Periprocedural Dynamics of Aortic Regurgitation in Patients Supported With an Impella Left Ventricular Assist Device.

OBJECTIVES: To determine the presence of and periprocedural changes caused by aortic regurgitation (AR) in patients supported with an Impella (Abiomed, Danvers, MA) left ventricular assist device. DESIGN: Retrospective. SETTING: Tertiary academic medical center. PARTICIPANTS: Patients who underwent insertion of an Impella device at Allegheny General Hospital from January 2015 to December 2018. INTERVENTIONS: Analysis of patient electronic medical records. MEASUREMENTS AND MAIN RESULTS: Demographic information; comorbidities; duration of support; and the presence and severity of AR pre-procedure and post-procedure, as reported by echocardiography, were analyzed. The electronic medical records of 69 patients were included in the present study. Before placement of the Impella device, 25 (35%) patients showed detectable AR, with 18 (26%) showing mild AR and 7 (10%) showing moderate AR. After the removal of the Impella device, AR remained steady or increased in 61 patients. Fifteen patients (22%) demonstrated mild AR, 6 (8.7%) demonstrated moderate AR, and 2 (2.9%) demonstrated severe AR. An increase in severity of AR was noted in 9 patients (14.7%), and 52 patients (85%) had no change in the severity of AR. The duration of support with the Impella device, demographic variables, and comorbidities were not associated with a statistically significant risk for increased severity of post-procedural AR in multiple multivariable logistic regression analyses. CONCLUSIONS: The presented data suggest that after Impella device support, a significant proportion of patients may show evidence of increased AR. Additional studies are needed to understand the etiology and significance of this observation.

Perioperative Opioid Use and Chronic Post-Surgical Pain after Liver Transplantation: A Single Center Observational Study.

OBJECTIVES: To investigate the opioid requirements and prevalence of chronic postsurgical pain (CPSP) in liver transplant (LT) recipients and to evaluate the association of opioid use with postoperative survival. DESIGN: Retrospective analysis. SETTING: A large academic medical center. PATIENTS: Cadaveric liver transplants recipients from 2008 to 2016. INTERVENTIONS: Analysis of demographic, perioperative, and outcome data. MEASUREMENTS AND MAIN RESULTS: This study measured the incidence and quantity of preoperative opioid use, postoperative opioid requirements, the incidence of CPSP, and survival in patients with and without CPSP. Opioid requirements were calculated in morphine milligram equivalents. In total, 322 LT recipients satisfied the inclusion criteria. The cohort of interest included 61 patients (18.9%) who were prescribed opioids before LT, compared to the control group of 261. Postoperative opioid requirements were significantly higher in the cohort of interest in the first 24 hours (205.9 ± 318.5 v 60.4 ± 33.6 mg, p < 0.0001) and at 7 days after transplant (57.0 ± 70.6 mg v 19.2 ± 15.4 mg, p < 0.0001). Incidence of CPSP was significantly higher in the cohort of interest at 3 months (70.5% v 45.5%, p < 0.0001), at 2 years (38% v 12%), and at 5 years (29.8% v 6.9%) postoperatively. CPSP was a significant risk factor for patient mortality after transplantation (p = 0.038, HR 1.26). CONCLUSIONS: Opioid use is relatively frequent in patients waiting for LT. It significantly affects the postoperative opioid requirements and the incidence of CSPS. CPSP may significantly affect survival after LT.

Inferior Vena Cava Tumor Thrombus Dynamics and Perioperative Pulmonary Embolism: A Single-Center Experience.

