Factor V Deficiency (Owren's Disease) in a Patient at High Risk for Transfusion-Associated Circulatory Overload and Bleeding During Laser Lead Extraction.

Congenital factor V deficiency is an extremely rare abnormality and may be associated with significant bleeding as a result of trauma or surgery. Perioperative management primarily includes the administration of fresh frozen plasma to replace the deficient clotting factor. Acute administration of multiple blood products is a risk factor for transfusion-associated circulatory overload. Herein, the case of a 71-year-old man with an ejection fraction of 13% and a history of congenital factor V deficiency who was at risk for significant bleeding and transfusion-associated circulatory overload who underwent successful complex extraction of a right atrial pacing lead is reported.

Perioperative Management of Cardiac Implantable Electronic Devices: A Single-Center Report of 469 Interrogations.

OBJECTIVE: Anesthesiologists increasingly are involved in the perioperative management of cardiac implantable electronic devices (CIEDs). The variety of devices available and the ongoing advancements in technology, programming capabilities, and responses to conventional management (eg, magnet application) complicate the management of these devices. As an aid to this clinical challenge, this manuscript reviews 469 interrogations performed by a single cardiac anesthesiologist during a 4.5-year period to derive useful information with which to guide anesthesiologists who have chosen to pursue training in this area of perioperative care. DESIGN: Retrospective review of prospectively collected data. SETTING: Single institution, quaternary care hospital. PARTICIPANTS: Patients with CIEDs presenting for surgery; the quality assurance (QA) reports of 469 interrogations performed between May 2015 and September 2019 were reviewed. INTERVENTIONS: No intervention. MEASUREMENT AND MAIN RESULTS: The distributions of surgical procedures, device types, device manufacturers, pacing modes, rate-response sensors, special functions, and performed interventions were reviewed and analyzed. The QA reports were evaluated to identify information or experiences that demonstrated important lessons for anesthesiologists engaging in perioperative CIED management. CONCLUSIONS: This database review provides general guidance for anesthesiologists managing CIEDs in the perioperative period. Concepts germane to the operating room are emphasized.

Nontransvenous Cardiovascular Implantable Electronic Device Technology-A Review for the Anesthesiologist.

There has been a recent shift in bradycardia pacing and defibrillation therapy to leadless pacemakers and extrathoracic cardioverter-defibrillator technology due to complications associated with transvenous devices. These innovations have implications for anesthesia care, as these novel devices have design and functionality features different from transvenous devices. Current perioperative guidelines do not address management of leadless pacemakers and the subcutaneous implantable cardioverter-defibrillator, although implantation rates are increasing globally. This article addresses the features and capabilities of nontransvenous cardiac implantable electronic devices, such as the Micra and the subcutaneous implantable cardioverter-defibrillator, and provides guidance for perioperative management.

Implantable Cardioverter-Defibrillator Shock Delivered During Electroconvulsive Therapy Despite Magnet Application: A Case Report.

Electroconvulsive therapy (ECT) in a patient with an implantable cardioverter-defibrillator (ICD) presents challenges to anesthesiologists. We encountered a patient who received an inappropriate shock during ECT despite magnet application. The phenomenon provides insight into how ICDs work-how they can inappropriately detect ECT stimulation and how they deliver antitachycardia therapy. We illuminate issues related to using magnets, discuss risks associated with inappropriate ICD therapy, and provide guidance for ICD management during ECT.

Management of Pulmonary Hemorrhage Complicating Pulmonary Thromboendarterectomy.

Airway management during pulmonary thromboendarterectomy (PTE) can prove challenging, especially in the face of unexpected intraoperative pulmonary hemorrhage. Utilization of proper airway equipment on induction is crucial for the successful management of intraoperative pulmonary hemorrhage. Our case series describes the preoperative risk factors that can lead to intraoperative pulmonary hemorrhage, the preinduction airway equipment considerations for PTE, and the intraoperative management of pulmonary hemorrhage. We summarize the lessons learned at our institution from four cases of post perfusion pulmonary hemorrhage.

Incidental Discovery of an Atypical Cardiac Tumor.

Primary cardiac tumors are rare, present in roughly 0.05% of the population. Cardiac papillary fibroelastoma (CPF) is the second most common, accounting for 10% of primary cardiac tumors.[1] Most cases of CPFs are discovered incidentally on autopsy; however, they may present clinically with systemic embolization or heart failure symptoms. The recommended treatment for symptomatic CPF patients is surgical resection.[1] Treatment in asymptomatic patients remains somewhat controversial with incidentally discovered tumors presenting a clinical dilemma. We present a case of an atypically located CPF that was discovered incidentally on intraoperative transesophageal echocardiography (TEE) during a routine coronary artery bypass graft operation. This case highlights several important points for cardiac anesthesiologists. The first is the importance of performing a comprehensive intraoperative TEE. Next, this case reinforces the broad utility of TEE for evaluation of intracardiac tumors. Finally, this case demonstrates the importance of precise localization of intracardiac tumors.

Intraoperative pacemaker rate changes associated with the rest mode.

Anesthesiologists frequently are required to provide perioperative management for patients with cardiac rhythm management devices. Here, I describe a case in which, despite efforts to ensure that the anesthesia care team understood the pacemaker and its settings, unanticipated pacing events occurred that created confusion about the status of the pacemaker in a pacemaker-dependent patient. The confusion was created by a relatively new function found in many current pacemakers, a rest mode.

The crossed swords sign: insights into the dilemma of repair in bileaflet mitral valve prolapse.

BACKGROUND: The need for bileaflet repair in bileaflet mitral valve prolapse (MVP) remains controversial. Will anterior leaflet prolapse resolve with posterior leaflet repair or should both leaflets be addressed? Single-leaflet MVP produces oppositely directed mitral regurgitant jets. Some patients show two crossed jets oppositely directed from the coaptation zone. We hypothesized that these indicate bileaflet lesions requiring complex repair. METHODS: Echocardiograms and surgical reports of 52 consecutive patients with MVP undergoing surgery were reviewed. RESULTS: First, all 14 patients with two oppositely directed jets had prolapse of more than one leaflet. Each jet was related to discrete leaflet distortions causing malcoaptation. Six underwent valve replacement. Seven had both leaflets repaired. One had posterior leaflet repair and annuloplasty, with persistent mitral regurgitation requiring valve replacement. Second, 36 of 38 patients with single jets had single-leaflet MVP. One underwent replacement; all others did well with single-leaflet repair. Two patients with bileaflet MVP but only one jet did well with single-leaflet repair or annuloplasty. CONCLUSION: This crossed swords sign is an important clue to bileaflet mechanism of mitral regurgitation in MVP, associated with complex repair procedures. Thus, it provides a clue in the dilemma of bileaflet versus single-leaflet repair.

Intraoperative transesophageal echocardiography in the early detection of acute tamponade after laser extraction of a defibrillator lead.

Laser-assisted intracardiac lead extraction is associated with a 1%-2% incidence of pericardial tamponade. Because of this risk, many of these procedures are being performed in an operating room with a cardiac surgeon immediately available. Transesophageal echocardiography is a useful intraoperative monitor during these procedures.