Reversal of Total Artificial Heart Mechanical Valve Thrombosis Using Catheter-Directed Thrombolysis.

Total artificial heart is associated with increased incidence of thromboembolism, which can prove to be fatal. The presence of four metallic tilting discs increases the chances of thrombus formation and sudden obstruction of the valve in a closed position resulting in severe hemodynamic collapse. Such a condition is conventionally treated by a surgical approach for device change; however, this procedure is extremely high risk and associated with complications and poor outcomes. We describe two total artificial heart patients with sudden obstruction to the filling of the right side due to fixing of the atrioventricular valve in a closed position due to a thrombus. After a quick diagnosis by rescue transesophageal echocardiography, we successfully treated these patients with catheter-directed thrombolysis with minimal adverse outcomes. We propose a carefully weighed application of this approach in hemodynamically unstable patients too tenuous for a timely surgery and with low risk for bleeding.

Heparin-Induced Thrombocytopenia: A Comprehensive Clinical Review.

Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.

Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: advantages of 3D TEE illustrated in three cases.

Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra-operatively, and it has the ability to provide continuous real-time information. Three-dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra-operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two-dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real-time 3D TEE during intra-operative management of a type A aortic dissection.

Avoiding ECMO in a patient with "pump" lung post-cardiopulmonary bypass.

As newer anesthesia ventilators are developed their capabilities are becoming more similar to intensive care unit (ICU) ventilators. However, in situations where there is severe decrease in lung compliance, an ICU ventilator may be superior in its ability to regulate inspiratory flow improving both ventilation and oxygenation. We present a case where an ICU ventilator was brought to the operating room and used in the treatment of ARDS post-cardiopulmonary bypass and ultimately allowed us to avoid extracorporeal membrane oxygenation (ECMO) therapy.