Cory Maxwell

Surgically Placed Left Ventricular Leads Provide Similar Outcomes to Percutaneous Leads in Patients with Failed Coronary Sinus Lead Placement

BACKGROUND Cardiac resynchronization therapy using a left ventricular (LV) lead inserted via the coronary sinus (CS) improves symptoms of congestive heart failure, decreases hospitalizations, and improves survival. An epicardial LV lead is often placed surgically after a failed percutaneous attempt, but whether it offers the same benefits is unknown. OBJECTIVE The purpose of this study was to determine if patients who receive a surgical LV lead after failed CS lead placement for cardiac resynchronization therapy derive the same benefit as do patients with a successfully placed CS lead. METHODS A total of 452 patients underwent attempted CS lead insertion. Forty-five patients who had failed CS lead placement and then had surgical LV lead placement were matched with 135 patients who had successful CS lead placement. RESULTS No major differences in preoperative variables were seen between groups. Postprocedural complications of acute renal injury (26.2% vs 4.9%, P <.001) and infection (11.9% vs 2.4%, P = .03) were more common in the surgical group. Mean long-term follow-up was 32.4 +/- 17.5 months for surgical patients and 39.4 +/- 14.8 months for percutaneous patients. At follow-up, all-cause mortality (30.6% vs 23.8%, P = .22) and readmission for congestive heart failure (26.2% vs 31.5%, P = .53) were similar between surgical and percutaneous groups. Improvement in New York Heart Association functional class (60.1% vs 49.6%, P = .17) was similar between surgical and percutaneous groups. CONCLUSION Surgical LV lead placement offers functional benefits similar to those of percutaneous placement but with greater risk of perioperative complications, including acute renal failure and infection.

New developments in the treatment of acute pain after thoracic surgery.

Purpose of review This review examines recent advances and findings in the field of pain management in patients undergoing thoracic surgery. Recent findings Acute and chronic postoperative pain continues to remain a major problem and a primary concern for patients. Although thoracic epidural analgesia is still considered a ‘gold standard’, more evidence exists that paravertebral blockade has similar efficacy with a better side-effect and safety profile. The cornerstone of pain management remains a multimodal therapeutic strategy that provides both a central and a peripheral block by combining regional techniques with opioid and nonopioid analgesics. Summary Pain after thoracic surgery has a profound impact on perioperative outcome. Beyond the immediate perioperative period, acute pain contributes to the development of the debilitating chronic pain syndrome. Going forward, both procedural and pharmacologic interventions for acute and chronic pain should be studied in definitive multicenter, well designed randomized clinical trials.

Assessment of Coronary Blood Flow by Transesophageal Echocardiography.

A 49-YEAR-OLD MALE presented in extremis after 3 weeks of malaise. Preoperative transthoracic echocardiography showed mild mitral regurgitation, mild pulmonic valve insufficiency (PI), and severe aortic insufficiency (AI) with a large mobile target on the aortic valve. Left heart catheterization confirmed the presence of severe AI and showed the presence of left-dominant circulation and the proximal occlusion of the left circumflex coronary artery (LCx) by a pseudoaneurysm of the aortic annulus lateral to the left coronary sinus of Valsalva (Fig 1). The patient was taken to the operating room for aortic valve conduit root replacement with coronary reconstruction (Bentall procedure) and possible coronary artery bypass graft (CABG) of the LCx. The prebypass intraoperative transesophageal echocardiographic (TEE) examination confirmed the findings of the preoperative studies but also showed severe PI and wall motion abnormalities in the inferior and lateral walls, consistent with left-dominant coronary circulation and LCx ischemia (Video 1). The patient underwent a Bentall procedure with a 21-mm Medtronic Freestyle porcine root (Medtronic, Minneapolis, MN), pulmonic valve replacement with a 27-mm CarpentierEdwards Perimount Magna pericardial valve (Edwards Lifesciences, Irvine CA), and saphenous vein harvest in anticipation of possible CABG. After excision of the aortic root pseudoaneurysm, the LCx artery looked normal during surgical inspection. Therefore, the decision was made to forego grafting of the LCx. The patient was successfully weaned from cardiopulmonary bypass (CPB). After the patient was weaned from CPB, TEE showed well-positioned and well-functioning aortic and pulmonic prosthetic valves but persistence of wall motion abnormalities in the LCx territory. Should CABG of the LCx be performed at this time due to the possibility of damage to the LCx after prolonged compression?

