Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review.

Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition.

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Positive Bubble Study But No Evidence of Interatrial Defect in a Patient with Recurrent Cryptogenic Stroke.

Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.

Gastrointestinal Complications After Transesophageal Echocardiography for Mitral Valve Transcatheter Edge-to-Edge Repair: Insights From a Large Contemporary Cohort.

OBJECTIVES: Transesophageal echocardiography-related complications (TEE-RC) are higher in structural heart interventions than in traditional operative settings. In mitral valve transcatheter edge-to-edge repair (MV-TEER), the incidence of TEE-RC may be higher than in other structural interventions. However, existing reports are limited and robust data evaluating TEE safety in this patient population are lacking. The authors sought to describe the incidence and risk factors of upper gastrointestinal injuries after TEE in patients undergoing MV-TEER. DESIGN: A retrospective observational study. SETTING: A single tertiary academic hospital. PARTICIPANTS: A total of 442 consecutive patients who underwent MV-TEER, specifically with MitraClip, between December 2015 and March 2022. INTERVENTIONS: Transesophageal echocardiography was performed intraoperatively to guide all MV-TEERs. MEASUREMENTS AND MAIN RESULTS: The study's primary goal was to investigate an association between TEE procedure duration and TEE-RC risk. The contribution of demographic risk factors and intraprocedural characteristics also was investigated. Transesophageal echocardiography-RCs were observed in 17 out of 442 patients (3.8%). Dysphagia was the most common TEE-RC (n = 9/17, 53%), followed by new gastroesophageal reflux (n = 6/17, 35%) and odynophagia (n = 3/17, 18%). There were no esophageal perforations or upper gastrointestinal bleeds. History of dysphagia was the only variable associated with TEE-RCs (p = 0.008; n = 9 [2.1%] v n = 3 [18%]), with a relative risk of 8.67 (95% CI 2.57, 29.16). The TEE procedure duration was not statistically different between the 2 groups (46 minutes [39-64] in TEE-RCs v 49 minutes [36-77] in no complications). CONCLUSION: In patients undergoing MV-TEER, TEE-RCs are uncommon, and major complications are rare. The authors' outcomes reflect those of a high-volume referral center with TEEs performed by cardiac anesthesiologists.

Diastolic Left Main Coronary Artery Flow Reversal.

In patients undergoing percutaneous cardiac interventions, perioperative transesophageal echocardiography is used routinely, often revealing an unusual pathology that was not previously detected with transthoracic echocardiography. In this e-challenge, the authors present a patient undergoing percutaneous transcatheter aortic valve replacement, with preprocedural transesophageal echocardiography revealing an abnormal color Doppler signal near the left main coronary artery during diastole.

Aortic Valve Repair Using HAART 300 Geometric Annuloplasty Ring: A Review and Echocardiographic Case Series.

Aortic valve repair (AVr) aims to preserve the native aortic leaflets and restore normal valve function. In doing so, AVr is a more technically challenging approach than traditional aortic valve replacement. Some of the complexity of repair techniques can be attributed to the unique structure of the functional aortic annulus (FAA), which, unlike the well-defined mitral annulus, is comprised of virtual and functional components. Though stabilizing the ventriculo-aortic junction (VAJ), a component of the FAA, is considered beneficial for patients with chronic aortic insufficiency (AI), the ideal AVr technique remains a subject of much debate. The existing AVr techniques do not completely stabilize the VAJ which may increase susceptibility to recurrent AI due to VAJ dilation. An emerging new technique showing promise for the treatment of both isolated and complex AI is AVr using HAART 300TM geometric annuloplasty ring (GAR). The GAR is implanted below the valve leaflets in the left ventricular outflow tract (LVOT), providing stability and creating a neo-annulus. As with other AVr subtypes, this procedure has a learning curve. There are unique surgical and echocardiographic aspects of AVr with GAR, including the appearance of the LVOT, the aortic valve leaflets, and their motion which cardiac anesthesiologists and echocardiographers must be familiar with. In this work, using an eight-patient echocardiographic case series, we provide an overview of this novel AVr technique, including some unique aspects of device sizing, patient selection, expected post-repair echocardiographic features, and a review of outcomes data.

Sensitivity of severe acute respiratory syndrome coronavirus type 2 rapid antigen point-of-care tests in vaccinated patients.

