Massive septic pulmonary embolism from infective endocarditis obstructing the right pulmonary artery: a case report.

Infective endocarditis (IE) is a relatively rare but life-threatening condition with potential complications such as valve dysfunction, abscess formation, development of penetrating lesions and embolization of septic material. In this case report, we describe the case of a 56-year-old with IE involving the tricuspid valve and resulting in near total occlusion of the right pulmonary artery due to embolization of a massive piece of septic material. While embolization of septic material is well documented, associated occlusion of the right pulmonary artery is rare.

Infective endocarditis (IE) is a rare but life-threatening condition with potential complications such as heart valve dysfunction, formation of collections of infected material, development of defects in the heart, and the travel of infected material causing blockages. In this case report, we describe the case of a 56-year-old with IE involving one of the heart valves and resulting in near total blockage of one of the main blood vessels to the lungs due to the dislodgement of a large piece of infected material. While dislodgement and travel of infected material is well documented, associated blockages of the main arteries is rare.

Right ventricular ejection fraction derived from intraoperative three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging.

PURPOSE: Right ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI. METHODS: We recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values. RESULTS: Twenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of -53 mL (95% confidence interval [CI], -80 to 26) and -21 mL (95% CI, -34 to -9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of -4% (95% CI, -8 to 1). Results were unchanged after excluding MRIs older than 180 days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively. CONCLUSIONS: Intraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.

RéSUMé: OBJECTIF: L'évaluation du ventricule droit (VD) est essentielle pendant la chirurgie cardiaque. L'évaluation traditionnelle consiste en une estimation visuelle et une mesure de paramètres validés. L'imagerie par résonance magnétique cardiaque (IRMc) est l'étalon-or pour l'analyse du VD, et l'échocardiographie transthoracique tridimensionnelle (3D) est validée par rapport cette modalité. Notre objectif était de démontrer que l'évaluation peropératoire du VD par l'échocardiographie transœsophagienne (ETO) était faisable et pouvait générer des résultats en corrélation avec l'IRMc. MéTHODE: Nous avons recruté des patient·es de chirurgie cardiaque ayant bénéficié d'une IRMc au cours des douze mois préopératoires précédents. Un protocole anesthésique a été suivi avant la sternotomie et un ensemble de données 3D sur le VD a été acquis. Nous avons utilisé le système TOMTEC 4D RV-Function pour calculer le volume télédiastolique (VTD), le volume télésystolique (VTS) et la fraction d'éjection (FE). Nous avons comparé ces données avec les valeurs correspondantes obtenues à l'IRM. RéSULTATS: Vingt-cinq personnes ont été incluses. Les valeurs de VTD et VTS obtenues à l'échocardiographie transœsophagienne différaient des mesures obtenues par IRM avec un biais moyen de ­53 mL (intervalle de confiance [IC] à 95 %, ­80 à 26) et ­21 mL (IC 95 %, ­34 à ­9). La FE obtenue par échocardiographie transœsophagienne ne différait pas significativement, avec un biais moyen de ­4 % (IC 95 %, ­8 à 1). Les résultats étaient inchangés après l'exclusion des IRM réalisés plus de 180 jours auparavant. Les coefficients de corrélation pour le VTD, le VTS et la FE étaient r = 0,85, 0,91 et 0,80, respectivement. Les coefficients de corrélation interclasse pour le VTD, le VTS et la FE étaient de 0,86, 0,89 et 0,96, respectivement. CONCLUSION: L'ETO peropératoire sous-estime les mesures du VD, du VTD et du VTS par rapport à l'IRMc en raison de facteurs d'analyse, d'anesthésie et de ventilation. La FE a montré une faible différence moyenne, et toutes les valeurs ont montré une forte corrélation avec l'IRM. La reproductibilité et la faisabilité étaient excellentes et une utilisation accrue dans la pratique clinique devrait être envisagée.

Canadian recommendations for training and performance in basic perioperative point-of-care ultrasound: recommendations from a consensus of Canadian anesthesiology academic centres.