Encouraging single-unit transfusions: a superior patient blood management strategy?

S ince the Transfusion Requirements in Critical Care (TRICC) trial published in 1999 demonstrated equivalent or improved outcomes when using a restrictive versus a liberal transfusion threshold in critically ill patients, providers and institutions have sought to decrease utilization of allogeneic red blood cells by promoting restrictive transfusion practices. Since that landmark trial, multiple other studies in different populations, including patients undergoing cardiac surgery, elderly patients undergoing hip replacement, medical patients with gastrointestinal bleeds, and patients with traumatic brain injury, have redemonstrated the equivalence or superiority of restrictive over liberal transfusion thresholds with regard to patient outcomes. However, despite a growing body of evidence supporting this practice, individuals and institutions have found it surprisingly difficult to adhere to these guidelines. Nonetheless, there remain multiple motivations for reducing superfluous transfusion; blood products are a finite resource subject to shortage, there are numerous risks associated with transfusion, and transfusion is an expensive endeavor from both direct (acquisition) and indirect (materials, labor, administration) costs. With the rising costs of health care, particular attention has been paid to areas of potential waste, including unnecessary transfusion. Blood transfusion remains one of the most common procedures performed in hospitals, with nearly 21 million blood components transfused in the United States each year. At the Joint Commission’s National Summit on Overuse in 2012, blood transfusion was listed as the number one most overused procedure; and, although it is difficult to retrospectively determine the appropriateness of all transfusions, studies have demonstrated significant variability in the transfusion practices of different providers, suggesting the potential for substantial waste. One single-institution study found that nearly half (47.8%) of transfusions had an inadequate indication, leading to a direct, five-figure cost to the center. With an acquisition cost of approximately

Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins

300 per unit of red blood cells and greater than 10 million units transfused in the United States alone, the economic impact of transfusions with questionable indications may be greater than

Intraoperative, Real-Time Three-Dimensional Transesophageal Echocardiography for the Transcatheter Placement of an Edwards SAPIEN Aortic Valve in the Mitral Position for Severe Mitral Stenosis.

3 billion annually. Furthermore, these costs do not include either the indirect costs, which are estimated to drive the total cost of transfusion three to four times the acquisition cost, or the cost associated with treating any one of the numerous complications that can occur with transfusion. With this significant potential to reduce waste and cost, attention has focused on how different patient blood management (PBM) programs can help hospitals to decrease blood utilization. Although most of the emphasis has remained on hemoglobin triggers with regard to transfusion, the recently published “Choosing Wisely” guidelines from the AABB include a recommendation for single-unit transfusions in stable, anemic patients. In this month’s issue of TRANSFUSION, Dr Yang and colleagues describe the success of these two different PBM strategies to reduce transfusion across three community hospitals. The first strategy, encouraging restrictive hemoglobin triggers, had modest success. Fewer units of blood were ordered when the most recently measured hemoglobin was greater than 8 g/dL; however, in multivariate analysis, hemoglobin trigger was not significantly associated with decreased blood utilization. The second strategy focused on the dose of blood transfused, treating to a target hemoglobin level rather than using a trigger for transfusion by encouraging providers to order only single-unit transfusions in hemodynamically stable, nonbleeding patients. Coined “Why Give 2 When 1 Will Do,” this PBM measure met with superior success and had a significantly greater impact on decreasing blood utilization that remained a major influence after multivariate analysis. The authors speculate that providers may feel more comfortable with decreasing the amount transfused while still ordering a unit when they believe the patient requires it instead of adhering to stricter hemoglobin threshold guidelines. For decades, providers have been taught that, “If you are going to give one, you might as well give two,” stemming from a desire to avoid infectious risks of human immunodeficiency virus and hepatitis during the 1980s, when it was largely believed that single-unit transfusions were unnecessary. Ironically, this policy, which was intended to decrease unneeded transfusions, likely resulted in increased blood utilization; because, rather than doing away with superfluous transfusions (which could be avoided by using restrictive transfusion thresholds), it encouraged over-transfusion in patients who would have benefited sufficiently from a doi:10.1111/trf.14083

