Daniel A. Tolpin

Complications of cerebrospinal fluid drainage after thoracic aortic surgery: A review of 504 patients over 5 years

BACKGROUND Cerebrospinal fluid drainage, a well-established means of preventing paraplegia after thoracic aortic aneurysm surgery, can result in serious, sometimes lethal complications. In a large group of patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage, we examined the incidences of and potential risk factors for these outcomes. METHODS The records were reviewed of 504 patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage at the Texas Heart Institute at St. Lukes Episcopal Hospital between February 2005 and December 2009. All historical data, inpatient records, and billing data were searched for evidence of complications. RESULTS Of the 504 patients, 14 (2.8%) had intracranial hemorrhage, of whom 10 (72%) had subdural hematoma. Postdural puncture headache developed in 49 patients (9.7%), of whom 17 (34.6%) required epidural blood patch placement for resolution. Multivariable analysis identified having a connective tissue disorder (odds ratio, 3.08; 95% confidence interval, 1.33-7.13) as an independent predictor of postdural puncture headache, but not age less than 40 years (odds ratio, 0.97; 95% confidence interval, 0.94-0.99). CONCLUSIONS Cerebrospinal fluid drainage, as performed by our method, seems to be associated with a modest rate of intracranial bleeding in patients who undergo surgical thoracic aortic aneurysm repair. In contrast, postdural puncture headache is not uncommon, particularly in patients with connective tissue disease. Clinicians caring for these patients should consider the likelihood of postdural puncture headache, and any such patient with postoperative headache should be assessed for epidural blood patch placement.

Obesity is associated with increased morbidity after coronary artery bypass graft surgery in patients with renal insufficiency.

OBJECTIVE Although obesity is a major risk factor for cardiovascular disease, it is not clear whether obesity increases the risk of postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting surgery. Increasing evidence suggests that both obesity and renal insufficiency are associated with increased systemic inflammation, thrombogenicity, and endothelial dysfunction. Cardiac surgical patients with comorbid obesity and renal insufficiency might thus be at greater risk for systemic proinflammatory and thrombotic states, which in turn might increase the risk of adverse perioperative outcomes. We investigated the influence of obesity on adverse postoperative outcomes after coronary artery bypass grafting surgery in patients with and without renal insufficiency. METHODS A retrospective cohort study was performed of patients (n = 10,863) undergoing primary coronary artery bypass grafting surgery with cardiopulmonary bypass between January 1995 and June 2005. Patients with preoperative renal insufficiency (n = 1385) and patients with preoperative normal renal function (n = 9478) were further classified as obese (body mass index, > or =30 kg/m(2)) or nonobese (body mass index, 18.5-29.9 kg/m(2)). Multivariate, stepwise logistic regression was performed, controlling for demographic factors, medications, and perioperative risk factors to determine whether obesity is independently associated with an increased risk of adverse postoperative outcomes after coronary artery bypass grafting surgery in patients with or without renal insufficiency. RESULTS Obese patients with preoperative renal insufficiency had higher rates of postoperative myocardial infarction (5.9% vs 3.4%) and low cardiac output syndrome (24.5% vs 18.6%) and increased hospital stay (14.9 +/- 13.7 vs 13.2 +/- 13.0 days) than nonobese patients with preoperative renal insufficiency (all outcomes, P < .05). Multivariate analysis revealed that obese patients with preoperative renal insufficiency were independently associated with an increased risk of postoperative myocardial infarction (odds ratio, 1.82; 95% confidence interval, 1.07-3.07; P < .05) and low cardiac output syndrome (odds ratio, 1.53; 95% confidence interval, 1.15-2.03; P < .01) and increased hospital stay (P < .05). In contrast, obese patients with normal preoperative renal function were independently associated only with an increased risk of postoperative sternal wound infection (odds ratio, 2.55; 95% confidence interval, 1.40-4.67; P < .01) and leg wound infection (odds ratio, 2.27; 95% confidence interval, 1.71-3.02; P < .01). CONCLUSION Obesity is an independent risk factor for increased cardiovascular morbidity and prolonged hospital stay in patients with preoperative renal insufficiency undergoing primary coronary artery bypass grafting surgery.

