Costin Radu

Anesthesia and Perioperative Management of Patients Who Undergo Transfemoral Transcatheter Aortic Valve Implantation: An Observational Study of General Versus Local/Regional Anesthesia in 125 Consecutive Patients

OBJECTIVE To describe differences in intra- and postoperative care between general (GA) and local/regional anesthesia (LRA) in consecutive high-risk patients with aortic stenosis who underwent transfemoral transcatheter aortic valve implantation (TAVI). DESIGN A retrospective review of data collected in an institutional registry. SETTING An academic hospital. PARTICIPANTS One hundred twenty-five consecutive patients with severe aortic stenosis who underwent transfemoral TAVI. INTERVENTIONS GA versus LRA followed by postoperative care. Complications were defined by pre-established criteria. MATERIAL AND METHODS Consecutive patients referred for transfemoral TAVI between October 2006 and October 2010 initially underwent GA (n = 91) followed by LRA after March 2010 (n= 34). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. GA and LRA TAVI patients had similar preoperative characteristics. LRA was associated with a significantly shorter procedure duration (LRA: 80 [67-102]; GA: 120 [90-140 minutes]; p < 0.001), hospital stay (LRA: 8.5 [7-14.5]; GA: 15.5 [10-24] days; p < 0.001), intraoperative requirements of catecholamines (LRA 23%; GA: 90% of patients; p < 0.001), and volume expansion (LRA: 11 [8-16]; GA: 22 [15-36] mL/kg; p < 0.001). There were significant differences in delta creatinine (day 1, preoperative creatinine values; LRA: 0 [-12 to 9]; GA: -15 (-25 to 2.9) μmol, p < 0.004). The frequency of any postoperative complications was 38% (LRA) and 77% (GA) (p = 0.11). Thirty-day mortality was 7% (GA) and 9% (LRA) (p = 0.9). CONCLUSIONS This observational study suggests that LRA was associated with less intraoperative hemodynamic instability and significant shortening of the procedure and hospital stay. Changes in the anesthetic technique adapted to changes in TAVI interventional techniques and did not increase the rate of postoperative complications.

Transfemoral implantation of an Edwards SAPIEN valve in a tricuspid bioprosthesis without fluoroscopic landmarks.

AIMS We describe the first report of an Edwards SAPIEN valve implanted in a tricuspid bioprosthesis from the femoral vein. We highlight the feasibility of this previously avoided approach and the techniques involved. METHODS AND RESULTS A 61-year-old woman with multiple valve replacements for rheumatic heart disease presented with NHYA IV dyspnoea secondary to a severely stenosed tricuspid bioprosthesis. After failed aggressive medical therapy and surgical turn down, an Edwards SAPIEN XT valve was deployed in the tricuspid bioprosthesis via the right femoral vein. Adaptations to the standard transfemoral transcatheter aortic valve implantation (TAVI) technique included: (1) crossing the tricuspid bioprosthesis with a balloon floatation catheter; (2) temporary pacing wire in the coronary sinus rather than the right ventricle; (3) mounting of the SAPIEN XT valve in the reverse orientation to transfemoral TAVI; and (4) fine positioning of the final valve position pre-deployment by 3D transoesophageal echocardiography (3D TOE) alone due to complete radiolucency of the tricuspid bioprosthesis. The procedure was completed without complication and resulted in significant symptomatic improvement. CONCLUSIONS Deployment of an Edwards SAPIEN valve in a tricuspid bioprosthesis via the femoral vein is feasible and, with careful adaptations to established TAVI techniques, can be performed without complications and with good clinical response.

