Anesthetic implications for robot-assisted transaxillary thyroid and parathyroid surgery: a report of twenty cases.

Gasless transaxillary robot-assisted endoscopic thyroid surgery has recently been proposed and developed in South Korea and the United States. Perianesthetic implications and their evolution for 20 patients scheduled to undergo this innovative surgical technique are presented. The anesthetic considerations focus on the length of surgery due to the learning curve, the risk of the ipsilateral arm posture, and postoperative pain evaluation and management.

Pulmonary vein isolation using a single size cryoballoon chosen according to transesophageal echocardiography information.

BACKGROUND: Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter is a new technique for atrial fibrillation (AF) ablation. Previous studies used computer tomography (CT) or magnetic resonance imaging (MRI) scan to determine the pulmonary vein (PV) diameter and anatomy for choosing the CB size. We evaluated pre-ablation transoesophageal-echocardiography (TEE) as an alternative to CT/MRI scan in patients undergoing AF ablation for determining the appropriate size of the CB. METHODS: Fifty-five consecutive patients (men=43, women=12) with a mean age of 63 ± 12.5 years, and with drug-refractory paroxysmal AF (34 patients) or persistent AF (21 patients) were included in this prospective study. All patients underwent pre-ablation TEE. RESULTS: Hypertension was present in 19 patients (34%). Mean anterior-posterior left atrium diameter was 45.1 ± 8.9 mm. In total, 217 PV were targeted using a single 23-mm (n=14) or 28-mm (n=40) CB catheter chosen according to TEE-obtained measurements. PVI was achieved in 195 PV (90%). Mean number of CB applications per patient was 9.8 ± 2.1 (range 8-14). Mean procedure duration and fluoroscopy times were 131 ± 27 min (90-190 min) and 36 ± 12 min (22-66 min) respectively. Phrenic nerve palsy occurred in 3 patients (5.4%) and was transient (<1 month) in all of them. CONCLUSION: This study suggests that TEE is an easily available and effective tool to select the size of the CB for PVI according to evaluated PV diameters and anatomy.

Reduction of procedure duration and radiation exposure with a dedicated inner lumen mapping catheter during pulmonary vein cryoablation.

BACKGROUND: The Achieve catheter (AC; Medtronic-CryoCath, Pointe-Claire, Canada) is a circular mapping catheter introduced through the lumen of the cryoballoon (CB) catheter which is safe and effective to both navigate the CB to the pulmonary veins (PV) and allow PV potential recording during PV cryoablation. The aim of this study was to evaluate the impact of the use of the AC on procedural outcomes. METHODS: Sixteen consecutive patients (14 men) underwent AC-guided PV isolation (PVI) for drug-refractory paroxysmal atrial fibrillation (AF; AC group). Clinical and procedural data of these patients were compared to those obtained from 16 consecutive patients who had undergone PVI for paroxysmal AF with the regular "single transseptal" approach (control group). RESULTS: Clinical characteristics of patients enrolled in both groups did not differ significantly. In the AC group, 64 PVs were targeted using a single 28-mm (n = 13) or 23-mm (n = 3) CB catheter with PVI achieved in 62 PVs (97%). In the control group, 66 PVs were targeted using a single 28-mm (n = 12) or 23-mm (n = 4) CB catheter with PVI achieved in 62 PVs (94%), (P = non-significant for CB size and PVI rate). Procedure duration and fluoroscopy time were significantly reduced in AC group compared to control group (96.6 ± 26 minutes vs 125.9 ± 25 minutes, P = 0.003 and 24.4 ± 10 minutes vs 32.6 ± 11 minutes, P = 0.04, respectively). CONCLUSION: The use of the AC significantly reduced procedure duration and radiation exposure during PVI with the CB technique.

Slow pathway elimination for atrioventricular nodal reentrant tachycardia with the 8-mm tip cryoablation catheter: an 18-month follow-up study.