Point-of-care ultrasound (POCUS) uses ultrasound at the bedside to aid decision-making in acute clinical scenarios. The increased use of ultrasound for regional anesthesia and vascular cannulation, together with more anesthesiologists trained in transesophageal echocardiography have contributed to the widespread use of POCUS in perioperative care. Despite the support of international experts, the practice of POCUS in perioperative care is variable as Canadian guidelines for anesthesiologists do not currently exist. Using a Delphi process of online surveys and a face-to-face national Canadian meeting, we developed a consensus statement for basic POCUS (bPOCUS) performance and training with a group of national experts from all Canadian universities. The group of experts consisted of 55 anesthesiologists from 12 Canadian universities considered local leaders in the field. An initial exploratory online survey of 47 statements was conducted. These statements were derived from previous generic guidelines or consensus conferences, or were based on current literature. Fourteen statements reached full consensus, 19 had 90-100% agreement, and 14 had less than 90% agreement. Eight new statements were proposed during the national meeting, and all statements without full agreement were discussed. A second online survey included 42 modified or new statements. From this second survey, 16 statements obtained full consensus, 39 had very good agreement, and one had good agreement. The final document includes 56 statements that define the scope of practice and necessary training for perioperative bPOCUS. The statements include five bPOCUS domains: cardiac, lung, airway, gastric, and abdomen. The use of bPOCUS is evolving and will play a significant role in perioperative medicine. This consensus statement aims to define a Canadian national standard on which curricula may be based. It also provides a framework to allow further development of bPOCUS in the perioperative setting.

RéSUMé: L'échographie ciblée (POCUS) utilise l'échographie au chevet des patients pour faciliter la prise de décisions dans les situations cliniques urgentes. L'utilisation accrue de l'échographie pour l'anesthésie régionale et la cannulation vasculaire, ainsi que l'augmentation du nombre d'anesthésologistes formés à l'échocardiographie transesophagienne, ont contribué à l'utilisation généralisée de l'échographie ciblée dans les soins périopératoires. Malgré son endossement par des experts internationaux, la pratique de l'échographie ciblée en soins périopératoires est variable, car il n'existe pas, à l'heure actuelle, de lignes directrices canadiennes destinées aux anesthésiologistes. À l'aide d'un processus Delphi de sondages en ligne et d'une réunion nationale canadienne en personne, un groupe d'experts nationaux provenant de toutes les universités canadiennes a élaboré une déclaration consensuelle pour la formation de base en et l'exécution de l'échographie ciblée (bPOCUS). Le groupe d'experts était composé de 55 anesthésiologistes issus de 12 universités canadiennes considérés comme des chefs de file locaux dans le domaine. Un premier sondage exploratoire en ligne comportant 47 énoncés a été réalisé. Ces énoncés étaient dérivés de lignes directrices antérieures ou de conférences consensuelles, ou étaient fondés sur la littérature actuelle. Quatorze énoncés ont obtenu un consensus complet, 19 ont atteint un taux de 90 à 100 %, et 14 ont obtenu moins de 90 % d'accord. Huit nouveaux énoncés ont été proposés au cours de la réunion nationale, et tous les énoncés n'ayant pas obtenu d'accord complet ont été discutés. Un deuxième sondage en ligne comprenait 42 énoncés modifiés ou nouveaux. Dans ce deuxième sondage, 16 énoncés ont obtenu un consensus total, 39 un très bon accord et un énoncé un bon accord. Le document final comporte 56 énoncés qui définissent le champ de pratique et la formation nécessaire pour l'échographie ciblée périopératoire de base. Les énoncés portent sur cinq domaines de l'échographie ciblée de base : échographie cardiaque, pulmonaire, des voies respiratoires, gastrique et abdominale. L'utilisation de l'échographie ciblée de base évolue et jouera un rôle important en médecine périopératoire. Cette déclaration consensuelle vise à définir une norme nationale canadienne sur laquelle les programmes d'études pourront s'appuyer. Elle fournit également un cadre pour encourager le développement ultérieur de l'échographie ciblée de base dans un contexte périopératoire.

Outcomes of Solo Smart valve in a single-center experience of 270 patients.

