Daryl A. Oakes

Safety of transesophageal echocardiography.

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Factor VIII Inhibitor Bypass Activity and Recombinant Activated Factor VII in Cardiac Surgery

OBJECTIVE Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding. DESIGN This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications. SETTING Single university hospital. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULT Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar. CONCLUSIONS This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.

Cardiopulmonary Bypass in 2009 : Achieving and Circulating Best Practices

Christina T. Mora Mangano, MD As an intern at the Massachusetts General Hospital in 1932, Dr. John H. Gibbon Jr lamented the loss of one of his charges, a gravida who succumbed to an amniotic fluid embolus. He wrote, “During that long night’s vigil, the idea occurred to me that the patient’s life might have been saved if some of her cardiorespiratory function might be temporarily taken over by an extracorporeal blood circuit.” So began his more than 20-yr quest to develop an extracorporeal support device that would eventually permit open-heart surgery. In May 1953, at Jefferson College Hospital he culminated this effort with the successful repair of an atrial septal defect in an 18-yr-old woman using what is now known as cardiopulmonary bypass (CPB). This seminal event broke a long-standing barrier, operating on the heart, and initiated the era of modern cardiac surgery. Physicians treating patients suffering previously untreatable cardiac pathology (congenital lesions, valve malformations, coronary artery, and thoracic aortic disease) now had therapeutic options. Today, more than one million cardiac procedures that depend upon CPB are performed annually worldwide. Although the past 50 yr have brought improvements in extracorporeal technology, including improved gas exchange devices, venous reservoir construction, and heparin-coated circuits, the modern extracorporeal circuit is still remarkably similar to that developed a half century ago. However, over the last decade, a large body of research has substantially improved our understanding of the pathophysiology induced by CPB. Although we have learned much, the substantial morbidity still suffered by patients managed with CPB, amply demonstrates that we have more to learn than we have mastered. Adverse outcomes associated with bypass (Type I central nervous system events, 3%–6%; long-term cognitive dysfunction, 15%; renal dysfunction, 7%–9%; hemodialysis, 1%–2%) are substantial. Despite the advances, definitive answers and consensus on optimal practices are unrealized. Fundamental questions remain regarding the management of CPB; for example, what pump flow, arterial blood pressure, temperature, acid-base strategy, hematocrit, or glucose level should be targeted during bypass. This difficulty, in part, reflects the enormity of the task at hand: creation of a mechanical model for the complex and dynamic human circulatory system. This month’s journal features a comprehensive review by Murphy et al. that is substantial and timely. Their effort summarizes the evidence supporting or refuting the use of specific physiological goals during CPB, with particular consideration given to the components of the bypass circuit. The authors characterize the physiological parameters (mean arterial blood pressure, pump flow rate, hematocrit, temperature) and technologies (heparinized versus nonheparinized circuits, arterial line filters, pulsatile versus nonpulsatile pumps, centrifuge versus roller pumps) that may allow for “optimal perfusion.” Their article adds to the ongoing trend in medicine to standardize practices based on the best evidence available. Currently, the management of patients during CPB varies substantially by institution and even by practitioner (including the surgeon, anesthesiologist, or perfusionist involved). Department of Anesthesia, Stanford University, California. Accepted for publication January 9, 2009. Address correspondence and reprint requests to Christina T. Mora Mangano, Department of Anesthesia, Stanford University, Anesthesia, 300 Pasteur Dr., Stanford, CA 94305.Address e-mail to christina.mora@ stanford.edu. Copyright

Factors contributing to adverse perioperative events in adults with congenital heart disease: A structured analysis of cases from the closed claims project

OBJECTIVE Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations. DESIGN The study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database. SETTING We examined the largest national anesthesia malpractice claims database. PATIENTS We included all claims cases involving adult patients with congenital heart disease (CHD). INTERVENTIONS Patients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac). OUTCOME MEASURES Perioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists. RESULTS Of 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases. CONCLUSIONS Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.

The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography.

Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.

Factors contributing to adverse perioperative events in adults with congenital heart disease

OBJECTIVE Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations. DESIGN The study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database. SETTING We examined the largest national anesthesia malpractice claims database. PATIENTS We included all claims cases involving adult patients with congenital heart disease (CHD). INTERVENTIONS Patients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac). OUTCOME MEASURES Perioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists. RESULTS Of 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases. CONCLUSIONS Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.

Factors Contributing to Adverse Perioperative Events in Adults with Congenital Heart Disease: A Structured Analysis of Cases from the Closed Claims Project: Adverse Perioperative Events in ACHD

OBJECTIVE Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations. DESIGN The study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database. SETTING We examined the largest national anesthesia malpractice claims database. PATIENTS We included all claims cases involving adult patients with congenital heart disease (CHD). INTERVENTIONS Patients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac). OUTCOME MEASURES Perioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists. RESULTS Of 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases. CONCLUSIONS Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.

Tricuspid regurgitation jet velocity suggestive of severe pulmonary hypertension.

A 73-YEAR-OLD WOMAN suffered a cardiac arrest in the emergency department waiting room. After prompt resuscitation and admission to the coronary care unit, coronary angiography showed critical stenosis of the left main and left circumflex arteries. An intra-aortic balloon pump was placed, a heparin infusion was initiated, and the patient was brought for urgent coronary artery bypass grafting. Transesophageal echocardiography revealed the unexpected finding of near-systemic right ventricular systolic pressure by tricuspid regurgitation jet velocity on continuous wave Doppler. Midesophageal 4-chamber (Fig 1), midesophageal right ventricular inflowoutflow, and transgastric right ventricular inflow (Fig 2) views revealed a moderate tricuspid regurgitation jet with maximum velocity of 4.88 m/sec, which predicts a right ventricular

Perioperative Management of Combined Carotid and Coronary Artery Bypass Grafting Procedures

The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.