Brett Cronin

Case 13--2014: Management of pulmonary hemorrhage after pulmonary endarterectomy with venovenous extracorporeal membrane oxygenation without systemic anticoagulation.

From the *University of California, San Diego, Thornton Hospital, †University of Chicago, Chicago, IL, ‡University of Pittsburgh, Pittsburgh, PA; and §Duke University Medical Center, Durham, NC. Address reprint requests to Brett Cronin, MD, Dept. of Anesthesiology, University of California, San Diego, Thornton Hospital, 9300 Campus Point Drive #7770, La Jolla, CA 92037. E-mail: bcronin@ ucsd.edu

Pulmonary Artery Catheter Placement Using Transesophageal Echocardiography

OBJECTIVE To assess the feasibility of pulmonary artery catheter placement using transesophageal echocardiography inclusive of a description of the technique. DESIGN A prospective, proof-of-concept study. SETTING Single university hospital. PARTICIPANTS Twenty patients with chronic thromboembolic pulmonary hypertension scheduled for pulmonary thromboendarterectomy. INTERVENTIONS Pulmonary artery catheters were placed in 20 patients solely by transesophageal echocardiographic guidance. MEASUREMENTS AND MAIN RESULTS Placement of the pulmonary artery catheter in the pulmonary artery with transesophageal echocardiography guidance in fewer than 10 minutes was considered successful placement. The time to placement was measured from advancement of the pulmonary artery catheter in the superior vena cava (20 cm) to a final location at the junction of the right pulmonary artery and main pulmonary artery. All 20 pulmonary artery catheters were placed successfully using transesophageal echocardiography guidance and the median time to placement was 43 seconds. In 9 of the 20 patients (45%), the catheter was placed successfully on the first attempt without any adjustments. However, in 9 others (45%), the catheter required manipulation under transesophageal echocardiography vision. In 3 patients (15%), the pulmonary artery catheter was observed to be coiled in the right atrium and in 1 instance (5%) manipulation of the catheter in the right ventricle was required to enter the outflow tract. CONCLUSIONS Transesophageal echocardiography is a viable adjunctive method to conventional pressure waveform placement of pulmonary artery catheters in potentially difficult patients.

Perioperative Interrogation of St. Jude Cardiovascular Implantable Electronic Devices: A Guide for Anesthesiologists

Feelings of trepidation or uncertainty regarding cardiovascular implantable electronic devices (CIEDs) in the perioperative period can often be mitigated by a thorough knowledge of societal recommendations, recommended management options, and familiarity with CIEDs. Given that effective interpretation of an interrogation report is vital to determining perioperative management options and applying societal recommendations, the creation and interpretation of St. Jude CIED interrogation reports are discussed. In an effort to increase the familiarity with St. Jude transvenous CIEDs amongst anesthesiologists, basic programming of a St. Jude pacemaker and implantable cardioverter defibrillator (ICD) also are described.

Intraoperative Three Dimensional Echocardiography Derived Right Ventricular Volumetric Analysis in Chronic Thromboembolic Pulmonary Hypertension Patients Before and After Pulmonary Thromboendarterectomy