BACKGROUND: The Solo Smart pericardial aortic valve has been widely used in Europe as an option for aortic valve replacement (AVR). We are reporting early and midterm clinical outcomes of AVR with the Solo Smart valve in a single North America center. METHODS: This is a retrospective study of 270 consecutive patients who had AVR at Mazankowski Alberta Heart Institute from February 2011 to March 2015. Follow-up and echocardiographic data were collected retrospectively from electronic and paper charts. Univariate and multivariate analysis were performed to evaluate the results. RESULTS: The mean age was 71.2±10.0 years, 67.4% were male, and 79.3% had combined procedures. Mean STS Score was 4.18±3.91. Early mortality was 3.7% for the entire group and 0% for isolated AVR group. Mean cross-clamp time for isolated AVR and AVR with concomitant procedure was 70.8±12.7 min and 117.0±45.0 min, respectively. Permanent pacemaker implantation was necessary in 2.2% of patients. Echocardiography demonstrated a reduction in mean gradients from 40.8±17.4 mmHg to 7.6±3.7 mmHg and peak gradient from 72.5±48.8 mmHg to 15.5±7.5 mmHg. The 1-, 3-, and 5-year overall survival was 93.0%, 86.5% and 75.9%, respectively. At 5 years, freedom from valve-related death was 92.4%, freedom from structural valve deterioration and freedom from aortic valve reoperation were 96.4% and 98%, respectively. CONCLUSIONS: The Solo Smart valve is safe and has excellent hemodynamic performance. Aortic valve reoperation and rates of valve-related adverse events during midterm follow-up were low.

Aorto-Right Atrial Fistula After Sutureless Valve Implantation.

Aortic valve replacement with sutureless valves has many potential applications including in redo surgery, minimally invasive scenarios, and heavily calcified aortic roots. Herein we report a case of the development of an aorto-right atrial fistula after replacement of a Medtronic Freestyle stentless subcoronary bioprosthesis (Medtronic Inc, Minneapolis, MN) with a Perceval sutureless valve (LivaNova PLC, London, UK). This eventually necessitated repair with repeat surgery and aortic valve replacement with a stented valve. For patients with failing stentless bioprostheses returning for reintervention, we suggest removal of only Freestyle leaflet tissue without supra-annular debridement to avoid weakening of the native root tissue.

A case of acute respiratory distress syndrome responsive to methylene blue during a carcinoid crisis.

PURPOSE: In a carcinoid crisis, numerous vasoactive agents, such as bradykinin precursors, serotonin, and histamine, are secreted by tumour cells. Bradykinin has been shown to increase pulmonary vascular permeability and hypotension in animal models; however, little is known about its in vivo effects or targeted pharmacotherapy in a carcinoid crisis. We describe a case of acute respiratory distress syndrome (ARDS) in a carcinoid crisis refractory to conventional antiserotonin and antihistamine therapies. CLINICAL FEATURES: A 56-yr-old male with known liver metastases and previous resection of a small intestinal carcinoid tumour in 1991 underwent successful tricuspid and pulmonary valve replacements. On postoperative day 10, he developed hypotension, a fever, leukocytosis, and flushing. His hypotension was treated with a 200 µg octreotide iv bolus followed by a 150 µg·hr(-1) infusion, vasopressin, norepinephrine, and hydrocortisone. He also required tracheal intubation for ARDS (Pa02:FI02 ratio 96). After 72 hr of broad spectrum antibiotics and no clinical improvement, antiserotonin and antihistamine therapies were augmented with cyproheptadine, ranitidine, and serial octreotide boluses with an infusion of 1,500 µg·hr(-1). These interventions improved his oxygenation (Pa02:F i 02 ratio 162) and reduced his norepinephrine requirements. Following a methylene blue bolus (1 mg·kg(-1)) and 12-hr infusion (0.5 mg·kg(-1)·hr(-1)), all vasopressors were discontinued and his oxygenation improved (Pa02:F i 02 ratio 297). CONCLUSION: In a patient with a carcinoid crisis and ARDS refractory to conventional therapies, substantial hemodynamic and oxygenation improvements were observed following methylene blue administration. This case highlights the potential pathophysiologic role of bradykinin and methylene blue as an adjunct therapeutic option in carcinoid crises.