PURPOSE: The 9-French 8-mm tip cryoablation catheter confers a high rate of acute slow pathway (SP) elimination and an acceptable short-term outcome in patients with atrioventricular nodal reentrant tachycardia (AVNRT). The aim of this study was to investigate the long-term outcome of patients treated with this electrode in this indication. METHODS: Eighty-two patients (female = 52) with a mean age of 54.9 ± 17.7 years underwent SP elimination for typical AVNRT with the 8-mm tip cryocatheter in our institution between November 2009 to June 2012. Clinical and procedural characteristics were prospectively collected. RESULTS: Acute procedural success defined as AVNRT non-inducibility at the end of the procedure was obtained in 81/82 patients (98.7 %). Mean procedure duration and fluoroscopy time were 74.4 ± 28.7 min (range, 35-160 min) and 8.7 ± 5.3 min (range, 2-26 min), respectively. Mean number of energy applications was 4.0 ± 2.4 (range, 2-15). No permanent atrioventricular block was observed. Transient atrioventricular block occurred in 12 patients (14.6 %). Traumatic fast pathway conduction block occurred in one patient before cryoenergy delivery. Using an intention-to-treat analysis, 78 patients (95.1 %) remained free of AVNRT recurrence during a mean follow-up of 17.8 ± 9.3 months. CONCLUSIONS: This study confirmed that the 8-mm tip cryocatheter is both safe and highly effective for SP conduction elimination in patients with AVNRT and demonstrated a low recurrence rate during a long-term follow-up.

Indications for the gasless transaxillary robotic approach to thyroid surgery: experience of forty-seven procedures at the american hospital of paris.

BACKGROUND: Thyroid surgery is in a state of evolution from traditional open approaches to novel robotic techniques. The gasless transaxillary approach to thyroid surgery is effective in the management of thyroid cancer, and complications after robotic thyroidectomy are no higher than experienced after open or endoscopic techniques. The transaxillary robotic approach also avoids an anterior neck scar. This paper presents what the authors believe to be the largest cohort of patients reported in Europe undergoing gasless transaxillary robotic thyroid surgery, with the aim of defining the indications for this procedure. METHODS: Forty-six patients underwent robotic thyroid surgery via the transaxillary approach and were enrolled in this study between March 2010 and September 2012. All patients were operated on by one surgeon at one clinical center. Reviewed data included patient characteristics, pathological characteristics, extent of surgery and postoperative complications. The mean follow-up time was 7.29 months. RESULTS: Forty-six patients underwent 47 procedures, the average age of the patients was 43 years and the male to female ratio was 1:22. Undertaken were 30 lobectomies, 3 subtotal thyroidectomies, 13 total thyroidectomies and 1 totalization. One case was converted to an open procedure. The ratio of malignant to benign disease was 1:6.67 (6:40 cases) and analysis of the surgical specimens showed 6 follicular lesions, 24 follicular adenomas, 3 colloid lesions, 1 case of thyroiditis/lymphatic lesion, 3 adenomatoid lesions, 3 oncocytic adenomas, 3 papillary cancers and 3 microcapillary cancers. The overall average size of an individual specimen removed was 45.40 ± 28.95 cm(3) (range 5-160, n = 47) and the average largest diameter of the lesion removed was 3.72 ± 0.95 cm (range 1.4-6.0, n = 47). Postoperatively, there were 5 recurrent laryngeal nerve injuries (4 transient), 2 transient brachial plexopathies, 1 case of postoperative dysphagia and 1 of collection of blood at the site of surgery. There were no cases of disease recurrence at follow-up. CONCLUSIONS: The gasless robotic transaxillary approach to thyroid surgery has been predicted to become a standard technique. It has been shown to be efficacious in the management of thyroid cancer with lateral neck metastases; however, more data relating to oncological safety in long-term follow-up is required. This intervention is also appropriate for benign thyroid disease including Graves' disease. To achieve consistently successful results, careful patient selection is fundamental in terms of patient characteristics and the anatomical aspects of the lesion. This is especially important with a geographical expansion to include North America and Europe. The excellent cosmetic results of this procedure make it ideal for patients who have esthetic concerns regarding particular difficulties with healing; however, in common with all new surgical procedures, further evidence must be sought to confirm its indications over time.

Comparative cardiac effects of terlipressin, vasopressin, and norepinephrine on an isolated perfused rabbit heart.

