Anesthetic Management of Transapical Off-Pump Mitral Valve Repair With NeoChord Implantation.

OBJECTIVES: Various minimally invasive surgical approaches have been used in mitral valve (MV) surgery. The transapical off-pump mitral valve intervention with NeoChord implantation (TOP-MINI) is a minimally invasive, alternative procedure for the treatment of degenerative mitral regurgitation. There are several special considerations for the anesthesiologist during the TOP-MINI procedure. The main purpose of this study was to present the anesthetic management of the TOP-MINI procedure. DESIGN: An observational study. SETTING: Training and research hospital. PARTICIPANTS: Adult patients who underwent MV repair with the NeoChord DS1000 system (NeoChord Inc, St Louis Park, MN). INTERVENTIONS: The study included 12 consecutive patients who underwent MV repair with the NeoChord DS1000 system at the Antalya Training and Research Hospital, Antalya, Turkey, between June 2014 and December 2015. A record was made of preoperative demographic details, comorbidities, preoperative and postoperative mitral regurgitation severity, preoperative and postoperative forced expiratory volume in 1 second values, use of blood products and vasoactive drugs, surgical times, mechanical ventilation times, intensive care unit (ICU) and hospital length of stay, visual analog scale scores, analgesic requirement in ICU and perioperative complications. MEASUREMENTS AND MAIN RESULTS: TOP-MINI was performed completely off-pump in 12 patients. Intraoperative salvaged blood via cell-saver was 660±196 mL. Patients required 0.8±0.7 U of red blood cells and 2.0±0.9 U of fresh frozen plasma in the ICU. Inotropic support was used in 5 patients. There was a significant decline in mean arterial pressure from before surgery to during implantation (70.9±4.5 mmHg v 51.7±5.8 mmHg, respectively). A statistically significant increase was demonstrated in mean arterial pressure from during implantation to postimplantation (51.7±5.8 mmHg v 67.0±6.8 mmHg, respectively). There were no significant differences in preoperative and postoperative forced expiratory volume in 1 second values. Defibrillation was required in 1 patient, and temporary atrial fibrillation was observed in 1 patient during the procedure. Atelectasis occurred in the postoperative period in 1 patient. The mean visual analog scale score was 3.6±1.4, and the mean tramadol consumption was 77±39 mg in the ICU. Extubation time and the mean length of stay in the ICU and hospital were 2.6±0.5 hours, 19.8±2.7 hours, 5±1 days, respectively. CONCLUSIONS: The TOP-MINI procedure requires complex anesthetic management. Transesophageal echocardiographic guidance is essential for this procedure. One-lung ventilation, fluid administration, avoidance of hypothermia, and pain management are the bases for anesthetic management.

Mitral valve repair facilitated with transapical beating heart NeoChord implantation in a non-Hodgkin's lymphoma patient.

Elderly patients with severe hematological malignancies may require cardiac surgery. The combined impact of cardiopulmonary bypass (CPB) and surgical trauma is a potent inflammatory activator and is increased by intraoperative and postoperative complications. To avoid the adverse effects of CPB, minimally invasive off-pump techniques may be used in these patients. The transapical off-pump mitral valve intervention with NeoChord implantation (TOP-MINI) is a minimally invasive technique for mitral valve repair, which makes it possible to avoid the risks of CPB in selected patients, such as elderly, cancer or immunosuppressive patients. We report here the case of a 78-year-old male with B-cell non-Hodgkin's lymphoma, who presented with severe mitral regurgitation. The patient was successfully treated with the TOP-MINI procedure.

Comparison of Transcutaneous Electrical Nerve Stimulation and Parasternal Block for Postoperative Pain Management after Cardiac Surgery.

