Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review.

BACKGROUND: Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications. METHODS: In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients. RESULTS: After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006). CONCLUSIONS: We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Radiation Exposure of Operators Performing Transesophageal Echocardiography During Percutaneous Structural Cardiac Interventions.

BACKGROUND: Transesophageal echocardiography operators (TEEOP) provide critical imaging support for percutaneous structural cardiac intervention procedures. They stand close to the patient and the associated scattered radiation. OBJECTIVES: This study sought to investigate TEEOP radiation dose during percutaneous structural cardiac intervention. METHODS: Key personnel (TEEOP, anesthetist, primary operator [OP1], and secondary operator) wore instantly downloadable personal dosimeters during procedures requiring TEE support. TEEOP effective dose (E) and E per unit Kerma area product (E/KAP) were calculated. E/KAP was compared with C-arm projections. Additional shielding for TEEOP was implemented, and doses were measured for a further 50 procedures. Multivariate linear regression was performed to investigate independent predictors of radiation dose reduction. RESULTS: In the initial 98 procedures, median TEEOP E was 2.62 µSv (interquartile range [IQR]: 0.95 to 4.76 µSv), similar to OP1 E: 1.91 µSv (IQR: 0.48 to 3.81 µSv) (p = 0.101), but significantly higher than secondary operator E: 0.48 µSv (IQR: 0.00 to 1.91 µSv) (p < 0.001) and anesthetist E: 0.48 µSv (IQR: 0.00 to 1.43 µSv) (p < 0.001). Procedures using predominantly right anterior oblique (RAO) and steep RAO projections were associated with high TEEOP E/KAP (p = 0.041). In a further 50 procedures, with additional TEEOP shielding, TEEOP E was reduced by 82% (2.62 µSv [IQR: 0.95 to 4.76] to 0.48 µSv [IQR: 0.00 to 1.43 µSv] [p < 0.001]). Multivariate regression demonstrated shielding, procedure type, and KAP as independent predictors of TEEOP dose. CONCLUSION: TEE operators are exposed to a radiation dose that is at least as high as that of OP1 during percutaneous cardiac intervention. Doses were higher with procedures using predominantly RAO projections. Radiation doses can be significantly reduced with the use of an additional ceiling-suspended lead shield.

Percutaneous Transvenous Mitral Valve-in-Valve Implantation Using Commercially Available Transcatheter Valve. First Australian Experience.

In patients with a degenerative mitral bioprosthesis and prohibitive surgical risk there is emerging evidence for the feasibility of valve-in-valve procedures via a percutaneous transvenous transseptal approach. This paper describes the first time this procedure has been performed in Australia.

Clinical application of point of care transthoracic echocardiography in perioperative period.

Transthoracic echocardiography (TTE) has established its role for diagnosis and management in cardiology and is used by various other specialities in medicine, but it is not routinely practised by anaesthesiologists in the perioperative period including the pre-admission clinic/outpatient clinic. The last decade has seen the emerging role of anaesthesiologist as a 'Perioperative physician'. This review article highlights the potential role and clinical utility, education, teaching and limitations of point of care (POC) TTE modality in perioperative care. Various echocardiography society guidelines and endorsements, diagnostic protocols and limitations are enumerated. This article also discusses some of the possibilities for future education and development related to clinical ultrasound including POC TTE in anaesthetic training curriculum.