BACKGROUND: Terlipressin, a synthetic analog of arginine-vasopressin (AVP), has been proposed as an effective vasopressive therapy in catecholamine-resistant vasodilatory shock. Although beneficial effects of terlipressin on systemic arterial pressure have been clearly demonstrated, its intrinsic effects on coronary circulation and myocardial performances remain unknown. METHODS: The authors compared the coronary and myocardial effects of terlipressin (1-100 nM, n = 10), AVP (10-1000 pM, n = 10), and norepinephrine (1-100 nM, n = 10) on an erythrocyte-perfused isolated rabbit heart. The cardiac effects of terlipressin were also assessed in erythrocyte-perfused hearts in which the myocardial oxygen delivery was maintained constant and buffer-perfused hearts. Finally, the cardiac effects of terlipressin and AVP were studied in hearts pretreated by [d(CH2)5Tyr(Me)]AVP (0.1 microM), a selective V1a receptor antagonist. RESULTS: Norepinephrine induced a biphasic coronary effect associated with a concentration-dependent increase in myocardial performances. AVP and terlipressin significantly decreased coronary blood flow and impaired myocardial performances from 30 pM and 30 nM, respectively (P < 0.05). The cardiac side-effects of terlipressin were confirmed in buffer-perfused hearts but the maintenance of a constant myocardial oxygen delivery constant abolished its effects on myocardial performances. The cardiac effects induced by terlipressin and AVP were nearly completely abolished on hearts pretreated by [d(CH2)5Tyr(Me)]AVP. CONCLUSIONS: On isolated rabbit heart, terlipressin induced a coronary vasopressor effect and in turn myocardial depression only at supratherapeutic concentrations (> or =30 nM). Its effects are mainly mediated via V1a receptors. However, these potential negative side effects on the heart were less pronounced than were those of AVP.

Routine use of bilateral skeletonized internal thoracic artery grafts in middle-aged diabetic patients.

BACKGROUND: The purpose of this study was to determine whether middle-aged diabetic patients aged less than 70 years could have routine use of bilateral skeletonized internal thoracic artery grafting without an increased surgical risk. METHODS: Between January 1997 and December 2003, 712 consecutive patients aged less than 70 years underwent bilateral internal thoracic artery grafting. Among these, 164 were diabetic and underwent bilateral internal thoracic artery grafting without other preoperative selection than age. The postoperative results of these 164 nonselected consecutive diabetic patients were compared to these of the 548 nondiabetic patients. RESULTS: The operative mortality rate was 4.3% (7 patients) in the diabetic group and 2.4% (13 patients) in the nondiabetic group (p = not significant [NS]). Deep sternal wound infection was observed in 2 patients (1.1%) in the diabetic group and in 6 patients (1.2%) in the nondiabetic group (p = NS). There were no significant difference in the morbidity rate between the two groups except for renal failure without dialysis (6.7% in the diabetic group vs 2.0% in the nondiabetic group, p < 0.01). CONCLUSIONS: Routine use of bilateral internal thoracic artery grafting was performed in nonselected middle-aged diabetic patients without increased morbidity. The low rate of deep wound infections could be related to the skeletonized technique of internal thoracic artery harvesting.

Predictive performance and variability of the cardiac anesthesia risk evaluation score.

BACKGROUND: The Cardiac Anesthesia Risk Evaluation (CARE) score, a simple Canadian classification for predicting outcome after cardiac surgery, was evaluated in 556 consecutive patients in Paris, France. The authors compared its performance to those of two multifactorial risk indexes (European System for Cardiac Operative Risk Evaluation [EuroSCORE] and Tu score) and tested its variability between groups of physicians (anesthesiologists, surgeons, and cardiologists). METHODS: Each patient was simultaneously assessed using the three scores by an attending anesthesiologist in the immediate preoperative period. In a blinded study, the CARE score category was also determined by a cardiologist the day before surgery, by a surgeon in the operating room, and by a second anesthesiologist at arrival in intensive care unit. Calibration and discrimination for predicting outcomes were assessed by goodness-of-fit test and area under the receiver operating characteristic curve, respectively. The level of agreement of the CARE scoring between the three physicians was then assessed. RESULTS: The calibration analysis revealed no significant difference between expected and observed outcomes for the three classifications. The areas under the receiver operating characteristic curves for mortality were 0.77 with the CARE score, 0.78 with the EuroSCORE, and 0.73 with the Tu score (not significant). The agreement rate of the CARE scoring between two anesthesiologists, between anesthesiologists and surgeons, and between anesthesiologists and cardiologists were 90%, 83%, and 77%, respectively. CONCLUSIONS: Despite its simplicity, the CARE score predicts mortality and major morbidity as well the EuroSCORE. In addition, it remains devoid of significant variability when used by groups of physicians of different specialties.

Remifentanil induces systemic arterial vasodilation in humans with a total artificial heart.