Randomized, controlled trial comparing the effects of anesthesia with propofol, isoflurane, desflurane and sevoflurane on pain after laparoscopic cholecystectomy

BACKGROUND Pain is the primary complaint and the main reason for prolonged recovery after laparoscopic cholecystectomy. The authors hypothesized that patients undergoing laparoscopic cholecystectomy will have less pain four hours after surgery when receiving maintenance of anesthesia with propofol when compared to isoflurane, desflurane, or sevoflurane. METHODS In this prospective, randomized trial, 80 patients scheduled for laparoscopic cholecystectomy were assigned to propofol, isoflurane, desflurane, or sevoflurane for the maintenance of anesthesia. Our primary outcome was pain measured on the numeric analog scale four hours after surgery. We also recorded intraoperative use of opioids as well as analgesic consumption during the first 24h after surgery. RESULTS There was no statistically significant difference in pain scores four hours after surgery (p=0.72). There were also no statistically significant differences in pain scores between treatment groups during the 24h after surgery (p=0.45). Intraoperative use of fentanyl and morphine did not vary significantly among the groups (p=0.21 and 0.24, respectively). There were no differences in total morphine and hydrocodone/APAP use during the first 24h (p=0.61 and 0.53, respectively). CONCLUSION Patients receiving maintenance of general anesthesia with propofol do not have less pain after laparoscopic cholecystectomy when compared to isoflurane, desflurane, or sevoflurane.

Left atrial dissection associated with pulmonary vein cannulation.

A 46-yr-old man underwent bioprosthetic aortic valve replacement, ascending aortic arch aneurysm repair, and graft repair of the left main coronary artery. The surgery was complicated by postbypass left ventricular failure requiring intraoperative Levitronix (Levitronix GMBH, Waltham, MA) left ventricular assist device (LVAD) placement and subsequent implantation of a HeartMate II LVAD (Thoratec, Pleasanton, CA). Two days after HeartMate II placement and 9 days after the original surgery, the patient returned to the operating room for sternal closure and transesophageal echocardiography (TEE) examination revealing multiple thrombi in the left ventricular outflow tract, aortic root, and right atrium. The surgical plan was altered to include initiation of cardiopulmonary bypass to allow for closure of the aortic valve, revision of the coronary graft, and removal of all visualized clots. Post–cardiopulmonary bypass imaging revealed a new hypoechoic mass between the endocardium and epicardium along the right posterior wall of the left atrium (LA) extending into the lateral wall (Fig. 1) (Video 1; please see video clips available at www.anesthesia-analgesia.org; see Supplemental Digital Content 1, http://links.lww.com/AA/A22, midesophageal, 4-chamber view demonstrating the initial view of a left atrial mass during weaning from cardiopulmonary bypass and initiation of left ventricular assist device [LVAD] flow [with Color flow Doppler]; in this video, the following can be seen: severely depressed left ventricular function and a hypoechoic space between the endocardium and epicardium of the left atrial wall; no communication between the left atrium [LA] and the hypoechoic mass is visualized with color flow Doppler; RA right atrium; RV right ventricle; LV left ventricle). After protamine administration, the mass became more hyperechoic. Intramural dissection was diagnosed. Continued expansion of the intramural hematoma threatened to impede blood flow from the LA into the left ventricle and to reduce LVAD performance (Fig. 2). Direct surgical inspection revealed a large intramural thrombus, which was excised (Video 2; please see video clips available at www.anesthesia-analgesia.org; see Supplemental Digital Content 2, http://links.lww.com/AA/A23, midesophageal, 4-chamber view demonstrating the left atrium [LA] after removal of an intramural thrombus; in this video, the following can be seen: normalization of left atrial size after intramural thrombectomy; left ventricular assist device [LVAD] inflow cannula in the apex of the left ventricle [LV], and a dilated right ventricle [RV]; RA right atrium). Postoperatively, the patient’s clinical condition improved, and he was discharged home with a HeartMate II LVAD to await heart transplantation.

