Angela Gologorsky

Left atrial compression by a pericardial hematoma presenting as an obstructing intracavitary mass: a difficult differential diagnosis.

IMPLICATIONS The differential diagnosis of extracavitary, intramural and intracavitary disease may be difficult. An extrinsic compression of the left atrium by a dissecting pericardial hematoma was misdiagnosed as an intracavitary mass, by echocadiography and computer tomography. This case emphasizes the importance of patient history and clinical setting.

Intraoperative Stress Cardiomyopathy

The authors discuss and present transesophageal echocardiographic images of intraoperative tako-tsubo cardiomyopathy in a female patient under general anesthesia. Intraoperative transesophageal echocardiography was performed in an attempt to manage a sudden episode of hypotension and mild pulmonary edema coincidental with surgical incision. The suspected diagnosis of stress cardiomyopathy was confirmed by computed tomographic angiography and cardiac catheterization. The patient made a complete recovery. This case report stresses the utility of transesophageal echocardiography in the differential diagnosis of intraoperative hypotension and suspected acute coronary syndrome.

Devastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation

Fewer than 80 cases of intracardiac thrombosis and intraoperative pulmonary thromboembolism during liver transplantation have been described. We present a patient who suffered an intraoperative fulminant intracardiac and aortic thrombosis and posthumously was found to have had high anticardiolipin immunoglobulin M concentration and markers of hyperfibrinolysis in preoperatively collected plasma. Hemostatic therapy in the presence of circulating antiphospholipid antibodies and the pathogenesis of a catastrophic antiphospholipid syndrome are discussed.

Monitoring of Aortic Valve Opening and Systolic Aortic Insufficiency in Optimization of Continuous-Flow Left Ventricular Assist Device Settings

d v w a AORTIC INSUFFICIENCY (AI) in patients after left ventricular assist device (LVAD) implantation is one of the nintended and potentially harmful consequences.1,2 Excessive LVAD flows, resulting in diminished and infrequent aortic valve (AV) opening, may facilitate AI progression and extend its duration to the systolic phase of the cardiac cycle.2,3 The igh temporal resolution of the echocardiographic M mode akes it very effective in monitoring the effects of LVAD speeds n AV function in real time. This case report describes the pathohysiology of AV leaflets akinesis and systolic aortic insufficiency n patients supported with continuous-flow LVAD and shows the rayscale and color M-mode AV surveillance in the perioperative ptimization of the LVAD setting.

Factors Which Predict Safe Extubation in the Operating Room Following Cardiac Surgery

Abstract  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. (J Card Surg 2012;27:275‐280)

Transesophageal Echocardiography Images of an Inferior Wall Pseudoaneurysm: A Difficult Differential Diagnosis

A 72-year-old man was transferred from an outside hospital after a cardiac catheterization revealed total occlusion of his right coronary artery, an inferior wall aneurysm, and a ventricular septal defect (VSD) 3 weeks after a myocardial infarction. Emergent coronary revascularization and VSD repair were planned. Informed consent for this presentation was obtained from the patient. Intraoperative transesophageal echocardiography (TEE) revealed a mildly dilated left ventricle (LV), with basal inferolateral, inferior, and inferoseptal akinesis (Video 1, loop 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A160; see Appendix for video legend). In transgastric (TG) midpapillary shortaxis view, a large aneurysmal cavity broadly connected to the inferior wall medial to the posteromedial papillary muscle was identified (Video 1, loop 2, http://links.lww.com/AA/A160). In TG mid short-axis and deep TG long-axis views, the walls of the aneurysmal sac were seen comprising connective tissue and lined with thrombotic material (Figs. 1 and 2) (Video 1, loops 2, 3, and 4; http://links.lww.com/AA/A160). Echographically, the thrombotic material appeared well circumscribed, homogeneously soft, with irregular borders and multiple mobile fibrillary projections into the aneurysmal cavity, markedly distinct from the LV myocardium and from the highly echo-reflective pericardium. Blood flow between the LV and the aneurysmal cavity appeared laminar based on color Doppler study (Video 1, loop 5, http://links.lww.com/AA/A160). Upon further examination in the deep TG view, this aneurysm appeared to communicate with the right ventricle through a defect in the inferior septum (Video 1, loop 6, http://links.lww.com/AA/A160); pulse-wave and color Doppler examination confirmed left-to-right systolic flow through this defect (Fig. 3) (Video 1, loop 7, http://links.lww.com/AA/A160). These data were communicated to the surgical team. Upon entry into the mediastinum, extensive dense pericarditis was noted, and a large LV inferior wall pseudoaneurysm, contained by the adherent pericardium and communicating with the right ventricle through the postinfarct VSD, was identified. The patient underwent coronary revascularization and closure of the defects in the interventricular septum and LV inferior wall with bovine pericardium and BioGlue Surgical Adhesive (CryoLife Inc., Kennesaw, GA). He made an uneventful recovery and was discharged in satisfactory condition. Myocardial infarction can result in rupture of a free LV wall in 4% of patients. Overlying adherent pericardium may contain the defect, giving rise to a false (pseudo) aneurysm. Lacking the structural support of myocardium, an LV pseudoaneurysm carries a significant risk of expansion and fatal rupture. This entity needs to be differentiated from a true LV aneurysm, arising in an area of a thinned or scarred myocardium. Both true and false LV aneurysms may result in heart failure, thromboembolic events, and ventricular arrhythmias secondary to sluggish blood flow in a noncontractile aneurysmal cavity and disrupted ventricular conduction. Distinguishing between true and false LV aneurysms is essential in determining the appropriate therapeutic approach and prognosis. Pseudoaneurysms specifically require urgent surgical intervention. The most important fundamental feature differentiating true and false aneurysms is the presence of a continuous surrounding myocardial wall in the former, and its absence in the latter. Demonstration of myocardial wall discontinuity may be confounded by the presence of thrombotic material lining the adherent pericardium. Pseudoaneurysmal wall composition (pericardium with mural thrombus) should be carefully distinguished from a true aneurysm’s myocardium. Analysis is greatly facilitated by the use of appropriately focused zoomed images of the aneurysmal neck and sack walls. Only if myocardial continuity and aneurysmal wall composition are uncertain should secondary characteristics be used. Traditionally, an LV pseudoaneurysm is described as a globular, echo-free cavity connected to the ventricular chamber via a relatively narrow orifice (neck), with a ratio of the maximum neck diameter to the maximum aneurysm diameter (Gatewood and Nanda index) 0.5. Turbulent blood flow through the neck or within the cavity is another secondary characteristic of pseudoaneurysms. Conversely, true LV aneurysms are usually characterized by laminar flow through a mouth as wide as or wider than their internal diameter. Significantly, these surrogate criteria may not be universally applicable, because pseudoaneurysms resulting from inferior wall myocardial infarctions (posterior descending artery distribution in our case) are From the *Department of Anesthesiology, CVT Division, and ‡Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami; and †Department of Anesthesia, Memorial Regional Hospital East, Hollywood, Florida.