Background. Parasternal block and transcutaneous electrical nerve stimulation (TENS) have been demonstrated to produce effective analgesia and reduce postoperative opioid requirements in patients undergoing cardiac surgery. Objectives. To compare the effectiveness of TENS and parasternal block on early postoperative pain after cardiac surgery. Methods. One hundred twenty patients undergoing cardiac surgery were enrolled in the present randomized, controlled prospective study. Patients were assigned to three treatment groups: parasternal block, intermittent TENS application, or a control group. Results. Pain scores recorded 4 h, 5 h, 6 h, 7 h, and 8 h postoperatively were lower in the parasternal block group than in the TENS and control groups. Total morphine consumption was also lower in the parasternal block group than in the TENS and control groups. It was also significantly lower in the TENS group than in the control group. There were no statistical differences among the groups regarding the extubation time, rescue analgesic medication, length of intensive care unit stay, or length of hospital stay. Conclusions. Parasternal block was more effective than TENS in the management of early postoperative pain and the reduction of opioid requirements in patients who underwent cardiac surgery through median sternotomy. This trial is registered with Clinicaltrials.gov number NCT02725229.

Effects of N-acetyl cysteine on renal functions evaluated by blood neutrophil gelatinase-associated lipocalin levels in geriatric patients undergoing coronary artery bypass grafting.

OBJECTIVE: Recent conflicting studies on the renal effects of N-acetyl cysteine (NAC) after cardiac surgery have been published. The aim of this study was to evaluate the renal effects of NAC using neutrophil gelatinase-associated lipocalin (NGAL) blood levels in elderly patients undergoing coronary artery bypass grafting (CABG). METHODS: This randomized, double-blinded, placebo-controlled study was conducted among geriatric patients (>65 years) scheduled to undergo CABG. A total of 60 consecutive patients were randomly assigned to 2 groups. The first group received I.V. NAC (n=30) and the second group received placebo (n=30) at induction of anesthesia and then for 20 h. NGAL values were determined and conventional renal function tests were performed. Statistical analysis was performed using SPSS 17.0 (IL, Chicago, USA). A p value of <0.05 was considered statistically significant. RESULTS: Plasma creatinine levels at 24 h postoperatively were significantly higher in the placebo group than in the NAC group (1.41±0.63 vs. 1.13±0.35; p<0.05). The mean serum NGAL levels at 3 h postoperatively were higher in the placebo group than in the NAC group (104.94±30.51 vs. 87.82±25.18; p<0.05). NGAL levels were similar between the groups at all other measurement time points. Plasma creatinine levels of ≥1.5 mg/dL or >25% of the baseline value at any time during the study period were observed in 27% of patients in the NAC group and 37% of patients in the placebo group; the difference was statistically significant (p<0.05). CONCLUSION: In the present study, we found that I.V. NAC infusion in elderly patients undergoing CABG reduced the incidence of acute kidney injury as determined by blood NGAL and creatinine levels.

Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy.

OBJECTIVES: Carotid endarterectomy under regional anesthesia may be performed by using superficial, intermediate, deep or combined cervical plexus block. The authors compared the combined and intermediate cervical plexus block by use of ultrasound guidance in patients undergoing carotid endarterectomy. DESIGN: A prospective, randomized, double-blinded trial. SETTING: Education and research hospital. PARTICIPANTS: Adult patients undergoing carotid artery surgery. INTERVENTIONS: Forty-eight patients were randomized to receive either combined cervical plexus block (deep plus superficial) or intermediate cervical plexus block by use of ultrasound guidance for carotid endarterectomy. The primary outcome measure was the amount of supplemental 1% lidocaine used by the surgeon. Secondary outcome measures were the time for the first analgesic requirement after surgery, block-related complications, postoperative visual analog scale score, and patient and surgeon satisfaction. MEASUREMENTS AND MAIN RESULTS: Intraoperative supplemental lidocaine requirements were 3.0±1.9 mL in the combined-block group and 7.8±3.8 mL in the intermediate block group. These differences were statistically significant. There were no significant differences between the 2 groups in block-related complications and the time between the block completion and the first administration of the first dose of intravenous analgesic. In the combined-block group, maximum visual analog scale score was lower at 3 hours (2.2 [1-5] v 5.3 [3-8]), and patient satisfaction score was higher than the intermediate-block group (4.3 [3-5] v 3.1 [1-4]). One regional anesthesia procedure was converted to general anesthesia in the combined-block group. CONCLUSIONS: Ultrasound-guided combined cervical plexus block compared to intermediate cervical plexus block led to less additional analgesic use, lower visual analog scale score, and higher patient satisfaction.

