Jeremy M. Bennett

Anesthetic management and outcomes for patients with pulmonary hypertension and intracardiac shunts and Eisenmenger syndrome: a review of institutional experience

STUDY OBJECTIVE To propose a set of recommendations for the perioperative management of patients with Eisenmenger syndrome and similar physiology, based on 20 years of experience at a single institution. DESIGN Retrospective study of institutional outcomes of Eisenmenger syndrome patients and patients with balanced or fixed right-to-left intracardiac shunts with pulmonary hypertension undergoing noncardiac surgery. SETTING Single center, university-affiliated hospital. MEASUREMENTS Measurements included data from patients with Eisenmenger syndrome or similar physiology, shunt direction, right ventricular systolic pressure, congestive heart failure classification, noncardiac surgery, type of anesthesia, echocardiographic and catheterization data, mortality within 30 days of surgery, choice of monitoring, and vasopressor use. MAIN RESULTS 33 patients with Eisenmenger syndrome or similar physiology undergoing 53 general, regional and/or monitored anesthetic procedures were identified. Significant systemic arterial hypotension occurred in 14 individuals (26%) and oxygen desaturation in 9 (17%) patients. Administration of an intravenous (IV) vasopressor agent during induction significantly decreased the incidence of hypotension. The type of IV induction agent did not influence hemodynamic alterations, though patients who received propofol experienced a trend towards increased hypotension (83% of pts) when a vasopressor was not used. Inhalational induction, regardless of vasopressor use, was more likely to result in hypotension (60% of pts). The 30-day mortality was 3.8% (two pts). Both patients had minor elective procedures with monitored anesthesia care (MAC). CONCLUSIONS Hypotension is more common in patients with Eisenmenger syndrome and similar physiology when a vasopressor is not used during the peri-induction period, regardless of induction agent. Etomidate tended to have better hemodynamic stability than other induction agents. The use of a vasopressor is recommended. We present general recommendations for anesthesiologists and strongly recommend use of a vasopressor before or during induction to reduce hypotension along with complete avoidance of inhalational induction. Further, MAC anesthesia has been associated with perioperative and 30-day mortality.

Hyperlactemia Predicts Surgical Mortality in Patients Presenting with Acute Stanford Type-A Aortic Dissection

OBJECTIVE Inspired by the limited facility of the Penn classification, the authors aimed to determine a rapid and optimal preoperative assessment tool to predict surgical mortality after acute Stanford type-A aortic dissection (AAAD) repair. DESIGN Patients who underwent an attempted surgical repair of AAAD were determined using a de-identified single institution database. The charts of 144 patients were reviewed retrospectively for preoperative demographics and surrogates for disease severity and malperfusion. Bivariate analysis was used to determine significant (p≤0.05) predictors of in-hospital and 1-year mortality, the primary endpoints. Receiver operating characteristic curve generation was used to define optimal cut-off values for continuous predictors. SETTING Single center, level 1 trauma, university teaching hospital. PARTICIPANTS The study included 144 cardiac surgical patients with acute type-A aortic dissection presenting for surgical correction. INTERVENTIONS Surgical repair of aortic dissection with preoperative laboratory samples drawn before patient transfer to the operating room or immediately after arterial catheter placement intraoperatively. MEASUREMENTS AND MAIN RESULTS The study cohort comprised 144 patients. In-hospital mortality was 9%, and the 1-year mortality rate was 17%. Variables that demonstrated a correlation with in-hospital mortality included an elevated serum lactic acid level (odds ratio [OR] 1.5 [1.3-1.9], p<0.001), a depressed ejection fraction (OR 0.91 [0.86-0.96], p = .001), effusion (OR 4.8 [1.02-22.5], p = 0.04), neurologic change (OR 5.3 [1.6-17.4], p = 0.006), severe aortic regurgitation (OR 8.2 [2.0-33.9], p = 0.006), and cardiopulmonary resuscitation (OR 6.8 [1.7-26.9], p = 0.01). Only an increased serum lactic acid level demonstrated a trend with 1-year mortality using univariate Cox regression (hazard ratio 1.1 [1.0-1.1], p = 0.006). Receiver operating characteristic analysis revealed optimal cut-off lactic acid levels of 6.0 mmol/L and 6.9 mmol/L for in-hospital and 1-year mortality, respectively. CONCLUSION Lactic acidosis, ostensibly as a surrogate for systemic malperfusion, represents a novel, accurate, and easily obtainable preoperative predictor of short-term mortality after attempted AAAD repair. These data may improve identification of patients who would not benefit from surgery.

Malignant Hyperthermia During Double-Lung Transplantation.

MALIGNANT HYPERTHERMIA (MH) is an uncommon, life-threatening hypermetabolic response to the exposure of halogenated anesthetic gases and/or succinylcholine. Larach et al introduced the clinical rating scale on which the features of this hypermetabolic response are ranked. The authors report here the perioperative course of a patient who developed MH during lung transplantation. Signs of MH include sinus tachycardia, profound hyperthermia, ventricular tachycardia requiring multiple cardioversions, metabolic and respiratory acidosis, and elevated serum myoglobin. Cardiopulmonary bypass (CPB) was beneficial and enabled the successful lung transplant. A discussion of the complicated intraoperative diagnostic and therapeutic considerations, including mechanical circulatory support, follows.

Left Atrial Appendage Occlusion Devices

Atrial fibrillation is a very common arrhythmia whose prevalence is expected to increase significantly as the population ages. The associated stroke risk is a major cause of morbidity and mortality. Stroke prevention by anticoagulation carries its own risks, leading to the search for alternative strategies. Multiple techniques have been developed to exclude the left atrial appendage (the main source of thromboembolism in atrial fibrillation) from the circulation. Such techniques offer the hope of stroke prevention without the risks of anticoagulation. This article describes the percutaneous approaches being currently performed in the United States. Particular emphasis is placed on the use of transesophageal echocardiography to guide these procedures.