Aortic Valve Fibroelastomas as an Incidental Intraoperative Transesophageal Echocardiographic Finding

IMPLICATIONS We report incidental findings of aortic valve fibroelastomas during routine intraoperative transesophageal echocardiography examination in cardiac surgery. Preoperative echocardiography failed to identify this potentially devastating pathology. The echocardiographic features of this lesion are reviewed, and the importance of diligence and complete examination are emphasized.

An Adult Patient with Fontan Physiology: A TEE Perspective

Fontan and Baudet described in 1971 the separation of the pulmonary and systemic circulations resulting in univentricular physiology. The evolution of the Fontan procedure, most notably the substitution of right atrial-to-pulmonary artery anastomosis with cavopulmonary connections, resulted in significantly improved late outcomes. Many patients survive well into adulthood and are able to lead productive lives. While ideally under medical care at specialized centers for adult congenital cardiac pathology, these patients may present to the outside hospitals for emergency surgery, electrophysiologic interventions, and pregnancy. This presentation presents a “train of thought,” linking the TEE images to the perioperative physiologic considerations faced by an anesthesiologist caring for a patient with Fontan circulation in the perioperative settings. Relevant effects of mechanical ventilation on pulmonary vascular resistance, pulmonary blood flow and cardiac preload, presence of coagulopathy and thromboembolic potential, danger of abrupt changes of systemic vascular resistance and systemic venous return are discussed.

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

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.

Pulmonary artery catheter in cardiac surgery revisited.

To the Editor We believe that the findings of Schwann et al. are not applicable to patients undergoing cardiac surgery in general, title notwithstanding, because they studied outcomes of only a narrow and nonrepresentative segment: coronary revascularization with the use of extracorporeal circulatory support and without transesophageal echocardiography guidance. The presumed cause-and-effect conclusions and the discussion of various potential etiologies of detrimental outcomes in patients in whom pulmonary artery catheters (PACs) were used were based on the statistical analysis of outcomes of propensity-matched patients. The logical absurdity of this approach could be illustrated by the following “thought experiment”: substitute the procedure in question (placement of PAC) with another (for example, performance of cardiopulmonary resuscitation [CPR]). State-of-the-art statistical analysis would show higher mortality and morbidity rates in those patients to whom CPR was administered, compared with propensity-matched patients to whom CPR was not administered. Should we call for a reassessment of CPR as a procedure associated with worse outcomes? In addition to the many concerns and limitations discussed in the accompanying editorial, two sources of potential bias stand out: first, the absence of pulmonary hypertension and right ventricular dysfunction, arguably the most important indications for perioperative pulmonary arterial catheterization from the list of covariates used for propensity matching analysis. The second is a significant heterogeneity of perioperative surgical care introduced by noninclusion of specific institutions and surgeons as analysis covariates. It remains entirely plausible that institutions with low frequency of pulmonary artery catheterizations also have more experienced and proficient surgeons, shorter cardiopulmonary bypass times, “better” intensive care unit care, and achieve lower morbidity and mortality rates in otherwise propensity-matched populations. This possibility might explain the mysterious doubling of mortality in patients monitored with PACs despite very modest changes in fluid balance and/or use of vasoactive support statistically attributed to PACs. We applaud the efforts to establish parameters for the perioperative use of invasive hemodynamic monitoring in cardiac surgery, but caution against extrapolating the potentially biased outcomes of on-bypass coronary revascularization in low-risk population to the entire field.