Effects of Parasternal Block on Acute and Chronic Pain in Patients Undergoing Coronary Artery Surgery.

Background Sternotomy causes considerable postoperative pain and postoperative pain management encompasses different analgesic regimens. In this study, we aimed to investigate the effect of peroperative parasternal block with levobupivacaine on acute and chronic pain after coronary artery bypass graft surgery. Materials and Methods A total of 81 patients undergoing coronary artery bypass graft surgery were included in this study. Patients were randomly allocated by opening an envelope to receive either parasternal block with pharmacologic analgesia (group P; before sternal wire placement: sternotomy and mediastinal tube sites were infiltrated with local anesthetics) or pharmacologic analgesia alone (group C) for postoperative pain relief. All patients received intravenous tramadol with patient-controlled analgesia at the end of the surgery. Demographic characteristics, vital signs, tramadol consumption, analgesic intake, and intensity of pain with a visual analogue scale were recorded for each patient. Six months after surgery, the patients' type of chronic pain was evaluated using the Leeds Assessment Neuropathic Symptoms and Signs pain scale questionnaire. Results Patients who received parasternal block experienced less pain and needed less opioid analgesic (125.75 ± 28.9 mg in group P vs 213.17 ± 61.25 mg in group C) for 24 hours postoperatively (P < .001). There was no significant difference in nociceptive and neuropathic pain between the groups. Conclusion Parasternal block had a benefical effect on the management of postoperative acute pain and decreased opioid consumption after surgery but had no significant effect in chronic post surgical pain.

Simultaneous Bilateral Carotid Endarterectomy under Cervical Plexus Blockade.

In patients with severe carotid artery stenosis who developed transient ischemic attack, carotid endarterectomy is one of the most effective treatments. In particular, in patients with contralateral carotid artery lesions, there is a risk of serious neurologic complications during the intra-operative period. Experienced staff can perform simultaneous bilateral carotid endarterectomy safely in carefully selected patients. The advantages of regional anaesthesia in carotid endarterectomy are evaluation of intra-operative neurological condition and defining correct indications for shunt usage. It is a cheap, reliable and easy method that reduces the length of stay in the intensive care unit and in the hospital and may influence the overall cost of care. However, it is important to make dose adjustments to avoid potential complications of nerve involvement during bilateral procedure. In this case report, we share our experiences regarding bilateral carotid endarterectomy under cervical plexus blockade.

Comparison of the effects of desflurane and propofol anesthesia on the inflammatory response and s100ß protein during coronary artery bypass grafting.

Cardiopulmonary bypass (CPB) contributes to the secretion of anti-inflammatory cytokines that mediate the inflammatory response observed during open heart surgery. In addition to many factors, type of anesthesia management affects immune response and central nervous system in cardiac surgery. The aim of this study was to assess the effect of propofol versus desflurane anesthesia on systemic immune modulation and central nervous system on patients undergoing coronary artery bypass grafting. Forty patients undergoing elective coronary artery bypass graft surgery with CPB were included in this prospective randomized study. Patients were allocated to receive propofol (n = 20) or desflurane (n = 20) for maintenance of anesthesia. The blood samples for IL-6, IL-8, TNF-α, and S100ß were drawn just prior to the operation before the induction of anesthesia, second before cardiopulmonary bypass, third after CPB, fourth 4 h postoperatively at the ICU. Major finding in our study is that S100ß levels were lower in propofol group when compared to desflurane anesthesia. And also immune reaction was less in patients exposed to desflurane anesthesia when compared to propofol anesthesia as indicated by lower plasma concentrations of IL-8 and IL-6. Propofol is more preferable in terms of S100ß for anesthetic management for CABG.