Outcomes of percutaneous femoral cannulation for venoarterial extracorporeal membrane oxygenation support

Introduction: We report and examine the outcomes of emergency venoarterial extracorporeal membrane oxygenation (ECMO) support initiated via percutaneous cannulation of the femoral vessels. Patients and methods: Fifteen patients undergoing percutaneous venoarterial ECMO under emergency circumstances between January 2009 and July 2011 were identified. The implantation technique employed the Seldinger’s technique for both arterial and venous cannulae. Whenever possible antegrade perfusion of the ipsilateral lower limb was performed through percutaneous catheterization of the superficial femoral artery (SFA). Results: ECMO support was indicated mainly for cardiac arrest (n=9, 60%) or cardiogenic shock (n=4, 27%), while two (13%) patients required ECMO support for acute respiratory failure. In five (33%) patients, ECMO was implanted during cardiopulmonary resuscitation manoeuvres. ECMO support was maintained for a mean of 4.9 days. Eight patients (53%) were successfully weaned from the device. Thirty-day mortality was 53%. Seven patients (47%) suffered early complications, namely two wound infections, one thrombosis of the venous cannula, one erroneous implantation of the arterial cannula into the femoral vein, one local dissection of the femoral artery, one retroperitoneal bleeding and one acute limb ischaemia. No long-term vascular complications were noted. Conclusion: Percutaneous femoral cannulation for ECMO support remains a prompt approach for establishing extracorporeal circulatory support in acute cardiopulmonary failure when conditions for performing femoral vessel cut down are not optimal. However, vascular complications are frequent and carry a significant morbidity and mortality.

Transseptal Implantation of a Transcatheter Heart Valve in a Mitral Annuloplasty Ring to Treat Mitral Repair Failure

A 56-year-old woman was admitted for recurrent, refractory congestive heart failure. When she was aged 17 years, she had a Hodgkin lymphoma treated by chest radiation. She then developed postradiation heart disease, which required surgery in 2004, combining mitral valve repair using a Physio semirigid ring sized 28 mm (Edwards Lifesciences Inc; Irvine, CA) and tricuspid annuloplasty. In March 2009, the patient experienced recurrent congestive heart failure due to mitral valve stenosis. Percutaneous mitral commissurotomy achieved transient symptom relief, but her clinical status severely worsened in the past year. On admission, the patient was in New York Heart Association class IV heart failure. Physical examination showed worrying skin sequelae of chest radiation and severe congestive heart failure. Echocardiography demonstrated severe mitral valve stenosis (mean gradient, 11 mm Hg), regurgitation (grade 3+), dilatation of the right atrium and ventricle, moderate tricuspid regurgitation, and estimated systolic pulmonary artery pressure >60 mm Hg (Move 1). On multislice CT, the anteroposterior diameter of the mitral ring was calculated at 16 mm and the intercommissural diameter at 27 mm. Because repeated surgery carried a prohibitive risk, a transcatheter option was considered. Because of the cutaneous lesions and postradiation cardiomyopathy, the transapical approach was deemed inadequate; thus, it was decided to intervene through the right femoral vein and a transseptal route. After transseptal catheterization and septal dilation with a 10-mm balloon, crossing the mitral valve …

Does a gentamicin-impregnated collagen sponge reduce sternal wound infections in high-risk cardiac surgery patients?

OBJECTIVES Sternal wound infections occurring after cardiac surgery have a critical impact on morbidity, mortality and hospital costs. This study evaluated the efficacy of a gentamicin-collagen sponge in decreasing deep sternal-wound infections in high-risk cardiac surgery patients. METHODS We conducted a quasi-experimental single-centre prospective cohort study in diabetic and/or overweight patients undergoing coronary-artery bypass surgery with bilateral internal mammary artery grafts. The end-point was the rate of reoperation for deep sternal wound infection. The period from January 2006 to October 2008, before the introduction of the gentamicin sponge, was compared with the period from November 2008 to December 2010. RESULTS Of 552 patients (median body mass index, 31.5; 37.7% with diabetes requiring insulin), 68 (12.3%) had deep sternal wound infections. Reoperation for deep sternal wound infections occurred in 40/289 (13.8%) preintervention patients and 22/175 (12.6%) patients managed with the sponge. Independent risk factors were female sex and longer time on mechanical ventilation, but not use of the sponge (adjusted odds ratio, 0.95; 95% confidence interval, 0.52-1.73; P = 0.88). The group managed with the sponge had a higher proportion of gentamicin-resistant micro-organisms (21/27, 77.8%) compared with the other patients (23/56, 41.1%; P < 0.01). The median time to reoperation for wound infection was higher with the sponge (21 vs 17 days, P < 0.01). CONCLUSIONS A gentamicin-collagen sponge was not effective in preventing deep sternal wound infections in high-risk patients. Our results suggest that a substantial proportion of wound contaminations occur after bypass surgery with bilateral internal mammary artery grafts.

