Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Factors which predict safe extubation in the operating room following cardiac surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. METHODS: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co-morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re-exploration, surgical and OR times, and ICU and hospital lengths of stay. RESULTS: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off-pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off-bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high-risk procedures (2.5%). CONCLUSIONS: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR.

Transesophageal echocardiography after contrast-enhanced CT angiography in the diagnosis of type A aortic dissection.

Contrast-enhanced CT angiography (CTA) currently is considered the diagnostic modality of choice in the diagnosis of acute type A aortic dissection. However, pitfalls associated with acquisition and interpretation of CTA images may result in misdiagnosis. We present examples of false-positive and false-negative interpretations of CTA in emergency situations that underline the importance of intraoperative preincision transesophageal echocardiography (TEE) in the diagnosis and management of this highly lethal entity.

Pulmonary Perfusion and Ventilation during Cardiopulmonary Bypass Are Not Associated with Improved Postoperative Outcomes after Cardiac Surgery.

OBJECTIVES: Clinical trials of either pulmonary perfusion or ventilation during cardiopulmonary bypass (CBP) are equivocal. We hypothesized that to achieve significant improvement in outcomes both interventions had to be concurrent. DESIGN: Retrospective case-control study. SETTINGS: Major academic tertiary referral medical center. PARTICIPANTS: Two hundred seventy-four consecutive patients who underwent open heart surgery with CBP 2009-2013. INTERVENTIONS: The outcomes of 86 patients who received pulmonary perfusion and ventilation during CBP were retrospectively compared to the control group of 188 patients. MEASUREMENTS AND MAIN RESULTS: Respiratory complications rates were similar in both groups (33.7 vs. 33.5%), as were the rates of postoperative pneumonia (4.7 vs. 4.3%), pleural effusions (13.9 vs. 12.2%), and re-intubations (9.3 vs. 9.1%). Rates of adverse postoperative cardiac events including ventricular tachycardia (9.3 vs. 8.5%) and atrial fibrillation (33.7 vs. 28.2%) were equivalent in both groups. Incidence of sepsis (8.1 vs. 5.3%), postoperative stroke (2.3 vs. 2.1%), acute kidney injury (2.3 vs. 3.7%), and renal failure (5.8 vs. 3.7%) was likewise comparable. Despite similar transfusion requirements, coagulopathy (12.8 vs. 5.3%, p = 0.031) and the need for mediastinal re-exploration (17.4 vs. 9.6%, p = 0.0633) were observed more frequently in the pulmonary perfusion and ventilation group, but the difference did not reach the statistical significance. Intensive care unit (ICU) and hospital stays, and the ICU readmission rates (7.0 vs. 8.0%) were similar in both groups. CONCLUSION: Simultaneous pulmonary perfusion and ventilation during CBP were not associated with improved clinical outcomes.

An Adult Patient with Fontan Physiology: A TEE Perspective.

Fontan and Baudet described in 1971 the separation of the pulmonary and systemic circulations resulting in univentricular physiology. The evolution of the Fontan procedure, most notably the substitution of right atrial-to-pulmonary artery anastomosis with cavopulmonary connections, resulted in significantly improved late outcomes. Many patients survive well into adulthood and are able to lead productive lives. While ideally under medical care at specialized centers for adult congenital cardiac pathology, these patients may present to the outside hospitals for emergency surgery, electrophysiologic interventions, and pregnancy. This presentation presents a "train of thought," linking the TEE images to the perioperative physiologic considerations faced by an anesthesiologist caring for a patient with Fontan circulation in the perioperative settings. Relevant effects of mechanical ventilation on pulmonary vascular resistance, pulmonary blood flow and cardiac preload, presence of coagulopathy and thromboembolic potential, danger of abrupt changes of systemic vascular resistance and systemic venous return are discussed.

A silent patent ductus arteriosus: a culprit or an innocent bystander?

A 4-mm patent ductus arteriosus (PDA) was serendipitously diagnosed during intraoperative transesophageal echocardiography for a noncardiac procedure in an obese adult patient with a history of decreased exercise tolerance and dyspnea, despite a negative preoperative transthoracic examination. This uncommon event poses questions regarding the relevance of this finding to the differential diagnosis of dyspnea in an obese adult with a negative transthoracic echocardiography study, given the unknown prevalence of this pathology and the absence of consensus regarding the clinical management.