Advantages of autologous blood transfusion in off-pump coronary artery bypass.

BACKGROUND: In this randomized controlled study, we investigated the effects of autologous Hemobag blood transfusion (AHBT) and allogenic blood transfusion (ABT) in off-pump coronary artery bypass (OPCAB) surgery. METHODS: Sixty patients who underwent surgery between February 2008 and August 2008 were randomized into 2 groups. The AHBT group (n = 30) consisted of patients who received autologous Hemobag blood transfusion, and the ABT group (n = 30) consisted of patients who received allogenic blood transfusion. All patients underwent OPCAB via sternotomy. The time to extubation, chest tube drainage volume, postoperative white blood cell counts, amount of blood transfusion, sedimentation rate, C-reactive protein concentration, postoperative temperature, and the presence of atelectasis were recorded in the intensive care unit. RESULTS: Intraoperative bleeding and fluid resuscitation were similar in the 2 groups (P > .05); however, there were significant decreases in postoperative blood loss, extubation period, postoperative white cell counts, sedimentation rate, incidence of atelectasis, C-reactive protein, and fever in the AHBT group compared with the ABT group (P < .05). The rate of atrial fibrillation in the AHBT group tended to be lower than in the ABT group. CONCLUSION: Autologous blood transfusion in OPCAB may be beneficial in certain cardiac surgery patients; however, these beneficial effects require further study to be proved.

Comparison of continuous and intermittent transcutaneous electrical nerve stimulation in postoperative pain management after coronary artery bypass grafting: a randomized, placebo-controlled prospective study.

OBJECTIVE: We compared the effectiveness of continuous transcutaneous electrical nerve stimulation (TENS) and intermittent TENS in the management of pain after coronary artery bypass grafting (CABG). METHODS: We randomized 100 patients who had undergone median sternotomy for CABG into 4 groups with 25 patients each: (1) continuous TENS (CTENS) and pharmacologic analgesia, (2) intermittent TENS (ITENS) and pharmacologic analgesia, (3) placebo TENS (PTENS) and pharmacologic analgesia, and (4) pharmacologic analgesia alone (control). We studied these groups with regard to the relief of postoperative pain during the first 24 hours. For each patient we recorded the following: demographic characteristics; vital signs; intensity of pain with a visual analogue scale (VAS) before treatment (VAS(0)), at the 12th hour (VAS(12)), and at the 24th hour (VAS(24)); and analgesic intake. RESULTS: The groups were comparable with respect to age, sex, and body mass index at baseline. Mean VAS scores decreased within each group; however, the mean VAS(12) and VAS(24) scores decreased significantly in the CTENS and ITENS groups, compared with PTENS and control groups (P < .05). We found no significant difference between the CTENS and ITENS groups with respect to decreasing VAS(12) and VAS(24) scores (P > .05). Narcotic intake was significantly less in the CTENS and ITENS groups than in the control and PTENS groups (P < .01). Furthermore, narcotic requirements were significantly lower in the CTENS group than in the ITENS group (P < .01). CONCLUSIONS: CTENS and ITENS after median sternotomy for CABG decreased pain and reduced narcotic requirements more than in the PTENS and control treatments during first postoperative 24 hours. Neither CTENS nor ITENS is superior to the other in decreasing pain; however, CTENS leads to a greater reduction in the narcotic requirement than ITENS.

Gastrointestinal ischemia related mortality in patients undergoing off- or on-pump coronary artery bypass grafting.

