Bonnie L. Milas

Stroke After Aortic Valve Surgery Results From a Prospective Cohort

Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P=0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P=0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P =0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P =0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality. # CLINICAL PERSPECTIVE {#article-title-47}

Clinical management of cardiogenic shock associated with prolonged propofol infusion.

This case report details the development of cardiogenic shock after craniotomy in a patient sedated with a propofol infusion. The patient survived with the assistance of extracorporeal membrane oxygenation. A literature review summarizes the syndrome of cardiogenic shock associated with prolonged propofol infusion. This is the first report of survival in this syndrome resulting from mechanical circulatory support.

Successful Treatment of Aspergillus Prosthetic Valve Endocarditis with Oral Voriconazole

Aspergillus endocarditis is very difficult to cure, even with aggressive surgical debridement and antifungal therapy. Patients with embolic involvement of the central nervous system have an extremely poor prognosis. We describe a patient with prosthetic valve endocarditis due to Aspergillus fumigatus who developed emboli in the brain, eye, and lower extremities. With aggressive surgical debridement of involved sites, aortic valve and root replacement, and long-term therapy with oral voriconazole, he remains without any evidence of infection 2 years later.

Antiphospholipid Syndrome: Intraoperative and Postoperative Anticoagulation in Cardiac Surgery

HE ANTIPHOSPHOLIPID SYNDROME (APLS) is a disorder characterized by arterial and/or venous thrombosis or recurrent fetal loss accompanied by persistent APL antibodies. 1 APL antibodies are a heterogenous group of antibodies that interact with anionic phospholipid cardiolipin (diphosphatidylglycerol) and other phospholipid-binding protein cofactors, the major one being the serum protein 2glycoprotein I (also known as apolipoprotein H). Although these patients are at an increased risk of thrombotic complications, they paradoxically have an abnormal profile of coagulation testing exhibiting prolonged activated partial thromboplastin time (aPTT). Patients with APLS are at risk for recurrent vascular occlusive disease (cerebrovascular accident, migraine headaches, and deep venous thrombosis) and other systemic manifestations (myocardial infarction, endocarditis, and pulmonary embolism). 2 They can develop vasculo-occlusive complications before surgery with the reversal of preoperative anticoagulation, intraoperatively because of inadequate anticoagulation during bypass, and postoperatively before adequate anticoagulation is achieved. The risk of perioperative complications is of critical importance during cardiovascular surgical procedures. In two retrospective case series, 8 of 9 patients in one study and 16 of 19 patients in the other developed major complications including cerebrovascular accident, myocardial infarction, and vena caval thrombosis. 3,4 Perioperative diagnosis and management of these patients can be especially challenging. The conduct of anticoagulation for cardiopulmonary bypass in patients having APLS is not readily apparent, especially in those patients showing the phenomenon of a “lupus anticoagulant,” which prolongs the aPTT but does not protect the patient from thrombosis. Moreover, prolongation of the aPTT complicates monitoring the effects of heparin, Warfarin, and other anticoagulants. 5 There is no consensus regarding intraoperative management of anticoagulation in patients with the APLS. A search of the literature yielded 6 other cases of patients with APL antibodies that detailed the anticoagulation strategy for cardiopulmonary bypass; each case was managed using a different approach. The management of anticoagulation for a woman with APLS undergoing mitral valve repair and a review of the other management strategies is described.

What does transesophageal echocardiography add to valvular heart surgery

No single monitoring tool in the last decade has had more of an effect on intraoperative decision making and surgical management of cardiac valvular pathologies than has TEE. It has become the standard of care for evaluating reparative valvular procedures, thus providing an immediate gauge of the surgical results and helping to avoid suboptimal surgical outcomes. As the technology of TEE and its application advance, so too should the ability to diagnose and manage valvular pathologies, broaden the range of surgical options, and ultimately improve patient outcomes.

Pseudoaneurysm of the Ascending Aorta After Aortic Valve Replacement

A 58-year-old man with fever and chest wall tenderness was seen 8 weeks after aortic valve replacement. His initial postoperative course had been complicated by mediastinitis, requiring antibiotics and surgical debridement. A transthoracic echocardiogram did not reveal the culprit lesion. Pseudoaneurysm of the ascending aorta was suspected, based on computerized tomographic and magnetic resonance images of the chest. Intraoperative transesophageal echocardiography confirmed the diagnosis of pseudoaneurysm and was a key component in the patients operative management.

Intracardiac Thrombosis after Emergent Prothrombin Complex Concentrate Administration for Warfarin Reversal

458 August 2015 R ECENTLY published clinical practice guidelines recommend prothrombin complex concentrate (PCC) for urgent reversal of vitamin k antagonists.1,2 Both three-factor and four-factor PCC have been shown to be superior to fresh-frozen plasma for international normalized ratio normalization; with the added benefit of quicker access and administration, decreased transfusion-related morbidity, and fewer adverse events secondary to volume overload. A 74-yr-old, 67-kg female who previously received a mechanical mitral valve replacement was dosed 3,420 units of Profilnine (threefactor PCC) for urgent reversal of warfarin (international normalized ratio 5.5/prothrombin time 54.4) in preparation for emergent cervical spine surgery due to cord compression. Fifty-five minutes after PCC administration, the patient developed hypoxia and hemodynamic instability. Advanced cardiac life support was initiated. Emergent transesophageal echo revealed extensive thrombus of the mechanical mitral valve (fig. A) and the descending thoracic aorta (fig. B). Thromboembolic events, especially during anesthesia, are a rare but known side effect of PCC administration. A recently completed prospective, randomized, multicenter study comparing PCC with fresh-frozen plasma found thrombotic events occurred in 3.9% of patients treated with PCC.3 Rapid international normalized ratio normalization has been documented in doses ranging from 12.5 to 50 units/kg; however, a clinically effective yet safe dose of PCC before surgery has yet to be determined. When considering PCC administration, the patients’ native hemostatic mechanism must be considered. Patients with underlying thrombogenic potential may benefit from decreased PCC dose or alternative therapeutic options to avoid stroke, pulmonary embolism, myocardial ischemia, or death due to PCC-related thromboembolic events.

Infected Patent Ductus Arteriosus

Patent ductus arteriosus (PDA) is a common congenital abnormality that is associated with left-to-right shunting and risk of endocarditis. Percutaneous closure is now often recommended to prevent risk of endocarditis. A 64-year-old male with a history of a small patent ductus arteriosus was admitted with 2 months’ history of intermittent fevers, chills, and muscle aches. Blood cultures at our institution grew Gamella species. Transthoracic echocardiography demonstrated a PDA with left-to-right shunting by color Doppler, with normal right heart size and pulmonary pressures. Transesophageal echocardiography demonstrated …

Stroke After Aortic Valve Surgery

Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P=0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P=0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P =0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P =0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality. # CLINICAL PERSPECTIVE {#article-title-47}

Clinical Management of Cardiogenic Shock Associated with Prolonged Propofol Infusion: [2002][A-208]

This case report details the development of cardiogenic shock after craniotomy in a patient sedated with a propofol infusion. The patient survived with the assistance of extracorporeal membrane oxygenation. A literature review summarizes the syndrome of cardiogenic shock associated with prolonged propofol infusion. This is the first report of survival in this syndrome resuiting from mechanical circulatory support.