Jennifer M. Banayan

Pulmonary Hypertension in Pregnancy: A Report of 49 Cases at Four Tertiary North American Sites.

OBJECTIVE To identify whether pregnancy outcomes vary by etiology and severity of pulmonary hypertension and whether contemporary therapies influence outcomes. METHODS A retrospective review of medical records at four academic institutions was conducted to identify pregnant women with pulmonary hypertension (2001-2015). International Classification of Diseases, 9th Revision codes for pulmonary hypertension and pregnancy were used to identify potential participants. Medical records were abstracted for demographics, management, and outcomes. Women were classified according to the 2013 World Health Organization (WHO) pulmonary hypertension classification groups 1-5. Mild pulmonary hypertension was defined as a mean pulmonary artery pressure 25-49 mm Hg and severe pulmonary hypertension as mean pulmonary artery pressure 50 mm Hg or greater or systolic pulmonary artery pressure 70 mm Hg or greater. Descriptive statistics were used to compare outcomes. RESULTS Forty-nine women were identified. Mortality rate was 16% (n=8/49); all deaths occurred postpartum, and seven of eight deaths occurred in women with WHO group 1 pulmonary hypertension (mortality rate 23%, n=7/30). Of the women who had documented live births with known mode of delivery (n=41), mortality was 4 of 22 among women with severe pulmonary hypertension and 1 of 19 among women with mild pulmonary hypertension. Mortality among women who delivered by cesarean was 4 of 22 and was 1 of 19 among women who delivered vaginally. Neuraxial anesthesia was performed in 20 of 22 cesarean and 17 of 19 vaginal deliveries with no anesthesia-related adverse events. Women with severe pulmonary hypertension needed more advanced therapies such as inotropes, pulmonary vasodilators, and extracorporeal membrane oxygenation than did women with mild pulmonary hypertension, 19 of 26 compared with 7 of 22. Preterm delivery was more common in women with severe compared with mild pulmonary hypertension, 19 of 23 compared with 8 of 17. There was one 25-week intrauterine fetal demise, but no neonatal deaths. CONCLUSION In this large series of pulmonary hypertension in pregnancy, mortality remained high despite advanced therapies. Maternal mortality was specific to WHO group 1 pulmonary hypertension and possibly associated with severe pulmonary hypertension. In selected patients with a favorable prognosis for vaginal birth, a trial of labor can be considered.

Right Ventricular Rupture during Insertion of an Avalon Elite® Catheter

As an adjunct to the recent case report by Kessler et al on the rotational malposition of the Avalon Elite bicaval dual-lumen catheter (AEC) (Maquet, Cardiopulmonary, Rastatt, Germany), we describe another possible complication during placement, a case of right ventricular rupture resulting in acute tamponade. A 57-year-old man with a history of sarcoidosis underwent an uncomplicated left single-lung transplant. During the immediate postoperative period, he developed severe pulmonary edema and hypoxia. Bedside transesophageal echocardiography (TEE) findings suggested pulmonary vein thrombosis, and he was transported emergently to the operating room for exploration via thoracotomy. Given his respiratory failure, an AEC was inserted via the right internal jugular vein for venovenous extracorporeal membrane oxygenation (ECMO). The surgeon did not find any evidence of pulmonary vein thrombosis, and the patient returned to the intensive care unit without a clear etiology for his decompensation. The patient recovered sufficiently to tolerate weaning of his ECMO flows, and the cannula was removed on postoperative day 3. A few hours later, the patient again developed respiratory failure and was transferred to the operating room for reinitiation of ECMO via an AEC with TEE guidance. The surgeon placed a wire through the existing right internal jugular introducer, which was observed via TEE in the IVC (bicaval view). Before placing a 27-French AEC, serial dilations (4 in total of increasing size) of the soft tissue were performed. During passage of the last dilator, the patient became acutely hypotensive. The decision was made to complete AEC insertion to help provide hemodynamic support, and contemporaneous TEE revealed a new, large, rapidly expanding pericardial effusion with global biventricular hypokinesis. The patient required an emergency median sternotomy. Despite evacuation of a large pericardial effusion, the hemodynamics did not improve. The patient was placed on cardiopulmonary bypass and cooled. Surgical exploration revealed a small perforation in the apex of the right ventricle (RV) that was repaired surgically with 2 interrupted 3-0 Prolene pledgeted sutures. Following repair, intraoperative TEE revealed a return to baseline cardiac function. The patient was taken to the ICU with stable hemodynamics on a dobutamine infusion (5 μg/kg/ min). Despite every effort, the patient never regained mental status. Care was withdrawn on postoperative day 11. As described by Kessler et al insertion of the cannula can be technically challenging, and a variety of techniques to guide optimal positioning during AEC insertion such as fluoroscopy, transthoracic echocardiography (TTE), and TEE have been described. Each imaging modality has advantages and disadvantages. Techniques using echocardiography allow the