OBJECTIVE: Gastrointestinal ischemia (GII) after heart surgery is a rare but devastating condition. The aim of this study was to compare the occurrence of GII after coronary artery bypass grafting (CABG) performed off-pump (OPCAB) vs on-pump (ONCAB). METHODS: We retrospectively evaluated 2625 adult patients who underwent isolated coronary artery surgery during a 6-year period. The OPCAB group included 658 patients and the ONCAB group 1967 patients. Patients were evaluated, and GII, morbidity, and mortality in the 2 groups were compared. RESULTS: GII developed in 0.4% (7 of 1967) patients in the ONCAB group and in 0.2% (1 of 658) patients in the OPCAB group (P = .28). Mortality rates due to GII were 0.2% (4 of 1967) in the ONCAB group, and no deaths occurred in the OPCAB group (P < .04). Postoperative atrial fibrillation incidence with GII was 100% (7 of 7) in ONCAB group and 0% (0 of 1) in the OPCAB group (P < .01). CONCLUSIONS: Compared to ONCAB, the OPCAB procedure has lower GII related mortality rates, which is an important cause of morbidity and mortality in the postoperative period of CABG surgery.

Control of acute postoperative pain by transcutaneous electrical nerve stimulation after open cardiac operations: a randomized placebo-controlled prospective study.

OBJECTIVE: We investigated the effectiveness of transcutaneous electrical nerve stimulation (TENS) therapy on pain during the first 24 hours after a cardiac surgical procedure. METHODS: A total of 60 patients who had undergone median sternotomy (MS) for coronary artery bypass graft (n = 55) or valve repair surgery (n = 5) were randomized to receive TENS and pharmacologic analgesia, placebo TENS and pharmacologic analgesia, or pharmacologic analgesia alone (control group). For each group we recorded severity of pain, analgesic intake, and pulmonary complications. Pethidine HCL and metamizol sodium were administered for postsurgical analgesia. RESULTS: Pain after MS was measured on a 10-point visual analogue scale (VAS). Mean scores in the TENS, placebo TENS, and control groups, respectively, were 5.70 +/- 1.78, 5.75 +/- 1.83, and 5.95 +/- 1.63 before treatment (P >.05); 2.40 +/- 1.18, 3.90 +/- 1.48, and 3.55 +/- 1.60 on the 12th hour of the intervention (P < .05); and 1.25 +/- 0.91, 2.30 +/- 1.34, and 2.15 +/- 1.13 on the 24th hour of the intervention (P < .05). The mean VAS scores decreased within each group (P < .05). However, the mean VAS scores decreased much more significantly in the TENS group (P < .05). Metamizol sodium intake was 1.05 +/- 0.39 g, 2.30 +/- 1.08 g, and 2.90 +/- 1.20 g and pethidine HCL intake was 17 +/- 16.25 mg, 57 +/- 21.54 mg, and 51.50 +/- 18.99 mg, respectively, in the TENS, placebo TENS, and control groups. Metamizol sodium and pethidine HCL intake was least in the TENS group (P < .05). Postoperative complications were observed in 6 (10%) of patients. The most frequent complication was atelectasia. CONCLUSIONS: TENS was more effective than placebo TENS or control treatments in decreasing pain and limiting opioid and nonopioid medication intake during the first 24-hour period following MS.

Influence of intracoronary shunt on myocardial damage: a prospective randomized study.

OBJECTIVE: We aimed to evaluate whether surgical intracoronary shunt protects myocardium in patients with moderate left ventricular dysfunction (MLVD). METHODS: Thirty-nine patients consisted the shunt group and 43 patients consisted the shuntless group. Troponin I, CK, and CK-MB were measured preoperatively, and at 6 and 24h postoperatively. Cardiac enzymes, rate of postoperative atrial fibrillation (AF) and third month ejection fraction (EF) were compared between the groups. RESULTS: There were no significant differences between the groups for preoperative troponin I, CK, CK-MB, and postoperative CK levels (at 6 and 24h). Postoperative troponin I and CK-MB levels were significantly lower in the shunt group (p<0.001). Although preoperative EF of the patients were not significantly different between groups, the third month EF were significantly increased in both groups, and this increment was significantly higher in the shunt group than the shuntless group. One patient (2.3%) died in the shuntless group whereas there was no death in the shunt group. CONCLUSION: Intracoronary shunt has protective effects on myocardium in patients with moderate left ventricular dysfunction.

Repair of the inferior vena cava with autogenous peritoneo-fascial patch graft following abdominal trauma: a case report.