Association Between Preoperative Aspirin-dosing Strategy and Mortality After Coronary Artery Bypass Graft Surgery.

Objective: To determine whether preoperative aspirin—acetylsalicylic acid (ASA)—timing or dose independently affects 30-day all-cause mortality. Background: Preoperative ASA administration is associated with reduced morbidity and mortality after coronary artery bypass graft (CABG). However, data are lacking regarding optimal timing and dosing of ASA. Methods: We retrospectively reviewed data from 3018 consecutive patients who underwent CABG surgery between July 2005 and May 2011. Patients were assigned to 3 groups according to the time of the last preoperative ASA dose: (1) 24 hours or less preoperatively (n = 1173), (2) between 24 and 72 hours (n = 876), and (3) more than 72 hours or none (n = 969). In a separate analysis, patients were grouped according to ASA dose: 81 mg (n = 1285), 325 mg (n = 1004), and none (n = 543). The primary outcome was 30-day all-cause mortality. Results: The 30-day mortality rate was significantly lower in patients who took ASA 24 hours or less preoperatively (1.5%) than in those who took it between 24 and 72 hours (3.2%) or more than 72 hours or none (2.9%). Multivariate analysis showed that ASA within 24 hours preoperatively was associated with reduced mortality (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.20–0.82; P = 0.01). Moreover, mortality was significantly reduced for patients taking 81 mg of ASA (1.4%) compared with 325 mg (2.9%) or none (3.9%). Multivariate analysis demonstrated that 81 mg of ASA decreased mortality risk by 66% (OR, 0.34; 95% CI, 0.18–0.66; P < 0.01), whereas 325 mg of ASA had no mortality benefit (OR, 0.74; 95% CI, 0.41–1.35; P = 0.33) compared with no ASA. Conclusions: Low-dose ASA use within 24 hours of CABG is independently associated with decreased early postoperative mortality.

Anesthetic Management of Patients Undergoing Percutaneous Endocardial and Epicardial Left Atrial Appendage Occlusion

Atrial fibrillation is the most common cardiac arrhythmia in adults affecting almost 6 million adults in the United States. The 2 most common comorbidities associated with atrial fibrillation are heart failure and thromboembolic events. Heart failure symptoms may be treated with rate control, antiarrhythmic medications or by catheter ablation. Unfortunately, despite optimal medical management, thromboembolic events still occur. Recently, there has been a great deal of interest and innovation in finding an alternative to chronic anticoagulation. Several percutaneous left atrial appendage occlusion devices have been developed over recent years, some of which have proven to be noninferior to anticoagulation in preventing strokes in atrial fibrillation patients. The 2 most widely used left atrial appendage occlusion devices are the WATCHMAN (Atritech Inc, Plymouth, MN, USA) and the LARIAT (SentreHEART, Palo Alto, CA, USA) devices. After a detailed description of the procedures, the anesthetic considerations of each procedure and management of specific adverse events are discussed within this review.

Anesthetic Management of Laser Lead Extraction for Cardiovascular Implantable Electronic Devices

Cardiovascular implantable electronic devices (CIEDs) play a significant role in the modern management of cardiovascular disease. CIEDs include implantable pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. These devices improve the quality of life of their recipients and help reduce the incidence of sudden cardiac death. Traditionally, CIEDs have been reliant on the use of transvenous endocardial leads to directly connect with the heart. Over time, these endovascular leads may become endothelialized rendering removal extremely difficult. As the indications for CIEDs expands and with the continuing evolution of these devices, the number of patients requiring explantation for device recall, malfunction, and infection continues to increase. In this manuscript, we review the most common CIEDs, the indications and process of lead removal/device explantation, potential complications associated with the procedure and the anesthetic management of these patients.