OBJECTIVES To assess the change in 3-dimensional (3D) echocardiography-derived right ventricular volumes before and after pulmonary thromboendarterectomy (PTE) and to evaluate the correlation of these variables with right heart catheterization-calculated pulmonary vascular resistance (PVR). SETTING Single university hospitals. PARTICIPANTS Patients undergoing elective PTE surgery between November 2016 and February 2018. METHODS All patients received a pulmonary artery catheter and arterial line, and transesophageal echocardiographic monitoring was performed. Transesophageal echocardiographic monitoring before surgery (pre-PTE) and postsurgery (post-PTE) included comprehensive 2D examinations and 3D right ventricular data set acquisition for offline volumetric analysis. Right ventricular fractional area of change (RVFAC) was measured from a right ventricular-focused midesophageal 4-chamber view. TomTec-Arena 4D RV-Function 2.0 offline software (TomTec Imaging Systems GmbH, Unterschlessheim, Germany) was used to measure right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), and right ventricular ejection fraction (RVEF). Paired t tests were used to evaluate for differences before and after surgery, and echocardiographic variables versus PVR were analyzed with linear regression. RESULTS Forty patients were scheduled for elective PTE surgery; 35 patients had complete hemodynamic profiles and echocardiographic data sets and were included in the evaluation. Mean pulmonary artery pressure decreased from 40 ± 11 to 28 ± 7 mmHg, and PVR decreased from 708 ± 432 to 285 ± 136 dynes*s/cm5 after PTE. RVEDV decreased from 106 ± 43 to 79 ± 35 cm3 (p < 0.001), and RVESV decreased from 77 ± 36 to 59 ± 31 cm3 (p < 0.001). A statistically significant change was not identified in RVEF or RVFAC post-PTE compared with pre-PTE values. All volumetric analyses and RVFAC correlated poorly with PVR (pre-PTE RVEDV correlation to PVR [R2 = 0.004]; post-PTE RVEDV correlation to PVR [R2 = 0.024]). CONCLUSION Even though RVEDV and RVESV displayed a statistically significant change after PTE, this study did not identify a correlation between those variables and PVR. In addition, markers of right ventricular systolic function (eg, RVFAC and RVEF) did not correlate with PVR. Therefore, the authors conclude that even though these echocardiographic measurements quantified a statistically significant change after PVR reduction, they cannot be reliably used as a surrogate marker of success immediately after PTE.

Pulmonary Artery Catheter Placement Aided by Transesophageal Echocardiography versus Pressure Waveform Transduction

OBJECTIVE To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. DESIGN A prospective, randomized trial. SETTING Single university hospital. PARTICIPANTS Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. INTERVENTIONS PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. MEASUREMENTS AND MAIN RESULTS Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. CONCLUSION TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.

Hemodynamic Consequence of Hand Ventilation Versus Machine Ventilation During Transport After Cardiac Surgery

OBJECTIVES The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO2 during transport and hemodynamic parameters in patients post-cardiac surgery. DESIGN A prospective, randomized trial. SETTING A university-affiliated tertiary care hospital. PARTICIPANTS Cardiac surgery patients. INTERVENTIONS Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO2) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. MEASUREMENTS AND MAIN RESULTS Outcomes were changes from baseline in end-tidal CO2, hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PAmean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. CONCLUSIONS Hand ventilation during transport was associated with greater change from baseline of ETCO2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated.

Imaging Artifacts and Common Misdiagnoses

The ability to identify imaging artifacts and normal anatomic variants commonly encountered during a TEE exam can be as important as identifying normal anatomy and function. Lack of knowledge regarding these anatomic structures and imaging artifacts can result in misdiagnoses and adverse effects for patients. Anatomic variants commonly encountered in a TEE exam include Lambl’s Excrescences, Eustachian Valve, Chiari Network, Moderator Band, Crista Terminalis, Nodules of Arantius, and the Coumadin Ridge. Imaging artifacts that result from the violation of the basic assumptions of ultrasound physics include Dropout, Acoustic Shadowing, Side Lobes, Reverberation, and Mirroring. The focus of this chapter will be the identification of the aforementioned anatomic variants/imaging artifacts and the general techniques the echocardiographer can utilize to distinguish them from pathology.

Low Cardiac Output After Orthotopic Heart Transplant Secondary to Large Inferior Vena Cava Thrombus After Prothrombin Complex.

Low cardiac output after orthotopic heart transplant (OHT) may be attributed to inadequate preload, vasodilation, and/or reduced inotropy. Inadequate preload because of an inferior vena cava (IVC) thrombus is a rare cause of low cardiac output and not frequently described in the literature. Although the use of prothrombin complex (PCC) has been associated with thrombus formation, its contribution to life-threatening IVC thrombosis has yet to be described. This case report describes the use of perioperative ultrasound in the diagnosis and management of a low cardiac output state induced by an IVC thrombus in an OHT recipient who received PCC.