BACKGROUND: To assess intrinsic vascular effects of remifentanil, increased concentrations were infused in critically ill patients with a total artificial heart. METHODS: In the early postoperative period after implantation of a total artificial heart, nine ventilated patients requiring short general anesthesia were included in this study. After anesthesia was induced with 0.3 mg/kg intravenous etomidate, the artificial heart settings were modified to render cardiac output "preload-independent." While maintenance of anesthesia was ensured by a continuous infusion of etomidate, increased concentrations of remifentanil (from 0.1 to 1 microg x kg(-1) x min(-1)) were infused in steps of 5 min under hemodynamic monitoring, including left and right atrial pressures, systemic and pulmonary arterial pressures, and left and right cardiac indices. The invasive procedure was started under the highest concentration of remifentanil tolerated by the patient. Infusion of remifentanil was stopped at the end of the invasive procedure, while etomidate infusion was maintained. New hemodynamic measurements were performed at the end of the 12-min recovery period. RESULTS: Remifentanil produced a dose-dependent and significant decrease in systemic arterial pressure and vascular resistances (n = 9) from a concentration of 0.25 microg x kg(-1) x min(-1). No significant changes were observed on pulmonary vascular resistances (n = 6). Neither right (n = 9) nor left (n = 6) atrial pressures were affected by remifentanil infusion. Hemodynamic variables returned to baseline value over the 12-min recovery period. CONCLUSIONS: In humans with a total artificial heart, remifentanil induces a systemic arterial vasodilation without significant effect on the capacitance vessels.

Amplification by hyperoxia of coronary vasodilation induced by propofol.

UNLABELLED: We tested the hypothesis that in vitro coronary and myocardial effects of propofol (10-300 microM) should be significantly modified in an isolated and erythrocyte-perfused rabbit heart model in the absence (PaO(2) = 137 +/- 16 mm Hg, n = 12) or in the presence (PaO(2) = 541 +/- 138 mm Hg, n = 12) of hyperoxia. The induction of hyperoxia provoked a significant coronary vasoconstriction (-13% +/- 7%). Propofol induced increased coronary vasodilation in the presence of hyperoxia. Because high oxygen tension has been reported to induce a coronary vasoconstriction mediated by the closure of adenosine triphosphate-sensitive potassium channels, we studied the effects of propofol in 2 additional groups of hearts (n = 6 in each group) pretreated by glibenclamide (0.6 microM) and cromakalim (0.5 microM) in the absence and presence of hyperoxia, respectively. The pretreatment by glibenclamide induced a coronary vasoconstriction (-16% +/- 7%) which did not affect propofol coronary vasodilation. The pretreatment by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. Propofol induced a significant decrease in myocardial performance for a concentration >100 micro M both in the absence and presence of hyperoxia. We conclude that propofol coronary vasodilation is amplified in the presence of hyperoxia. This phenomenon is not explained by the previous coronary vasoconstriction induced by glibenclamide. However, the pretreatment of hearts by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. The myocardial effects of propofol were not affected by the presence of hyperoxia. IMPLICATIONS: Propofol induced a coronary vasodilation that was amplified in the presence of hyperoxia. This phenomenon does not seem to be related to previous coronary vasoconstriction. The myocardial effects of propofol were not significantly modified in the presence of hyperoxia.

Terlipressin versus norepinephrine to correct refractory arterial hypotension after general anesthesia in patients chronically treated with renin-angiotensin system inhibitors.

BACKGROUND: Terlipressin, a precursor that is metabolized to lysine-vasopressin, has been proposed as a drug for treatment of intraoperative arterial hypotension refractory to ephedrine in patients who have received long-term treatment with renin-angiotensin system inhibitors. The authors compared the effectiveness of terlipressin and norepinephrine to correct hypotension in these patients. METHODS: Among 42 patients scheduled for elective carotid endarterectomy, 20 had arterial hypotension following general anesthesia that was refractory to ephedrine. These patients were the basis of the study. After randomization, they received either 1 mg intravenous terlipressin (n = 10) or norepinephrine infusion (n = 10). Beat-by-beat recordings of systolic arterial blood pressure and heart rate were stored on a computer. The intraoperative maximum and minimum values of blood pressure and heart rate, and the time spent with systolic arterial blood pressure below 90 mmHg and above 160 mmHg, were used as indices of hemodynamic stability. Data are expressed as median (95% confidence interval). RESULTS: Terlipressin and norepinephrine corrected arterial hypotension in all cases. However, time spent with systolic arterial blood pressure below 90 mmHg was less in the terlipressin group (0 s [0-120 s] vs. 510 s [120-1011 s]; P < 0.001). Nonresponse to treatment (defined as three boluses of terlipressin or three changes in norepinephrine infusion) occurred in zero and eight cases (P < 0.05), respectively. CONCLUSIONS: In patients who received long-term treatment with renin-angiotensin system inhibitors, intraoperative refractory arterial hypotension was corrected with both terlipressin and norepinephrine. However, terlipressin was more rapidly effective for maintaining normal systolic arterial blood pressure during general anesthesia.

