Emily J. MacKay

Aortic Regurgitation in Acute Type-A Aortic Dissection: A Clinical Classification for the Perioperative Echocardiographer in the Era of the Functional Aortic Annulus

The functional aortic annulus offer s a clinical approach for the perioperative echocardiographer to classify the mechanisms of aortic regurgitation in acute type A dissection. Comprehensive interrogation of the functional aortic annulus in this setting by TEE can guide surgical therapy for the aortic root by considering the following important aspects: severity and mechanism of aortic regurgitation; extent of root dissection; and, the pattern of coronary artery involvement. The final choice of surgical therapy should also take into account factors such as patient presentation and surgical experience to limit mortality and morbidity from this challenging acute aortic syndrome. This review explores these concepts in detail within the framework of the functional aortic annulus, detailed anatomical considerations, and the latest literature.The functional aortic annulus offers a clinical approach for the perioperative echocardiographer to classify the mechanisms of aortic regurgitation in acute type-A dissection. Comprehensive examination of the functional aortic annulus in this setting using transesophageal echocardiography can guide surgical therapy for the aortic root by considering the following important aspects: severity and mechanism of aortic regurgitation, extent of root dissection, and the pattern of coronary artery involvement. The final choice of surgical therapy also should take into account factors, such as patient presentation and surgical experience, to limit mortality and morbidity from this challenging acute aortic syndrome. This review explores these concepts in detail within the framework of the functional aortic annulus, detailed anatomic considerations, and the latest literature.

Surgical Aortic Valve Replacement—Clinical Update on Recent Advances in the Contemporary Era

From the *Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, AZ, †Department of Anesthesiology and Critical Care; and §Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Address reprint requests to John G. Augoustides, MD, Professor Anesthesiology and Critical Care, Dulles 680, HUP, 3400 Spruce Street, Philadelphia, PA, 191014. E-mail: yiandoc@hotmail.com

Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm

Audrey Spelde, MD n , Toby Steinberg, MD n , Prakash A. Patel, MD n , Harry Garcia, MD n , Jeremy D. Kukafka, MD n , Emily MacKay, DO n , Jacob T. Gutsche, MD n , Jonathan Frogel, MD n , Michael Fabbro, DO † , Jessie M. Raiten, MD ‡ , John G.T. Augoustides, MD, FASE, FAHA n,1 Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

OBJECTIVE The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery. DESIGN This study was a retrospective cohort analysis. SETTING The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015. PARTICIPANTS The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery. INTERVENTIONS This was an observational analysis without interventions. MEASUREMENTS AND MAIN RESULTS Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001). CONCLUSION Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.

Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis

Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA

Reducing Perioperative Mortality with the Intra-Aortic Balloon Pump

The intra-aortic balloon pump (IABP) enhances myocardial performance by minimizing oxygen supply/demand mismatch [1–6]. Balloon inflation during diastole enhances myocardial oxygen delivery due to increased diastolic coronary perfusion pressure [4–6]. Balloon deflation just prior to systole reduces myocardial oxygen demand by unloading the left ventricle [4–6]. Recent evidence has identified the IABP as a therapeutic modality that may reduce perioperative mortality due to these myocardial benefits [1–3].