Challenges after the first decade of transcatheter aortic valve replacement: focus on vascular complications, stroke, and paravalvular leak.

Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2012.

Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.

Progress in perioperative echocardiography: focus on safety, clinical outcomes, 3-dimensional imaging, and education.

Gastric decompression with an orogastric tube after anesthetic induction does not appear to enhance image quality for routine cases. The insertion of a transesophageal echocardiographic (TEE) probe can cause significant upper-airway trauma, which can be minimized with rigid laryngoscopy. Limited TEE imaging without transgastric views appears to be safe and clinically adequate in patients with advanced liver disease and esophageal varices. Although esophagogastric perforation because of transesophageal echocardiography is rare, the risk is significantly higher with advanced age and female sex. The echocardiographic assessment of right ventricular function and left ventricular diastolic function can improve the prediction of atrial arrhythmias after elective lung resection. Furthermore, asymptomatic left ventricular systolic or diastolic dysfunction is an independent predictor of cardiovascular mortality and morbidity after open vascular surgery. Advances in 3D echocardiography have shown that hypertrophic cardiomyopathy frequently is associated with changes in the mitral valve complex that predispose to left ventricular outflow tract obstruction. Furthermore, 3D imaging of the mitral apparatus has highlighted the importance of the annular saddle shape and the anatomic variability in ischemic mitral regurgitation. Education in perioperative echocardiography is experiencing high demand that can be satisfied partially with simulators and Internet-based educational activities. These modalities will aid in the dissemination of echocardiography through perioperative practice.

Postoperative hemodynamic instability after simultaneous bilateral total knee arthroplasty.

OBJECTIVES: After a simultaneously performed bilateral total knee arthroplasty, our institutional clinical experience suggested that there was an alarming incidence of severe postoperative hypotension and bradycardia. We therefore performed this study to define the incidence of postoperative hemodynamic instability and identify associated risk factors. METHODS: This study involved a retrospective review of 312 consecutive patients undergoing bilateral total knee arthroplasty. The primary outcome was a hypotensive event in the postoperative period. This was defined as a systolic blood pressure of less than 85 mm Hg and/or the need for emergency postoperative medical management. Logistic regression was used to estimate odds ratios. RESULTS: The incidence of hypotensive events in the postanesthesia care unit was 17% (95% confidence interval [CI], 13%-22%). The incidence of simultaneous hypotension and bradycardia was 7% (95% CI, 4%-10%). Of all patients, 10% required emergent treatment with vasopressors or vagolytics (95% CI, 7%-13%). The performance of the operation under spinal anesthesia was an independent risk factor (odds ratio = 4.5, P < 0.01) for the development of postoperative hypotension (21%) compared with general anesthesia (5.7%). Spinal anesthesia continued to predict hypotension in multivariate modeling that controlled for confounding variables. CONCLUSIONS: Hypotension was common after bilateral total knee replacement in our series. Performance of the operation under spinal anesthesia was a significant risk factor for the development of postoperative hypotension compared with general anesthesia. General anesthesia may offer a greater margin of postoperative hemodynamic stability and perhaps safety for patients undergoing this procedure.