Brachial plexus nerve block exhibits prolonged duration in the elderly.

BACKGROUND: Upper limb trauma occurs frequently in elderly patients for whom peripheral nerve blocks are often preferred for anesthesia. The characteristics of such regional blocks have, however, never been described in an elderly population. Therefore, the authors assessed prospectively the onset and duration of upper extremity peripheral nerve block (the mid-humeral block) in elderly and young patients undergoing emergency upper extremity surgery. METHODS: Consecutive patients aged > 70 yr or < 70 yr received a mid-humeral block with a small volume of ropivacaine, 0.75%. Five milliliters was injected onto each of the musculocutaneous, radial, ulnar, and median nerves. Time to complete sensory and motor block and durations of complete sensory and motor block were assessed. Results are shown as median and its 95% confidence interval. RESULTS: Median ages were 77 yr (95% CI, 72-81 yr) and 39 yr (95% CI, 27-46 yr) in the two groups. Both groups had similar times to complete sensory blockade. The elderly group had longer durations of complete sensory (390 min [range, 280-435 min] vs.150 min [range, 105-160 min]; P< 0.05) and motor (357 min [range, 270-475 min] vs. 150 min [range, 90-210 min]; P< 0.05) blockade. Duration of complete sensory block was significantly correlated with age (rho = 0.56; P< 0.05). CONCLUSIONS: Age is a major determinant of duration of complete motor and sensory blockade with peripheral nerve block, perhaps reflecting increased sensitivity to conduction failure from local anesthetic agents in peripheral nerves in the elderly population.

Incidence, risk factors, and prognosis of a moderate increase in plasma creatinine early after cardiac surgery.

OBJECTIVE: To evaluate the incidence and prognosis of a moderate increase in serum creatinine early after cardiac surgery. DESIGN: Retrospective clinical study. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: Five hundred and ninety-one consecutive adult patients operated on for cardiac surgery during 1 year. INTERVENTIONS: Plasma creatinine was measured systematically before and during the first 3 days after surgery. Comorbid events were assessed as organ dysfunction (cardiac, pulmonary, hematologic, and neurologic), allowing us to calculate for each patient a dysfunction score (0-5). MEASUREMENTS AND MAIN RESULTS: Postoperative plasma creatinine increased by > or =20% in 15.6% of patients; eight of these required dialysis. A 20% increase in plasma creatinine was associated with other organ dysfunction in 79.3% of patients. Overall mortality rate was 2.7% and increased with the dysfunction score (17.7% for a dysfunction score > or =3). Mortality rate was 12.0% for patients who had 20% increased plasma creatinine with other organ dysfunction but was 0% for patients without other organ dysfunction. A logistic regression analysis revealed that the most important prognostic factors of death were cardiac dysfunction (odds ratio, 8.5; 95% confidence interval, 2.2-32.5) and the association of renal dysfunction and hematologic dysfunction (odds ratio = 12.0; 95% confidence interval, 3.9-37.2). Mean intensive care unit stay of patients with increased plasma creatinine was significantly longer (8.1 +/- 5.6 vs. 4.3 +/- 1.4 days, p <.01) and increased significantly with the dysfunction score (p <.01). Patients with isolated increased plasma creatinine had a significantly longer stay in the intensive care unit than patients without any organ dysfunction (4.6 +/- 1.4 vs. 3.9 +/- 0.9, p <.01). CONCLUSION: Our results suggest that a postoperative 20% increase in plasma creatinine after cardiac surgery is not rare and has a significant impact on postoperative outcome, mainly when multiple organ dysfunction occurs. Any preoperative reduced renal reserve or perioperative renal ischemia increases the renal risk.

Intraoperative diagnosis of an unsuspected left atrial myxoma by transesophageal echocardiography.

IMPLICATIONS: The authors report the intraoperative diagnosis using transesophageal echocardiography (TEE) of an unsuspected myxoma in a patient admitted for an acute occlusion of the aorta, resulting in emergency excision of the atrial tumor. This observation illustrates the usefulness of intraoperative TEE examination to identify life-threatening pathology.