ABSTRACT
Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room.
Subject(s)
Heart Failure , Heart Transplantation , Adult , Humans , United States , Heart Transplantation/methods , Heart Failure/surgery , Tissue Donors , MorbidityABSTRACT
Cardiopulmonary bypass (CPB) is a complex biomechanical engineering undertaking and an essential component of cardiac surgery. However, similar to all complex bioengineering systems, CPB activities are prone to a variety of safety and biomechanical issues. In this narrative review article, the authors discuss the preventative and intraoperative management strategies for a number of intraoperative CPB emergencies, including cannulation complications (dissection, malposition, gas embolism), CPB equipment issues (heater-cooler failure, oxygenator issues, electrical failure, and tubing rupture), CPB circuit thrombosis, medication issues, awareness during CPB, and CPB issues during transcatheter aortic valve replacement.
Subject(s)
Embolism, Air , Transcatheter Aortic Valve Replacement , Humans , Cardiopulmonary Bypass/adverse effects , Emergencies , Oxygenators , Transcatheter Aortic Valve Replacement/adverse effectsABSTRACT
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 (â¼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (â¼29%) 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.
Subject(s)
Aortic Dissection , Cardiac Surgical Procedures , Aortic Dissection/diagnostic imaging , Aortic Dissection/etiology , Aortic Dissection/surgery , Aorta , Cardiac Surgical Procedures/adverse effects , Coronary Artery Bypass , Humans , Iatrogenic Disease/epidemiologySubject(s)
Antifibrinolytic Agents/administration & dosage , Antifibrinolytic Agents/adverse effects , Cardiac Surgical Procedures/trends , Postoperative Complications/chemically induced , Blood Loss, Surgical/prevention & control , Cardiac Surgical Procedures/adverse effects , Humans , Orthopedic Procedures/adverse effects , Orthopedic Procedures/trends , Postoperative Complications/blood , Postoperative Complications/prevention & controlABSTRACT
Aortic intramural hematoma (IMH) is a collection of blood within the aortic wall without an identifiable intimal tear. It belongs to the spectrum of acute aortic syndrome (AAS) which also includes aortic dissection (AD), a well-defined entity. Principles of management guided by Stanford classification is similar in both entities. But with recent advances in imaging, certain features of IMH have been identified that affect the natural course of IMH. We report a unique case of iatrogenic IMH complicating a routine coronary artery bypass graft surgery (CABG) and how imaging guided intraoperative decision making toward conservative management.
Subject(s)
Aortic Diseases/diagnostic imaging , Hematoma/diagnostic imaging , Clinical Decision-Making , Coronary Artery Bypass , Disease Management , Echocardiography , Female , Humans , Iatrogenic Disease , Intraoperative Care , Middle Aged , Practice Guidelines as TopicSubject(s)
Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Arrhythmias, Cardiac/chemically induced , Perioperative Care/methods , Perioperative Period , Thrombosis/chemically induced , Anti-Inflammatory Agents, Non-Steroidal/pharmacology , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Arrhythmias, Cardiac/epidemiology , Humans , Risk , Tachycardia/chemically induced , Tachycardia/physiopathology , Thrombosis/epidemiologyABSTRACT
Renal cell carcinoma (RCC) is the most common primary renal neoplasm and is associated with the intraluminal growth into the venous system with possible extension into the inferior vena cava or even right heart. Intraoperative pulmonary embolism is a complication of resection of RCC, which may be mitigated by the use of the cardiopulmonary bypass with or without deep hypothermic circulatory arrest. We present a case of unexpected pulmonary embolism diagnosed during RCC surgery. The case highlights the central importance of intraoperative transesophageal echocardiography use and the need for proper preoperative planning for the use of cardiopulmonary bypass.