OBJECTIVES: To analyze preoperative tumor thrombus progression and occurrence of perioperative pulmonary embolism (PE) in patients with inferior vena cava tumor thrombus resection. DESIGN: Retrospective analysis. SETTINGS: University of Washington Medical Center. PARTICIPANTS: Patients who had undergone inferior vena cava tumor resection with thrombectomy from 2014 to 2017. INTERVENTIONS: Analysis of demographic, perioperative, and outcome data. Variables were compared between groups according to the level of tumor thrombus, the timing of the preoperative imaging, and the occurrence of perioperative PE. MEASUREMENTS AND MAIN RESULTS: Incidence, outcomes, and variables associated with perioperative PE and sensitivity/specificity analyses for optimized preoperative imaging timing, broken into 7-day increments, were assessed. Fifty-six patients were included in this analysis. Perioperative PE was observed in 6 (11%) patients, intraoperatively in 5 patients and in the early postoperative period in 1 patient. Of the 5 patients with intraoperative PE, 2 died intraoperatively. Perioperative PE occurred in 1 patient with tumor thrombus level I, in 2 patients with level II, in 2 patients with level III, and in 1 patient with level IV. Risks of preoperative tumor thrombus progression were minimized if the imaging study was performed within 3 weeks for level I and II tumor thrombi and within 1 week for level III tumor thrombus. CONCLUSIONS: Perioperative PE was observed in patients with all levels of tumor thrombus. Fifty percent of perioperative PE were observed in patients with infrahepatic tumor thrombus. Post-imaging progression of tumor thrombus was unlikely if the surgery was performed within 3 weeks in patients with levels I or II tumor thrombus or within 1 week in patients with level III tumor thrombus.

Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Endovascular repair of a thoracic aortic aneurysm in pregnancy at 22 weeks of gestation.

Thoracic aortic aneurysm is a rare condition that carries a critical risk of rupture and mortality. These risks are increased during pregnancy because of a progressively hyperdynamic pattern of circulation. Simultaneously, pregnancy-imposed limitations on the use of ionized radiation and intravenous contrast agents may render conventional techniques for imaging and repair confirmation less acceptable. We describe a novel approach to intraoperative management of an endovascular repair for symptomatic thoracic saccular aneurysm in a pregnant patient, based on intravascular ultrasound and transesophageal echocardiography, with maintenance of uterine perfusion. The patient recovered well and proceeded to a normal delivery. Despite a favorable outcome in this case, further studies of perioperative management of aortic disease in pregnancy are needed.

Hemodynamic recovery following postreperfusion syndrome in liver transplantation.

OBJECTIVES: The authors' current understanding of the phenomenon of significant and sustained decrease in arterial pressure following liver graft reperfusion (postreperfusion syndrome [PRS]), is derived from relatively small observational reports, and no large scale analysis of PRS exists up to date. This study investigated its incidence, risk factors, temporal course of hemodynamic recovery, and its impact on functional graft outcome. DESIGN: Retrospective observational study of 1,024 electronic records of orthotopic liver transplant recipients. SETTING: Major transplant center. MEASUREMENTS: Out of 1,024, 715 records satisfied the inclusion criteria. Data were analyzed by multivariable Cox's proportional hazard model to identify risk factors for PRS. Hemodynamic recovery patterns and functional graft outcomes were compared between the cohorts of interest (intraoperative PRS) and control (no intraoperative PRS) after propensity score-matching. Association between donor risk index and hemodynamic recovery after hepatic artery reperfusion was analyzed by a multivariable regression model. RESULTS: The overall incidence of PRS was 31.6% with associated mortality of 0.3%. Independent risk factors for PRS included older donor age, higher donor risk index, and lower central venous pressure at reperfusion. Hemodynamic recovery after PRS following portal vein reperfusion was delayed until hepatic artery reperfusion. The slope of hemodynamic recovery, expressed as %MAP/min, correlated negatively with donor risk index (p=0.014). Immediate and 1-year graft survival rates were similar in both cohorts. CONCLUSIONS: Host hemodynamic response to graft reperfusion appeared to be phasic: initial abrupt hypotension after portal vein reperfusion was followed by a period of gradual decline of blood pressure until hepatic artery reperfusion, and sustained hemodynamic recovery afterwards. The slope of hemodynamic recovery correlated negatively with the donor risk index. PRS was not associated with deterioration of post-transplant graft survival and function.

Invasive renal cell carcinoma with inferior vena cava tumor thrombus: cardiac anesthesia in liver transplant settings.