Fasting blood glucose levels in patients presenting for elective surgery.

OBJECTIVE: The incidence of diabetes mellitus (DM) is increasing worldwide; however, its diagnosis is often delayed. Identifying patients with abnormal fasting blood glucose (FBG) levels preoperatively may have important implications for immediate and long-term outcomes. The aim of the present study was to determine the prevalence of impaired fasting glucose (IFG) and provisional diagnosis of DM (PDD) with potential risk factors in patients presenting for elective surgery. METHODS: We measured FBG in consecutive adult patients undergoing elective non-cardiac surgery from September 2006 to August 2007. Patient age, sex, body mass index, and FBG were collected in the morning of their scheduled intervention. FBG was classified according to the World Health Organization categorization. Patients with a history of DM were excluded from the final analysis. The prevalence of IFG and PDD and odds ratio for risk factors were calculated. RESULTS: Four hundred ninety-three patients without a prior diagnosis of DM were sampled; 19.3% (95 of 493) had IFG and 6.5% (32 of 493) had PDD. Male subjects had a greater risk of PDD than female subjects (odds ratio 2.5, 95% confidence interval 1.2-5.5, P = 0.017). Increased body mass index was not a risk factor for IFG or PDD. The prevalence of IFG but not of PDD had a tendency to increase with age after 40 y. CONCLUSION: More than 25% of patients without a prior diagnosis of DM presenting for elective surgery had increased FBG levels. Obtaining this information may initiate not only an earlier detection of DM in some patients but also affect acute perioperative management and outcomes.

Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation.

BACKGROUND: Management of severe ischemic mitral regurgitation remains difficult with disappointing early and intermediate-term surgical results of valve repair. METHODS AND RESULTS: Forty-four patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation underwent mitral valve repair, with or without surgical revascularization, by posterior leaflet extension with a patch of bovine pericardium and a remodeling annuloplasty. Serial echocardiography was performed preoperatively, intraoperatively, and postoperatively to assess mitral valve competence. The postoperative functional status of patients was assessed. The average Parsonnet score was 38+/-13. Thirty-day mortality was 11%, and late mortality was 14%. Mean follow-up was 38 months. The actuarial freedom from moderate or severe recurrent mitral regurgitation was 90% at 2 years, whereas 90% of patients were in New York Heart Association class I at 2 years. CONCLUSIONS: Posterior leaflet extension with annuloplasty of the mitral valve for severe type IIIb ischemic regurgitation is a safe, effective method that provides good early and intermediate-term competence of the mitral valve and therefore good functional status.

Expert consensus for training in perioperative echocardiography in the province of Quebec.

PURPOSE: Establish an expert consensus for training in perioperative echocardiography in the province of Quebec. METHODS: Cardiac anesthesiologists practicing in the province of Quebec with expertise in echocardiography were involved in the development of a multicentre expert consensus on training in perioperative echocardiography. Guidelines for training in adult echocardiography, transesophageal echocardiography and perioperative echocardiography by the American Society of Echocardiography (ASE), the American College of Cardiology (ACC) and/or the Society of Cardiovascular Anesthesiologists (SCA) were reviewed. RESULTS: A basic, advanced and director level of expertise were identified for training in perioperative echocardiography. The total number of echocardiographic examinations to achieve each of these levels of expertise remains unchanged from the 2002 ASE-SCA guidelines. However, the recommended proportion of examinations performed personally is increased in the Quebec expert consensus for both the basic and the advanced level of training to ensure proficiency in echocardiography while providing anesthesia care to the patient. A level of autonomy in perioperative echocardiography is also identified in the basic level of training as defined in the Quebec expert consensus. Maintenance of competence, certification in the perioperative transesophageal echocardiography (PTE) examination and duration of training are outlined for each of the three levels of training in the Quebec expert consensus but are not part of the recent 2002 ASE-SCA guidelines. CONCLUSION: Adequate perioperative echocardiographic training is an important aspect of cardiovascular anesthesia. The ACC, ASE and SCA guidelines for training in echocardiography were modified to reflect the expert consensus of anesthesiologists in the province of Quebec.