Comparison of 2-Dimensional, 3-Dimensional, and Surgical Measurements of the Tricuspid Annulus Size: Clinical Implications.

Background—Associated tricuspid annuloplasty is recommended during left-heart valve surgery when the tricuspid annulus (TA) is dilated but methodology for the measurement of TA size and thresholds for TA enlargement are not clearly defined. Methods and Results—Measurement of the TA diameter (TAD) was prospectively performed using 2-dimensional transthoracic echocardiography (2D-TTE) in 282 patients in 4 different views (parasternal long axis, parasternal short axis, apical 4-chamber [A4C], and subcostal). TAD was also measured using 3D-transesophageal echocardiography in 183 patients (long axis), peroperatively in 120 patients who underwent a tricuspid valve surgery and using TTE (A4C) in 66 healthy volunteers. TAD was significantly different between the 4 2D-TTE views (3.85±0.58, 3.87±0.61, 4.02±0.69, and 3.92±0.65 cm, respectively; P<0.0001) but differences were small and the A4C was the most feasible (76%, 65%, 92%, and 73%, respectively; P<0.0001) and offered the highest reproducibility. TAD measured in A4C view was smaller than when measured by 3D-transesophageal echocardiography (3.90±0.63 versus 4.33±0.62 cm; P<0.0001) but correlation was excellent (r=0.84; P<0.0001) with a systematic 4-mm underestimation. In contrast, 2D-TTE measurements were significantly smaller and only modestly correlated to surgical measurements (4.11±0.61 versus 4.37±0.75 cm; P<0.0001; r=0.57; P<0.0001) which were poorly reproducible. In healthy volunteers, we suggested 42 mm or 23 mm/m2 as pathological values for the TAD in A4C. Conclusions—Measurements of the TAD using 2D-TTE in A4C were highly feasible and reproducible and despite being systematically smaller than 3D measurements, accurately reflected the degree of TA enlargement as assessed using 3D transesophageal echocardiography. We proposed the thresholds that may be used in future prospective studies to demonstrate whether a preventive strategy would improve the outcome.

Transarterial Medtronic CoreValve System Implantation for Degenerated Surgically Implanted Aortic Prostheses

Background— To assess the results of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve System (MCS), through the transarterial approach, in high-risk patients with degenerated surgically implanted aortic bioprostheses (SP). Methods and Results— Of 241 patients who underwent TAVI, 10 (4%) had a degenerated SP. The approach was percutaneous transfemoral in 9 cases and surgical transaxillary in 1. Patients were age 75±10 years of age. All were in New York Heart Association classes III or IV and at high risk for repeated surgery. Seven patients had stented, 2 stentless, and 1 homograft SP. The failure mode was predominant regurgitation in 7 cases and stenosis (aortic valve area, 0.7±0.2 cm2; mean gradient, 58±16 mm Hg) in 3. Based on the echographic measurements, 8 patients received a 26-mm, and 2 a 29-mm-diameter MCS. Procedural success rate was 100%. There was 1 in-hospital death, 1 stroke with moderate sequelae, and 1 pacemaker implantation. There were no other adverse events at 30 days. The mean postimplantation transprosthetic gradient was 13±7 mm Hg; periprosthetic regurgitation was absent or trivial in 9 cases and grade 2 in 1. After a median follow-up of 5 months, there were no additional adverse events. All but 1 of the hospital survivors were in New York Heart Association classes I or II. Conclusions— These results suggest that transarterial MCS implantation in degenerated SP is feasible and may lead to hemodynamic and clinical improvement in patients who are poor candidates for repeated surgery, pending confirmation in larger series with longer follow-up.