Abdominal vascular injuries are among the most challenging and lethal injuries in traumatized patients. Inferior vena cava is the most frequently injured vein during the blunt or penetrating trauma. The primary repair, end to end anastomosis, endovascular stenting, or graft interposition with autogenous or synthetic materials should be considered in selected cases. However, in cases the synthetic graft was preferred, intestinal contaminations due to small or large bowel perforation accompanying the trauma have been cited as a limiting factor for the use of such grafts as in the current case. However, a previous history of lower leg variceal surgery prevents the use of great saphenous vein as a graft. So in the present case, the authors report a patient with inferior vena cava injury repaired with autogenous peritoneo-fascial graft. The authors have used APF graft in traumatic inferior vena cava injury for the first time.

Dog bite causing ischemia and neurological deficit at the upper extremity: a case report.

We present a case with median and radial nerve injuries together with brachial artery occlusion after a dog bite that is seen rarely in the literature. A 26 year-old man was admitted to our emergency department with a complaint of dog bite and weakness of fingers at the left upper extremity. There were bite impressions at the left arm. The physical examination of the patient revealed no brachial and radial artery pulse. The neurological examination revealed radial and median nerve deficits. The patient underwent a thromboembolectomy operation following laboratory and radiological evaluations. The nerve injuries were evaluated as partial and medical treatment was administered.

Preoperative prophylaxis can decrease rates of atrial fibrillation in open heart surgery: a retrospective study.

BACKGROUND: We investigated the effects of preoperative administration of beta-blockers on the incidence of atrial fibrillation (AF) after cardiothoracic surgery and the resulting morbidity and mortality. METHODS: We retrospectively evaluated 181 patients who underwent operations between May 2004 and December 2007. We divided the patients into 2 groups according to their preoperative use beta-blockers. Group A (n = 89) consisted of patients who did not receive beta-blockers, and group B (n = 92) consisted of patients who received 50 mg metoprolol succinate daily. All patients underwent on-pump coronary artery bypass grafting (CABG) via sternotomy. RESULTS: Atrial sizes and the baseline clinical and laboratory data were similar for the 2 groups. The 2 groups were also similar with respect to the numbers of grafts per patient, preoperative ejection fractions, cross-clamp times, cardiopulmonary bypass times, and postoperative inotrope use (P > .05). AF occurred in 39 (21.5%) of the 181 patients after the operation. Postoperative AF occurred in 30 (33.7%) of the group A patients and in 9 patients (9.7%) in group B (P < .05). CONCLUSION: Postoperative AF increases the rates of morbidity and mortality and the length of hospital stay after CABG. The prophylactic use of beta-blockers decreases the rate of postoperative AF and thus AF-related complications.

IABP-Related vascular complications: who is responsible--the patient, the surgeon or the sheath? Part I: sheath-related complications.

INTRODUCTION: An intra-aortic balloon pump (IABP) is frequently used as a mechanical support during the treatment of low cardiac output syndrome. The use of a sheath during IABP treatment can be associated with ischaemic complications in the extremities. The aim of our study was to determine the isolated role of sheaths in the development of vascular complications following IABP catheterisation. METHODS: We evaluated a total of 81 patients who had received an IABP for haemodynamic stability, between January 2003 and October 2007, following cardiovascular surgery. To eliminate surgical-related variables, only patients with IABPs and size 8.5 or 9 French catheters (inserted by experienced cardiovascular surgeons using the percutaneous Seldinger technique) were included in the study. To eliminate patient-related variables, patients with a known risk factor for either thrombosis, embolus or peripheral arterial disease were excluded from the study. RESULTS: The patients were divided into two groups: Group 1 (sheathed catheter group; n=42), Group 2 (sheathless catheter group; n=39). Ischaemic complications were observed in a total of five patients. Four of these patients were from Group 1 and one was from Group 2. CONCLUSION: Sheathed catheterisation was found to increase the risk of vascular complications in patients who underwent IABP application. Therefore sheathless catheterisation is recommended for IABP application.