Anesthetic Management in Radiofrequency Catheter Ablation of Ventricular Tachycardia

Radiofrequency catheter ablation is increasingly being used to treat patients who have ventricular tachycardia, and anesthesiologists frequently manage their perioperative care. This narrative review is intended to familiarize anesthesiologists with preprocedural, intraprocedural, and postprocedural implications of this ablation. Ventricular tachycardia typically arises from structural heart disease, most often from scar tissue after myocardial infarction. Many patients thus affected will benefit from radiofrequency catheter ablation in the electrophysiology laboratory to ablate the foci of arrhythmogenesis. The pathophysiology of ventricular tachycardia is complex, as are the technical aspects of mapping and ablating these arrhythmias. Patients often have substantial comorbidities and tenuous hemodynamic status, necessitating pharmacologic and mechanical cardiopulmonary support. General anesthesia and monitored anesthesia care, when used for sedation during ablation, can lead to drug interactions and side effects in the presence of ventricular tachycardia, so anesthesiologists should also be aware of potential perioperative complications. We discuss variables that can help anesthesiologists safely guide patients through the challenges of radiofrequency catheter ablation of ventricular tachycardia.

Resection of Celiac Artery Aneurysm with Bypass Grafting to the Splenic and Common Hepatic Arteries

Celiac artery aneurysms are rare and typically warrant surgical treatment. Atherosclerosis is their chief cause. Symptomatic patients usually present with abdominal pain. Surgical resection of celiac artery aneurysms is associated with low morbidity and mortality rates. We report the case of a patient whose 2.2-cm celiac artery aneurysm we resected, with subsequent saphenous vein bypass grafting from the celiac trunk to the splenic and common hepatic arteries. In addition, we briefly discuss other treatment options.

Real-Time Transesophageal Echocardiography for Left Atrial Appendage Ligation Using the LARIAT Snare Device.

1204 www.anesthesia-analgesia.org June 2015 • Volume 120 • Number 6 A 79-year-old woman with a history of refractory atrial fibrillation (AF) presented for elective closedchest percutaneous left atrial appendage (LAA) ligation using the LARIAT snare device and EndoCATH balloon (SentreHEART, Inc., Palo Alto, CA) monitored with real-time transesophageal echocardiography (TEE). This approach uses a percutaneous approach for LAA ligation via the femoral vein and the epicardial space. After induction of general anesthesia, a TEE examination was performed and absence of LAA thrombus was confirmed. A femoral vein sheath was inserted by an interventional cardiologist for transseptal puncture of the atrial septum, for placement of the EndoCATH balloon catheter (SentreHEART, Inc.). An endocardial balloon catheter with a magnet-tipped guidewire was directed to the apex of the LAA using TEE and fluoroscopic guidance (Figs. 1 and 2A; Video 1, http:// links.lww.com/AA/B69). Subsequently, a second magnettipped wire was introduced into the epicardial space from a subxiphoid approach and positioned to make magnetic contact with the tip of the endocardial wire located in the apex of the LAA. The magnetic connection facilitated stabilization of the LAA (Fig. 2B). At this point in time, using real-time TEE guidance and fluoroscopy, it was confirmed that the EndoCATH’s inflated balloon was positioned in the proximal LAA, just past the ostium. Once this was confirmed, an over-the-wire approach was used to guide the LARIAT snare device over the LAA to allow closure and suture ligation of the LAA, once no evidence of color Doppler flow from the left atrium (LA) to the LAA was present (Video 2, http:// links.lww.com/AA/B70). Intraoperative TEE and LA angiography were used to confirm closure of the LAA (Video 3, http://links.lww.com/AA/B71). Patient consent for publication of this case report was obtained.