Enisa M. Carvalho

Pulmonary embolectomy: recommendation for early surgical intervention.

Abstract  Background: Acute pulmonary embolism (PE) is a life‐threatening disease which often results in death if not diagnosed early and treated aggressively. Despite all efforts at improving outcomes, there is no consensus on the management of acute severe PE. Methods: From May 2000 to June 2009, 16 consecutive patients underwent surgical pulmonary embolectomy at our institution. Mean age was 45 ± 17 years (range, 14 to 76) with nine (56%) males and seven (43%) females. Preoperatively, all cases were classified as massive PE; seven (43%) patients were in hemodynamic collapse and emergently underwent operation while receiving cardiopulmonary resuscitation. Results: There were nine (56%) urgent/emergent and seven (44%) salvage patients undergoing surgical pulmonary embolectomy. Of nine nonsalvage patients, seven (77%) patients presented with moderate to severe right ventricular (RV) dilation/dysfunction. Mean cardiopulmonary bypass time was 43 ± 41 minutes (range, 9 to 161). Mean follow‐up duration was 48 ± 38 months (range: 0.3 to 109), with seven in‐hospital deaths (43%): mortality was 11% (1/9) in emergent operations and 85% (6/7) in salvage operations. Conclusions: Surgical pulmonary embolectomy should be considered early in the management of hemodynamically stable patients with PE who show evidence of RV dilation and/or failure, as it is associated with satisfactory outcomes. Conversely, pulmonary embolectomy has dismal results under salvage conditions. Revision of current guidelines for the surgical management of this condition may be warranted. (J Card Surg 2010;25:261‐266)

Pulmonary protection during cardiac surgery: systematic literature review.

Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.

Catechol-o-methyltransferase polymorphisms predict opioid consumption in postoperative pain.

BACKGROUND:Previous studies have associated the catechol-O-methyltransferase (COMT) enzyme rs4680 polymorphism with opioid consumption in the treatment of chronic cancer pain. In this study, we evaluated the association between COMT rs4680 and rs4818 polymorphisms and opioid consumption in the acute postoperative period after a nephrectomy. METHODS:Opioid consumption and pain scores were evaluated in 152 patients for 48 hours after nephrectomy. The genotype of each patient was determined using polymerase chain reaction on DNA extracted from blood samples. The association between rs4680 and rs4818 genotypes and opioid consumption was evaluated using general linear model regression analysis. All P values and confidence intervals were Bonferroni corrected for the 3 comparisons among genotypes. RESULTS:In the 24-hour period after surgery (COMT rs4680), patients homozygous for the variant Val/Val consumed 36% (95% confidence interval, 31%–41%) more opioids than patients homozygous for the Met/Met group (P = 0.009). No statistically significant differences among the 3 genotype groups were noted for pain scores or emesis medication use in the first 24 hours after surgery. There was a statistically significant increase in emesis medication use in patients possessing the CC genotype of rs4818 when compared to patients carrying the GG genotypes (P = 0.035). In the 6- to 48-hour postsurgery period, there was significantly higher opioid consumption in the high-activity homozygotes Val/Val than in the homozygous Met/Met group for COMT rs4680 (0–6 h: P = 0.005; 0–12 h: P = 0.015; 0–24 h: P = 0.015; and 0–48 h: P = 0.023). Patients in the homozygous GG group COMT rs4818 single nucleotide polymorphism showed statistically significant differences in opioid consumption in the first 6 hours after nephrectomy compared with heterozygous CG patients (P = 0.02). CONCLUSIONS:The genetic variant of the COMT rs4680 single nucleotide polymorphism is associated with variability in opioid consumption in postoperative nephrectomy patients. The COMT rs4818 polymorphism may prove useful in predicting emesis medication use postoperatively.

Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery

Abstract  Background: Acute type A aortic dissection (ATAAD) is a life‐threatening disease entity. Untreated, it usually results in death due to rupture of the proximal aorta into the pericardial cavity, leading to cardiac tamponade. Should patients who have had prior cardiac surgery presenting with ATAAD be treated emergently with surgery, or should they be managed medically? We herein present preliminary evidence that suggests that medical treatment, at least initially, is the best option for these patients. Surgery is indicated in the follow‐up, depending on increased size of the dissection or aorta, or to prevent or treat complications. Patients and Methods: From January 2004 to November 2009, ten consecutive male patients with prior cardiac surgery were admitted to hospital with the diagnosis of ATAAD. Mean age was 61.90 ± 14.68 years (range, 36 to 79 years), with nine (90%) males and one (10%) female. All were treated medically as the definitive form of management. Results: Mean follow‐up duration was 14.62 ± 11.12 months (range, 1 to 31 months). Overall mortality during follow‐up was 20% (two patients). Eight patients (80%) are alive and well. Conclusions: This initial experience with a small, consecutive series of patients, suggests that medical treatment is an option in the initial management of patients with ATAAD who had prior cardiac surgery. It appears that emergency surgery is seldom needed. A larger series of patients and longer follow‐up period are needed prior to recommending this treatment approach for such patients. (J Card Surg 2010;25:387‐389)

Modified Cabrol Shunt After Complex Aortic Surgery

Uncontrollable hemorrhage during complex aortic surgery was controlled by a new modification of the Cabrol shunt, which is reported here.