Mitral Intervention With Left Ventricular Assist Device: Preparing for Recovery

COLD AGGLUTININS (CA) are circulating autoantibodies that reversibly bind red blood cells, causing agglutination and increased blood viscosity. Because cardiopulmonary bypass (CPB) can involve deliberate hypothermia of the systemic and coronary circulations, the adverse sequelae of CA have been feared and reported under such conditions. The authors present a case of successful perioperative management of a patient in whom CA activation was diagnosed after the initiation of CPB for coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). This patient also had a stenotic coronary sinus (CS), adding to the complexity of management of CPB and administration of cardioplegia. Patient permission was obtained for the publication of this case report.

Differentiating between cold agglutinins and rouleaux: a case series of seven patients:

1456 www.anesthesia-analgesia.org December 2015 • Volume 121 • Number 6 An 83-year-old man with a history of mitral valve replacement 11 years previously and aortic valve replacement (AVR) 5 years previously for rheumatic valve disease presented with symptoms of heart failure because of severe stenosis of the prosthetic mitral valve with a diastolic mean gradient of 23 mm Hg by transthoracic echocardiography. The prosthetic aortic valve was reportedly normal, with a mean systolic gradient of 4 mm Hg. He was deemed to be a poor operative candidate because of advanced age, previous sternotomies, and multiple comorbidities, including chronic atrial fibrillation, chronic obstructive pulmonary disease, and severe tricuspid regurgitation. He was evaluated by the multidisciplinary transcatheter valve team and was determined to have favorable anatomy for a transcatheter mitral valve replacement via a transapical approach. The previous valve was a 25-mm CE Perimount Plus bioprosthesis (Edwards Lifesciences Corporation, Irvine, CA). Written informed consent was obtained for publication of this report. General anesthesia was induced and the procedure progressed without incident. Under fluoroscopic and transesophageal echocardiographic (TEE) monitoring, an Edwards SAPIEN® 26-mm prosthetic valve (Edwards Lifesciences Corporation, Irvine, CA) was deployed. Because of possible foreshortening of the left ventricle (LV) apex by TEE, transthoracic echocardiography was performed before thoracotomy to identify the appropriate incision site to access the true apex for wire insertion. After thoracotomy, the apical location was confirmed by the surgical team through palpation and by TEE. The apex was subsequently cannulated with a 5F sheath for placement of the guidewire. Real-time 3D TEE was used to confirm the placement of the wire through the valve. The sheath was upsized to 24F, and the new prosthetic valve was placed retrograde across the mitral valve and deployed during rapid ventricular pacing, aided by real-time 3D TEE and fluoroscopy. The patient was tracheally extubated at the end of the case and taken to the intensive care unit in stable condition. The patient was discharged home on postoperative day 4, having received no transfusions or inotropic support during or after the procedure. At 1-month follow-up, the patient reported a dramatic improvement in symptoms.

Echocardiographic Confirmation of Coronary Blood Flow

Left ventricular assist device (LVAD) insertion is an increasingly common treatment of advanced heart failure. Insertion guidelines suggest regurgitant lesions of the mitral valve should not be addressed. However, recent evidence suggests that mitral regurgitation may not necessarily improve with LVAD insertion, and such patients may have worse outcomes. Thus, practice variability is high given the discrepancy between traditional thinking and new evidence that unrepaired mitral regurgitation may increase perioperative mortality. Additionally, the challenges of LVADs can make transesophageal echocardiography evaluation and assessment of mitral valve pathology difficult.

Using Zero-Balance Ultrafiltration With Dialysate as a Replacement Solution for Toxin and Eptifibatide Removal on a Dialysis-Dependent Patient During Cardiopulmonary Bypass

We present a case series of seven patients with suspected cold agglutinin antibodies, discovered after initiation of bypass. Laboratory analysis of blood samples intraoperatively determined the cause of the aggregation to be rouleaux formation in three of the patients and cold agglutinins in the other four.