesthesiology for Academic Practice in the Contemporary Era-Perspectives From Mentors Around the United States.

This special article presents perspectives on the mentoring of fellows for academic practice in adult cardiothoracic anesthesiology. A comprehensive mentoring model should address the areas of clinical care, educational expertise and exposure to scholarly activity. The additional value of educational exposure to patient safety, quality improvement and critical care medicine in this model is also explored.

Left Ventricular Outflow Tract Area Measurements by Planimetry Using Two-Dimensional Simultaneous Orthogonal Plane Imaging During Transesophageal Echocardiography.

OBJECTIVE: Calculations of the left ventricular outflow tract (LVOT) area are typically based on the assumption that the LVOT is circular. This study was conducted to determine whether simultaneous orthogonal plane imaging with tilt during two-dimensional (2D) transesophageal echocardiography provided more accurate measurements of the LVOT area than the standard method. DESIGN: The authors prospectively measured the LVOT area in 2D by (1) the standard calculation based on the diameter as viewed on the long axis, and (2) a direct measurement using planimetry of the short axis, in consecutive patients presenting for elective surgery. The authors validated the planimetric technique by obtaining three-dimensional (3D) measurements in a subset of the subjects. SETTING: An academic medical center. PARTICIPANTS: Adult surgical patients with no evidence of aortic stenosis. INTERVENTIONS: Transesophageal images were acquired by anesthesiologists certified by the National Board of Echocardiography. MEASUREMENTS AND MAIN RESULTS: Image acquisition and assessment were performed in the operating room and found to be adequate for analysis in 52 of 55 subjects. Simultaneous orthogonal plane imaging with tilt enabled long- and short-axis visualization of the LVOT. The authors found that the standard method underestimated the area by 0.78 cm(2) compared to the direct method (2D planimetry) when measured at the same beat at a similar point in the cardiac cycle. Moreover, 2D planimetry measurements were comparable to 3D planimetry measurements in the last 20 study subjects (R(2) = 0.88, p<0.0001). CONCLUSIONS: This study suggested that 2D planimetry may be more accurate than 2D diameter-based calculations.

The Feasibility of Simultaneous Orthogonal Plane Imaging with Tilt for Short-Axis Evaluation of the Pulmonic Valve by Transesophageal Echocardiography.

Simultaneous orthogonal plane imaging with tilt enables the display of two 2D, real-time images and the evaluation of structures that cannot be seen by conventional single-plane transesophageal echocardiographic (TEE) imaging. After a step-wise examination protocol, we used simultaneous orthogonal plane imaging to obtain the short-axis view of the pulmonic valve (PV) and assessed flow in both images simultaneously using color Doppler imaging in 100 consecutive patients undergoing intraoperative TEE. Our goals were to assess the ability of this technique to visualize all 3 leaflets of the PV, assess feasibility of planimetry to measure valve area, and assess flow using color Doppler imaging. All study images were obtained by anesthesiologists who are diplomates in Advanced Perioperative Transesophageal Echocardiography. All 3 leaflets of the PV were successfully visualized in the short-axis view in 65% of cases, 2 leaflets were visualized in 32% of cases, and only 1 leaflet could be imaged in 3%. The flow across the valve could be evaluated using color Doppler imaging in all cases. Planimetry for valve area was possible when all 3 leaflets were seen. It is important to inspect the PV during a routine TEE examination; however, the orientation of the PV in respect to the esophagus makes this evaluation challenging. We present a simple protocol to evaluate the PV in long-axis and short-axis views simultaneously that can potentially help evaluate for pathologies involving the PV.

Tricuspid Valve Excision Complicated by Postoperative Gerbode Defect Following Recurrent Infective Endocarditis: A Case Report.

Tricuspid valve infective endocarditis is an increasingly common sequela of the opioid epidemic. While often managed medically, certain subsets of patients will require surgical intervention, including repair, replacement, and possibly even excision. Historically, simple valvectomy was performed in instances of recidivism and reinfection; however, reoperation and replacement has become the preferred treatment in the current era. Given the increasing incidence of intravenous drug use and the increase in the number of patients presenting with recurrent infections, simple valvectomy has regained favor in recent years. In this article, we present the management of a critically ill patient with recurrent tricuspid valve endocarditis who underwent tricuspid valvectomy that was complicated by a left ventricle to right atrium fistula and discuss some of the most important perioperative issues and complications for patients who undergo tricuspid valvectomy.

Early Graft Dysfunction Following Heart Transplant: Prevention and Management.

Heart transplant can be considered as the "gold standard" treatment for end-stage heart failure, with nearly 5.7 million adults in the United States carrying a diagnosis of heart failure. According to the International Society for Heart and Lung Transplantation registry, nearly 3300 orthotopic heart transplants were performed in 2016 in North America. In spite of significant improvements in overall perioperative care of heart transplant recipients for the past few decades, the risk of 30-day mortality remains 5% to 10%, primarily related to early failure of the allograft. Early graft dysfunction (EGD) occurs within 24 hours after transplant, manifesting as left ventricular dysfunction, right ventricular dysfunction, or biventricular dysfunction. EGD is further classified into primary and secondary graft dysfunction. This review focus on describing overall incidences of EGD, potential risk factors associated with EGD, perioperative preventive measures, and various management options.

Transcatheter Aortic Valve Replacements: Current Trends and Future Directions.

Since the 1960s when the first aortic surgical aortic valve replacement (SAVR) was performed, continuous growth in the field of valvular technology has occurred. Although SAVR remains a lifesaving procedure, minimally invasive transcatheter aortic valve replacement has revolutionized and expanded aortic valve replacement to patients who were not previously SAVR candidates, increasing their quality of life and survival. Since its introduction in the United States in 2011, the technology and practice have rapidly expanded. Hybrid techniques have been developed that combine surgical access to the vasculature with valvular deployment over transcatheter systems. This literature review aims to describe the differences between the current available valve technologies, review approaches to surgical technique, discuss anesthetic considerations, and look forward to future directions, trends, and challenges.

Dilemma during ultrasound-guided internal jugular venous catheterization.

The presence of Internal Jugular Valves can pose a diagnostic and procedural challenge during ultrasound-guided cannulation. After ruling out dissection, thrombus, or ultrasound artifacts, it can still be accessed and successfully cannulated with appropriate precautions including use of Live ultrasound, positioning, use of soft-tipped catheters, and minimizing duration of catheter placement.

Unexpected presentation of a type IV laryngo-tracheo-oesophageal cleft: Anaesthetic implications of a rare case.

Laryngo-tracheo-oesophageal cleft (LTEC) is a congenital midline defect of the posterior larynx and trachea and the anterior wall of the oesophagus. Existence of these clefts may not be apparent during pre-operative evaluation. We present a rare case of a neonate initially scheduled for tracheo-oesophageal fistula repair. Unexplained air leak in spite of placement of size 4.0 mm endotracheal tube in a 2.5 kg neonate triggered extensive intra-operative evaluation of the airway anatomy via flexible and rigid bronchoscope. A type IV LTEC with an unusual anatomy was identified that was considered surgically irreparable. This case also highlights the need for a team approach and preparedness of anaesthesiologists for a difficult airway while managing such cases. Maintenance of high degree suspicion is warranted.