Gas Exchange During Lung Perfusion/Ventilation During Cardiopulmonary Bypass: Preliminary Results of A Pilot Study

Lung perfusion/ventilation was introduced as a means to minimize cardiopulmonary (CPB)-related pulmonary ischemic injury. Current results in the literature are divergent, and the role of gas exchange during lung perfusion/ventilation during CPB, remains undefined. This report details a) the technique of continuous lung perfusion/ventilation during CPB, b) provides initial observations, and c) discusses gas exchange during CPB.

Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery

Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off‐pump surgery.

Insertion of right ventricular assist device and its removal under local anesthesia.

Abstract  A patient with acute right ventricular infarction was treated with coronary artery bypass grafting. A few days later developed right ventricular failure and required insertion of a right ventricular assist device through a sternotomy approach (TandemHeart®, CardiacAssist, Inc., Pittsburgh, PA, USA). We herein report a technique in which the removal of the right ventricular assist device is performed under local anesthesia without a sternotomy incision. (J Card Surg 2010;25:113‐115)

Postoperative Cardiac Arrest after Heart Surgery: Does Extracorporeal Perfusion Support a Paradigm Change in Management?

Early institution of extracorporeal perfusion support (ECPS) may improve survival after cardiac arrest. Two patients sustained unexpected cardiac arrest in the Intensive Care Unit (ICU) following cardiac interventions. ECPS was initiated due to failure to restore hemodynamics after prolonged (over 60 minutes) advanced cardiac life support (ACLS) protocol-guided cardiopulmonary resuscitation. Despite relatively late institution of ECPS, both patients survived with preserved neurological function. This communication focuses on the utility of ECPS in the ICU as a part of resuscitative efforts.

Two Hearts in One Chest: Transesophageal Echocardiography Images of a Heterotopic Heart Transplant

A 77-year-old man presented for right video-assisted thoracoscopy, pleural biopsy, and pleurodesis. His medical history was significant for nonischemic cardiomyopathy with pulmonary hypertension, for which he had undergone a heterotopic heart transplant 7 years earlier, as well as chronic obstructive pulmonary disease, hypertension, and diabetes mellitus. Written informed consent for this presentation was obtained from the patient. Intraoperatively, transesophageal echocardiography (TEE) was used as a monitoring tool. Transgastric (TG) short-axis imaging visualized a severely dilated and hypokinetic native left ventricle (LV). Slight rotation to the right allowed an appreciation of the preserved native right ventricle (RV) function (Video 1, Clip 1 and Clip 2, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). Slowly withdrawing the transducer to the midesophageal (ME) 4-chamber view revealed spontaneous echo contrast in the native left atrium (LA) and LV and a continuous (systolic and diastolic) aortic insufficiency jet, as well as mild mitral insufficiency (Video 1, Clip 3, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). Color Doppler examination reveals continuous aortic insufficiency and mild mitral insufficiency. The donor heart was visualized to the right of the native heart in the right chest. Slowly turning the transducer rightward from the 4-chamber view of the native heart, after the wide connection between the native and donor left atria, allowed for a simultaneous visualization of the ME 4-chamber view of the native heart and the ME 2-chamber view of the donor left heart (Video 1, Clip 4, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). Anteflexion of the probe brought the ME short axis of the donor aortic valve into view (Video 1, Clip 5, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). Rotation of the imaging plane to 83° obtained the ME long-axis view of the donor LV and aortic valve (Video 1, Clip 6, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). TG short-axis view of the native LV (Video 1, Clip 7, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption) was obtained by slow advancement of the slightly anteflexed transducer and a backward rotation of the imaging plane (23° in our patient). The same view could also be obtained by a rightward turn from the TG short-axis view of the native heart with a slight withdrawal of the probe. Donor LV systolic function was preserved and the mitral and aortic valves were competent. Spontaneous echo contrast was seen entering the donor LA from the native LA. The donor RV could not be visualized because of the intervening air in the right pleural cavity during the right thoracoscopy. Postoperatively, the patient was noted to have sustained a mild embolic stroke despite stable hemodynamic and cerebral oximetry values and an unchanged TEE examination.