CASE 4—2014Ascending Aortic Pseudoaneurysm Repair With Deep Hypothermic Circulatory Arrest in an Adult Congenital Heart Disease Patient With Heparin-Induced Thrombocytopenia

Preoperative transthoracic echocardiography was notable for a mildly reduced left ventricular ejection fraction (47%), moderate stenosis of the mechanical valve in the pulmonic position (peak gradient 59 mmHg), and a well-seated mechanical prosthesis in the aortic position, without stenosis. Gated computed tomography angiography (Fig 1) showed the pseudoaneurysm and the proximity of the lesion to the coronary arteries. Multidisciplinary planning included the use of bivalirudin (The Medicines Company, Parsippany, NJ) at a targeted activated coagulation time (ACT) of 250-300 seconds to facilitate endovascular repair through the retrograde deployment of a stent from open access to the left common carotid artery through a neck incision. After uneventful initiation of general anesthesia and line placement (left radial arterial cannula, right internal jugular triple lumen, and introducer sheath catheters), the endovascular stent graft (Zenith TX2 36� 50 mm stent graft, Cook Medical, Bloomington, IN) was deployed but did not completely cover the pseudoaneurysm, so a second stent graft was inserted under a combination of fluoroscopic and transesophageal echocardiographic (TEE) guidance. However, adequate positioning could not be achieved during deployment of the second stent, and the device remained malpositioned in the arch. No hemodynamic changes occurred despite stent malposition. At the time, TEE did not show evidence of aortic dissection; left ventricular function remained at baseline (mildly depressed) without dynamic changes to suggest ischemia. Because the attempted endovascular repair had been performed in the cardiac catheterization suite (this institution does not have

Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample

ABSTRACT Objective: Cardiogenic shock (CS) may occur during pregnancy and dramatically worsen peripartum outcomes. Methods: We analyzed the National Inpatient Sample from 2002 to 2013 to describe the incidence of, risk factors for and outcomes of CS during pregnancy. Results: Of the 53,794,192 hospitalizations analyzed, 2044 were complicated by CS. The mortality rate in peripartum women with CS was 18.81% versus 0.02% without. It occurs more often during postpartum (58.83%) as compared with delivery (23.47%) or antepartum (17.70%) hospitalizations. Factors associated with CS -related death included cardiac arrest, renal failure, and sepsis. Conclusions: CS during pregnancy occurs more commonly in the postpartum period and is associated with a high mortality.

CASE 5—2012: Incidentally Detected Patent Foramen Ovale in A Patient Undergoing Aortic Valve Replacement: To Close or Not to Close?

g r ( a C r T b a n WITH THE INCREASING USE of routine intraoperative transesophageal echocardiography (TEE), cardiac anesthesiologists often discover a patent foramen ovale (PFO) in the operating room. Whether or not to repair the defect surgically is a difficult question to answer because this may involve altering surgical management (eg, converting from an off-pump technique to on-pump technique) and, thus, perhaps increasing surgical risk. Furthermore, noninvasive techniques (percutaneous closure in the catheterization suite) are available for closure as well. Lastly, depending on the physiologic effects and/or symptomatology, closure may not even be indicated clinically. This complex scenario is further complicated by the fact that the patient is unable to contemplate the risks and benefits of available options because he/she is under general anesthesia.

Blood: Can't live with it, can't live without it

From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Ill. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 31, 2016; accepted for publication April 1, 2016. Address for reprints: Mark A. Chaney, MD, Department of Anesthesia and Critical Care, University of Chicago, 5841 S Maryland Ave MC4028, Chicago, IL (E-mail: mchaney@dacc.uchicago.edu). J Thorac Cardiovasc Surg 2016;-:1-2 0022-5223/

A modified Delphi method to create a scoring system for assessing team performance during maternal cardiopulmonary arrest

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.04.017

AWARD WINNER – 4th Place Research Abstract Board 311 - Research Abstract Linking Performance Measurement and Scenario Design: Team Response to Maternal Cardiac Arrest (Submission #407)

Background: Maternal cardiopulmonary arrest is a rare but often fatal emergency. The authors used a modified Delphi method to create a checklist of tasks for practitioners. Methods: Within each round, experts ranked tasks on a scale from zero through five. Consensus was defined a priori as 80% exact agreement. Results: Three rounds were required to achieve consensus resulting in a checklist of 45 tasks. Round One results revealed five tasks, Round Two included 25 tasks, and Round Three resulted in 29 tasks with 80% exact agreement. Conclusions: The modified Delphi method resulted in a weighted scoring system that can be used to objectively assess team performance.