BACKGROUND AND IMPORTANCE: Rapid antigen point-of-care tests (antigen POC tests) are frequently used to detect COVID-19 infections. Based on clinical impressions, we suspected that the sensitivity of antigen POC tests might be lower in vaccinated patients. OBJECTIVE: To evaluate the sensitivity of antigen POC tests in vaccinated patients. DESIGN, SETTING AND PARTICIPANTS: We retrospectively evaluated all patients over 18 years of age that tested positive for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) in November 2021 at our institution, whose antigen POC test result had been recorded. We considered patients who were either fully vaccinated or unvaccinated, as well as whether they were symptomatic. OUTCOME MEASURE AND ANALYSIS: We calculated the sensitivity of antigen POC tests in vaccinated and unvaccinated as well as in symptomatic and asymptomatic patients and compared the results. RESULTS: A total of 4080 reverse transcription PCR tests were performed in our institution in November 2021, of which 360 patients tested positive for SARS-CoV-2. Of those, 234 patients met inclusion criteria and were further evaluated. The sensitivity of the antigen POC test was only 39.4% [95% confidence interval (CI), 31.3-48.1%] in vaccinated patients and differed significantly from the sensitivity of 53.3% (95% CI, 43.9-62.4%) in unvaccinated patients (difference of sensitivities, 13.9%; 95% CI, 1.1-26.1%). In symptomatic patients, the sensitivity increased by only 11.8% from 45.7% in all patients (95% CI, 39.5-52.1%) to 57.5% in symptomatic patients (95% CI, 49.9-64.7%). In asymptomatic patients, the antigen POC test was only able to detect SARS-CoV-2 positive patients in 16.4% of the cases (95% CI, 9.4-27.1%). CONCLUSION: Point-of-care antigen tests are likely not useful for ruling out SARS-CoV-2 infection, especially in vaccinated and asymptomatic patients, potentially due to lower viral load. Moreover, the use of these tests might lead to a false sense of security, especially when used by the public as part of a public health testing strategy.

Procedural, Short-Term, and Intermediate-Term Outcomes in Propensity-Matched Patients With Severe Mitral Valve Regurgitation Undergoing Urgent Versus Elective MitraClip Percutaneous Mitral Valve Repair.

OBJECTIVE: The study authors sought to compare outcomes in patients with severe mitral valve regurgitation (MR) undergoing urgent, as compared to elective, mitral valve repair employing MitraClip. They hypothesized that, compared to elective cases, MitraClip procedures performed for urgent indications would be associated with increased intraoperative and postoperative complications but have similar long-term outcomes. DESIGN: A retrospective chart review with 3:1 propensity score matching of elective-to-urgent cases. SETTING: A single, large-volume tertiary care academic medical center. PARTICIPANTS: All consecutive patients with severe MR who underwent elective or urgent MitraClip procedures between December 15, 2015, and October 26, 2020. INTERVENTIONS: MR repair with MitraClip. MEASUREMENTS AND MAIN RESULTS: As expected, patients in the urgent MitraClip group required a higher level of preprocedural care, and there were significant differences in baseline demographic and clinical variables as compared to the elective group. To reduce baseline characteristics heterogeneity, propensity matching was performed for age, left ventricular systolic dysfunction, congestive heart failure, chronic obstructive pulmonary disease, and smoking histories, using the nearest-neighbor matching with a caliper of 0.2 and with replacement. The final study cohort included 89 urgent and 252 matched elective cases, with a suitable alignment between the treatment groups. Propensity-matched urgent MitraClip patients experienced a longer hospital length of stay (p < 0.001), increased intensive care unit admissions (19% v 4%, p < 0.001) and mechanical ventilation (6.7% v 1.6%, p = 0.023), postprocedural atrial fibrillation (11% v 4.4%, p = 0.036), pericardial effusion (10% v 2.4%, p = 0.005), and acute kidney injury (7.9% v 2%, p = 0.016). Furthermore, patients in the urgent cohort incurred significantly higher 30-day cardiovascular mortality (6.7% v 2%, p = 0.039), increased 30-day (16% v 5.6%, p = 0.006), and 1-year (33% v 20%, p = 0.021) readmission rates. However, there were no statistically significant differences in 30-day and 1-year overall and 1-year cardiovascular mortality. CONCLUSIONS: Urgent MitraClip repairs can be performed successfully, when needed, in critically ill patients with severe MR. Despite the procedural success, patients undergoing urgent MitraClip repair remain at high risk for adverse outcomes in the short- and intermediate-term and incur increased cardiovascular mortality and morbidity. Further efforts are required to develop strategies to optimize short and intermediate outcomes in this vulnerable group of patients.