Delayed migration of a transfemorally implanted aortic bioprosthesis

CLINICAL SUMMARY An 85-year-old-man with symptomatic aortic stenosis was referred for transcatheter aortic valve implantation. He had a history of diabetes, hypertension, peripheral vascular disease, and patent coronary artery bypass grafts. Transthoracic echocardiography (TTE) and transesophageal echocardiography revealed a moderately calcified tricuspid aortic valve with area of 0.6 cm, mean gradient of 39 mm Hg, subvalvular nonobstructive septal hypertrophy measured at 16 mm, pulmonary artery systolic pressure of 40 mm Hg, and left ventricular ejection fraction of 45%. Aortic valve calcification score according to computed tomographic scan was 2980 Agatston units. The logistic EuroSCORE was 26%, and the Society of Thoracic Surgeons Predicted Risk of Mortality was 9%. Aortic annulus diameter was measured at 20 mm on TTE and transesophageal echocardiography and at 21.4326.1 mm on computed tomographic scan. Femoroiliac vessels were suitable for the transfemoral approach. The procedure was performed under fluoroscopic guidance, as detailed previously elsewhere, with the patient under locoregional anesthesia. Briefly, after insertion of the closing device in the left common femoral artery (Prostar; Abbott Vascular, Santa Clara, Calif), retrograde crossing, and predilatation of the native valve, a 23-mm SapienXT prosthesis (Edwards Lifesciences Inc, Irvine, Calif) was positioned within the aortic valve and delivered by balloon inflation under rapid ventricular pacing. The prosthesis position after implantation was correct according to

Acute Lower Limb Ischemia After Coronary Artery Bypass Grafting

THE INTERNAL MAMMARY ARTERY (IMA) is used as the conduit of choice in coronary artery bypass grafting (CABG) due to its superior long-term outcomes compared to venous grafts. The IMA collateralizes to the external iliac artery by anastomosis with the inferior epigastric artery. In patients with chronic aortoiliac occlusion, arterial perfusion of the lower limbs may be supplied mostly by this collateral pathway. In this case report, the authors describe the occurrence of acute bilateral lower limb ischemia following CABG using bilateral IMA grafts in a patient with severe aortoiliac occlusive disease.

Comparison of 2-Dimensional, 3-Dimensional, and Surgical Measurements of the Tricuspid Annulus Size

Background—Associated tricuspid annuloplasty is recommended during left-heart valve surgery when the tricuspid annulus (TA) is dilated but methodology for the measurement of TA size and thresholds for TA enlargement are not clearly defined. Methods and Results—Measurement of the TA diameter (TAD) was prospectively performed using 2-dimensional transthoracic echocardiography (2D-TTE) in 282 patients in 4 different views (parasternal long axis, parasternal short axis, apical 4-chamber [A4C], and subcostal). TAD was also measured using 3D-transesophageal echocardiography in 183 patients (long axis), peroperatively in 120 patients who underwent a tricuspid valve surgery and using TTE (A4C) in 66 healthy volunteers. TAD was significantly different between the 4 2D-TTE views (3.85±0.58, 3.87±0.61, 4.02±0.69, and 3.92±0.65 cm, respectively; P<0.0001) but differences were small and the A4C was the most feasible (76%, 65%, 92%, and 73%, respectively; P<0.0001) and offered the highest reproducibility. TAD measured in A4C view was smaller than when measured by 3D-transesophageal echocardiography (3.90±0.63 versus 4.33±0.62 cm; P<0.0001) but correlation was excellent (r=0.84; P<0.0001) with a systematic 4-mm underestimation. In contrast, 2D-TTE measurements were significantly smaller and only modestly correlated to surgical measurements (4.11±0.61 versus 4.37±0.75 cm; P<0.0001; r=0.57; P<0.0001) which were poorly reproducible. In healthy volunteers, we suggested 42 mm or 23 mm/m2 as pathological values for the TAD in A4C. Conclusions—Measurements of the TAD using 2D-TTE in A4C were highly feasible and reproducible and despite being systematically smaller than 3D measurements, accurately reflected the degree of TA enlargement as assessed using 3D transesophageal echocardiography. We proposed the thresholds that may be used in future prospective studies to demonstrate whether a preventive strategy would improve the outcome.