CASE 3—2012: Iatrogenic Circumflex Artery Injury During Minimally Invasive Mitral Valve Surgery

Introduction/Background Maternal cardiac arrest is a rare but often fatal emergency. The incidence of maternal cardiopulmonary arrest has increased in the United Kingdom with the latest figures revealing an incidence of 1:20,000, compared to 1:30,000 found just 3 years prior.1 This is consistent with United States data documenting increases in maternal mortality.2 Because of its rarity, most clinicians have little experience in managing such patients,3 and a variety of publications expose concerning deficits among clinicians in their management of such patients.3,-7 No accepted tool exists to assess performance of practitioners managing these patients. Therefore, the authors used a modified Delphi method8 to capture expert judgment to create a checklist of tasks practitioners should perform during the first five minutes of a maternal cardiac arrest. The objective was to create a weighted scoring system that could be used to quantitatively measure team performance during such emergencies and to use the resulting assessment tool as a curriculum blueprint9 to guide simulation scenario design. Methods After reviewing the literature and pooling internal clinician opinions, the authors created a list of tasks thought to be essential for management of maternal cardiac arrest. The list was distributed to seven recognized experts including obstetricians, anesthesiologists and advanced practice nurses to render judgments regarding appropriate management of maternal cardiac arrest. Within each round, experts ranked tasks on a scale from 0 through 5 (0 as dangerous/inappropriate, 5 extremely important) and could suggest items to add, delete or change. Medians of expert’s ratings were calculated; consensus was defined a priori as 80% exact agreement. Next, an interprofessional task force was formed to design a maternal arrest simulation, with representatives from each profession included in the scenario and clinical educators experienced in simulation. The task force assigned tasks to team members (i.e., determined which roles were appropriate for obstetricians, anesthesiologists, nurses, etc.). The original simulation scenario was adjusted in accordance with the Results of the modified Delphi. Results The original task list contained 48 tasks. Three rounds were required during the Delphi process to achieve consensus. The final assessment tool consisted of a checklist of 45 tasks. The task force assigned 19 tasks to nurses, 11 to obstetricians, 9 to anesthesiologists and 6 to be shared by the team (e.g., remaining in the patient room rather than moving to the operating room for the emergent caesarean delivery). Over 20 sessions, a total of 168 learners participated. Participants included 35 obstetric residents and attendings, 53 anesthesia residents and attendings, 67 nurses, 7 operating room surgical technicians and 6 unit secretarial clerks. Conclusion The modified Delphi method is a valuable tool used to obtain consensus among experts and was used in this study to identify the appropriate management of maternal cardiac arrest. After numerous modifications, edits, deletions and additions that improved the author’s original list of tasks, the process resulted in a weighted scoring system that can be used to objectively assess team performance during maternal cardiac arrest. This new weighted scoring system served as a useful curriculum blueprint for simulation team scenario design and can be used by other teams to design simulation scenarios for this emergency. References 1. Lewis G: The women who died 2006-2008BJOG 2011;118(Suppl1): 30-56 2. Berg CJ, Callaghan WM, Syverson C, Henderson Z: Pregancy-related mortality in the United States, 1998-2005Obstet Gynecol 2010;116:1302-9. 3. Einav S, Matot I, Berkenstadt H, Bromiker R, Weiniger CF: A survey of labour ward clinicians’ knowledge of maternal cardiac arrest and resuscitationInt J Obstet Anesth 2008;17:238-42. 4. Berkenstadt H, Ben-Menchem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I: Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: Results from the Israeli Board of Anesthesiologists Anesth Analg 2012;115:1122-6. 5. Cohen SE, Andes LC, Carvalho B: Assessment of knowledge regarding cardiopulmonary resuscitation of pregnant womenInt J Obstet Anesth 2008;17:20-5. 6. Fisher N, Eisen LA, Bayya JV, Dulu A, Bernstein PS, Merkatz IR, Goffman D: Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based trainingAm J Obstet Gynecol 2011;205:239.e1-5. 7. Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, Cohen SE, Druzin M: Deficites in the provision of cardiopulmonary resuscitation during simulated obstetric crisesAm J Obstet Gynecol 2010;203:179.e1-5. 8. Clayton MJ: Delphi: A technique to harness expert opinion for critical decision-making tasks in educationEduc Psychol 1997;17:373-86. 9. Thorndike R, Hagen E: Measurement and evaluation in psychology and education, 2nd edition 1991. Oxford, England: Wiley. Disclosures None.