James Eichelberger

Torsade de Pointes During Orthotopic Liver Transplantation

The patient was a 53-kg, 57-yr-old woman with Child-Pugh grade C alcohol-induced end-stage liver disease who was referred for orthotopic liver transplantation. The patient had a 90 pack/yr smoking history, mild chronic obstructive pulmonary disease, and a previous gunshot wound to the abdomen. Medications included omeprazole, lactulose, spironolactone, furosemide, ipratroprium, and albuterol. Preoperative evaluation included an electrocardiogram (EKG) with sinus rhythm at 66 bpm, a large U wave in lead V,, and an unrecognized mildly prolonged QTc interval of 0.53 s (normal <0.45 s) with QTc dispersion of 66 ms (normal 20-50 ms). An EKG obtained 1 yr earlier was similar, with a QTc interval of 0.50 s and QTc dispersion of 84 ms. The patient denied syncope or palpitations and had no family history of prolonged QT or sudden death. The patient was referred to a cardiologist because of increased pulmonary artery pressures detected by echocardiography. Preoperative right and left heart catheterizations revealed no significant coronary artery disease, normal left ventricular systolic function, mild pulmonary hypertension (35/20 mm Hg; normal 15-30/4-12 mm Hg), mildly increased left heart filling pressures (pulmonary wedge pressure and left ventricular end-diastolic pressure 19 mm Hg; normal 5-12 mm Hg), and an increased cardiac index (6.4 L . min-* * mP2; normal 2.5-4.2 L * mir-’ * rn-‘). Anesthesia for liver transplantation was induced with thiopental and succinylcholine and maintained with air/ oxygen, isoflurane, remifentanil, and cisatracurium. The patient received magnesium 4 g IV to treat a serum magnesium level of 1.2 mEq/L (normal 1.3-1.9 mEq/L). The dissection

Preoperative stress testing: new guidelines.

To date, there are no well controlled trials in the literature that demonstrate an outcome benefit using stress testing as a screening procedure before noncardiac surgery. Perioperative beta-blockade significantly decreases morbidity and mortality, and thus reduces any potential benefit stress testing may have in identifying patients who may advance to more invasive treatment. Preoperative percutaneous coronary intervention has unproven perioperative benefit, and coronary artery bypass graft carries risks that often offset the risk of noncardiac surgery. Unless an outcome benefit from cardiac testing and procedures can be demonstrated in a properly designed trial, their use should generally be restricted to situations in which symptoms or other cardiac findings warrant cardiac evaluation and treatment, regardless of upcoming surgery.

A 48-Year-Old Woman With a Large Mediastinal Mass

A 48-year-old black woman presented to the ED with a 1-year history of progressive dyspnea with exertion and chest discomfort. Four years prior, she presented to the ED with dyspnea and eye pain. A chest radiograph done at that time demonstrated hilar adenopathy and pulmonary parenchymal infi ltrates. Transbronchial biopsies were performed, and specimens showed epithelioid granulomas, leading to a diagnosis of sarcoidosis. Her dyspnea improved with prednisone, but she was subsequently lost to follow-up. On current presentation, she has no complaints of cough, ocular pain, visual changes, skin lesions, or other systemic symptoms. Her medical history includes schizophrenia, depression, and osteopenia. Medications were lamictal, fl uoxamine, seroquel, and depakote. The patient is a nonsmoker and lifelong resident of New York state. She has no history of travel or sick contacts. Family history is notable for laryngeal cancer in her father.

Common Adult Congenital Heart Disease Issues

There are more adults than children living with congenital heart disease (CHD) in the United States. Most adults with congenital heart disease should be seen at least periodically by adult congenital heart disease (ACHD) specialists. The general cardiology consultant also has a unique opportunity to improve the care of patients with ACHD by improving access to care, while patients are interacting with the healthcare system for other reasons such as noncardiac surgery or pregnancy. This chapter describes the epidemiology of ACHD, issues with accessing healthcare, and transitioning patients from a pediatric to adult model of care. We will outline general approaches including society guidelines to common issues including hypertension, dyslipidemia, heart failure and transplantation, arrhythmias, liver disease, hyperviscosity, preoperative risk assessment, imaging, pregnancy, contraception, exercise, and infective endocarditis. Finally, we will briefly review some of the more commonly encountered forms of cyanotic and acyanotic ACHD and describe surgical treatments including shunts and the Fontan palliation procedure.

Women with Adult Congenital Heart Disease

Complex congenital heart disease (CHD) is no longer just a pediatric problem. Advancements in pediatric cardiothoracic surgery and pediatric cardiology management are leading patients with complex CHD to significantly longer lives well into adulthood and often beyond an age where pediatric caregivers have been traditionally trained. In 2002, the incidence of total CHD cases was 12–14 per 1,000 live births of which 6 per 1,000 live births were severe or moderately severe forms [1]. A large percentage of children with CHD, 80–85 % up to as much as 95 % in some reports, are now reaching adulthood [2, 3] and require lifelong medical surveillance. Although prevalence of adult patients with congenital heart disease (ACHD) has variability in reporting, the overall prevalence has been estimated to be approximately 3,000 per million adults [4]. This is further classified by severity with 177 per million severe ACHD cases, 1,172 per million moderate, and 1,880 per million mild. The increasing prevalence of congenital heart disease in adults has led to recent establishment of specialty board certification in ACHD beginning in 2013. As seen in childhood, there remains a gender predominance within certain diagnoses in adults [3].

Cardiovascular Stress Testing

Establishing the anatomic presence of coronary stenosis has become increasingly important owing to the roles coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) have in the treatment of coronary artery disease (CAD). However, angina or myocardial infarction (MI) may occur in the absence of angiographically proven obstructive coronary lesions and, conversely, coronary obstructions may be asymptomatic and thus have uncertain prognostic significance [1–4]. Some have suggested that a functional evaluation may be more predictive of future cardiac events than anatomy alone [5, 6].

Assessment of the patient with cardiac disease.

To the Editor:-We read with interest Dr. Mangano’s paradigm for preoperative assessment of patients with cardiac disease.’ We have several concerns. First, the paradigm does not differentiate major surgery from minor surgery. Obviously, preoperative evaluation and perioperative treatment are different for patients undergoing cataract surgery, cholcystectomy, or abdominal aortic aneurysm resection. Second, the only management technique that has been proven to reduce perioperative morbidity is p bl~ckade , ’~~ and this should be included in the paradigm for patients with coronary artery disease or suspected coronary artery disease who are scheduled for intermediate or major surgery (unless contraindicated). Third, there is no substantial evidence that 24 48 h postoperative hemodynamic and ischemic monitoring will benefit patients with mild to moderately positive stress test results. Intensive care unit monitoring is costly and should be reserved for patients undergoing major surgery. Fourth, most patients with coronary artery disease and impaired functional status should not bypass stress testing and automatically undergo coronary angiography. A patient may have impaired functional status as a result of previous myocardial infarction, yet have a minimal amount of residual myocardium at risk. Also, impaired functional status may result from many nonischemic causes, including obesity and emphysema. A specialized stress test, such as an adenosine thallium scan or dobutamine echocardiography, assesses functional myocardium at risk in this subset, compared with angiography, which delineates only anatomic information. IJnfonunately, a randomized study that proves whether preoperative testing improves patient outcome has yet to be performed. It is unknown whether the risk-stratification costs (delays in surgery; money for testing; complications from angiography, angioplasty, and coronary artery bypass surgery) are offset by improved patient care.