OBJECTIVES: Resection of renal cell carcinomas (RCC) with tumor thrombus invasion into the inferior vena cava (IVC) is associated with significant perioperative morbidity and mortality. This study examined the intra- and inter-departmental collaboration among cardiac, liver transplantation, and urologic surgeons and anesthesiologists in caring for these patients. DESIGN: After IRB approval, medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 in this institution, were reviewed. Data were collected and analyzed by one way-ANOVA and chi-square test. SETTING: Major academic institution, tertiary referral center. PARTICIPANTS: This was a retrospective study based on the medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-eight patients (82.9%) with level III thrombus and 12 patients (17.1%) with level IV thrombus were analyzed. Sixty-five (92.9%) did not require any extracorporeal circulatory support; 5 (2 with level III and 3 with level IV; 7.1%) required cardiopulmonary bypass. No patients required veno-venous bypass. Compared to patients with level III thrombus extension, patients with level IV had higher estimated blood loss (6978±2968 mL v 1540±206, p<0.001) and hospital stays (18.8±1.6 days v 8.1±0.7, p<0.001). Intraoperative transesophageal echocardiography (TEE) was utilized in 77.6% of patients with level III thrombus extension and in 100% of patients with level IV thrombus extension. Intraoperative TEE guidance resulted in a significant surgical plan modification in 3 cases (5.2%). Short-term mortality was low (n = 3, 4.3%). CONCLUSIONS: Utilization of specialized liver transplantation and cardiac surgical techniques in the resection of RCC with extension into the IVC calls for a close intra-and interdepartmental collaboration between surgeons and anesthesiologists. The transabdominal approach to suprahepatic segments of the IVC allowed avoidance of extracorporeal circulatory support in most of these patients. Perioperative management of these patients reflected the critical importance of TEE-proficient practitioners experienced in liver transplantation and cardiac anesthesia.

Orbital compartment syndrome following extracorporeal support.

Orbital compartment syndrome (OCS) is a rare, catastrophic, but potentially treatable complication. It requires prompt diagnosis and immediate intervention, as critical period for possible functional recovery is very short. This report adds to our understanding of potential mechanisms of perioperative blindness, and suggests extracorporeal circulatory support, systemic inflammatory response, and massive blood and fluid resuscitation as potential risk factors for perioperative OCS.

Factors which predict safe extubation in the operating room following cardiac surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. METHODS: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co-morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re-exploration, surgical and OR times, and ICU and hospital lengths of stay. RESULTS: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off-pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off-bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high-risk procedures (2.5%). CONCLUSIONS: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR.

Transesophageal echocardiography after contrast-enhanced CT angiography in the diagnosis of type A aortic dissection.

Contrast-enhanced CT angiography (CTA) currently is considered the diagnostic modality of choice in the diagnosis of acute type A aortic dissection. However, pitfalls associated with acquisition and interpretation of CTA images may result in misdiagnosis. We present examples of false-positive and false-negative interpretations of CTA in emergency situations that underline the importance of intraoperative preincision transesophageal echocardiography (TEE) in the diagnosis and management of this highly lethal entity.

Unexpected persistent left superior vena cava and absent right superior vena cava in situs solitus patient.

We, herein, report a patient with persistent left superior vena cava with enlarged coronary sinus and absent right superior vena cava. This anomaly, diagnosed intraoperatively during the third open-heart surgery in the course of transesophageal echocardiography examination, was not mentioned during the patient's previous two cardiac operations. Challenges in intraoperative management and implications for subsequent treatments are discussed.

Left main coronary artery fistula to the right atrium and superior vena cava: case report and review of the literature.

A unique arteriovenous fistula, originating from the left main coronary artery and branching to drain into the right atrium and superior vena cava is presented with review of the literature.

Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening disease entity. Untreated, it usually results in death due to rupture of the proximal aorta into the pericardial cavity, leading to cardiac tamponade. Should patients who have had prior cardiac surgery presenting with ATAAD be treated emergently with surgery, or should they be managed medically? We herein present preliminary evidence that suggests that medical treatment, at least initially, is the best option for these patients. Surgery is indicated in the follow-up, depending on increased size of the dissection or aorta, or to prevent or treat complications. PATIENTS AND METHODS: From January 2004 to November 2009, ten consecutive male patients with prior cardiac surgery were admitted to hospital with the diagnosis of ATAAD. Mean age was 61.90 +/- 14.68 years (range, 36 to 79 years), with nine (90%) males and one (10%) female. All were treated medically as the definitive form of management. RESULTS: Mean follow-up duration was 14.62 +/- 11.12 months (range, 1 to 31 months). Overall mortality during follow-up was 20% (two patients). Eight patients (80%) are alive and well. CONCLUSIONS: This initial experience with a small, consecutive series of patients, suggests that medical treatment is an option in the initial management of patients with ATAAD who had prior cardiac surgery. It appears that emergency surgery is seldom needed. A larger series of patients and longer follow-up period are needed prior to recommending this treatment approach for such patients.