Failed Percutaneous Transcatheter Tricuspid Valve-in-Valve Replacement Caused by Retained Valve Holder.

34 www.anesthesia-analgesia.org January 2016 • Volume 122 • Number 1 A 54-year-old patient with 2 previous tricuspid valve (TV) replacements performed at a different institution presented with worsening symptoms of chronic congestive heart failure, including lower extremity edema. Preoperative echocardiography demonstrated severe bioprosthetic TV stenosis with a mean gradient of 10 mm Hg, trace tricuspid regurgitation, as well as P2 segment flail of the mitral valve with severe eccentric mitral regurgitation. Because of the perceived difficulty with a third tricuspid procedure, the surgical plan included initial percutaneous deployment of a 29-mm Sapien (Edwards Lifesciences, Irvine, CA) transcatheter heart valve-in-valve in the tricuspid position followed by a minimally invasive mitral valve repair through a right thoracotomy in a hybrid operating room. Intraoperative transesophageal echocardiography of the bioprosthetic TV was performed, demonstrating severely restricted leaflet motion on 2-dimensional (2D) images (Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/B251), mild prosthetic tricuspid regurgitation with color flow Doppler, and lack of visible leaflets on 3-dimensional (3D) images (Supplemental Digital Content 2, Video 2, http://links.lww.com/AA/ B252), with apparent heavy calcification of the prosthetic valve on 2D and 3D images (Figs. 1 and 2). Deployment of the transcatheter Sapien valve was complicated by the inability to place the guidewire in the central axis of the prosthetic valve. Failure to completely expand the Sapien valve resulted in severe paravalvular leak outside the Sapien valve but inside the previously placed prosthetic valve (Supplemental Digital Content 3, Video 3, http:// links.lww.com/AA/B253). The maximal mean pressure gradient through the Sapien valve was 8 mm Hg at a heart rate of 74 bpm. Placement of an Amplatzer plug (St. Jude Medical, Saint Paul, MN) did not improve the paravalvular leak. Because of the change in the surgical plan, the surgery was cancelled and the patient was brought back to the cardiac operating room on another day. For the second operation, a right anterior thoracotomy was performed. Upon opening the right atrium, it was discovered that the valve holder of the bioprosthetic TV had been left in place from the previous surgery 3 years earlier. The presence of the valve holder explained the presenting functional TV stenosis, the impression of severe valvular thickening and calcification, as well as the subsequent failure to fully expand the Sapien valve. The latter had been deployed in the space between the holder and the annulus of the bioprosthesis resulting in severe paravalvular leak (relative to the Sapien valve). The valve holder, Sapien valve, and Amplatzer plug (Fig. 3) were removed and the TV replaced with a new bioprosthetic valve in the tricuspid position. The patient provided written consent for this publication.

Hemodynamic instability in patients undergoing pulmonary embolectomy: institutional experience

OBJECTIVES Acute pulmonary embolism is a major cause of morbidity and mortality in patients presenting for emergent cardiac surgery with overall mortality ranging from 6% to as high as 85%. While the initial focus of treatment is nonsurgical or percutaneous interventions, surgical treatment continues to be a treatment for patients with refractory thrombus burden or cardiogenic shock. Our institution regularly performs surgical pulmonary embolectomy with improved outcomes compared to current reports. We thus performed a retrospective analysis of outcomes of pulmonary embolectomy patients and anesthetic management. DESIGN A retrospective review of 40 patients undergoing emergent pulmonary embolectomy over a 4 year period (2008-2012) at our institution was performed to assess for a 2nd period of critical instability. SETTING The study was conducted at a tertiary, level 1, trauma university medical center. PARTICIPANTS The study was performed through chart review of patient hospital records. INTERVENTIONS No interventions were performed. MEASUREMENTS Anesthetic records were reviewed along with echocardiographic records and surgical reports to assess cardiac function, need for emergent cardiopulmonary bypass, and degree of patient morbidity. CONCLUSIONS A total of 40 patients were studied. Hemodynamic instability occurred in 12.5% of patients at time of induction requiring emergent cardiopulmonary bypass. Another 17% of patients who remained stable following induction developed subsequent instability requiring emergent cardiopulmonary bypass during pericardial opening or manipulation which has not been previously reported. One patient died during hospitalization. Patients who required emergent bypass following induction of general anesthesia tended to receive higher doses of induction drugs than the other groups. In patients who needed emergent bypass during pericardial manipulation there were no identifiable factors suggesting that these patients remain at risk despite a stable post-induction course.

Twinkling artifact associated with guidewire placement.

July 2015 • Volume 121 • Number 1 www.anesthesia-analgesia.org 69 A 68-year-old man with atrial fibrillation presented for elective pulmonary vein isolation via cryoablation. He underwent general anesthesia and transesophageal echocardiography probe placement (IE33 X7-2t xMATRIX array probe connected to a Philips CX50 ultrasound system, Philips Healthcare, Andover, MA) for assessment of left atrial appendage thrombus and guidance of interatrial septal puncture for placement of a left atrial ablation catheter. While assessing the interatrial septum for a patent foramen ovale using color-flow Doppler, the electrophysiologist passed a superstiff 0.032-inch guidewire (St. Jude Medical, St. Paul, MN) from the right femoral vein through the right atrium into the superior vena cava to position the transseptal guiding introducer (St. Jude Medical). During this time, the echocardiographer identified the sudden appearance of a high-velocity, left-to-right flow pattern (Fig. 1; Supplemental Digital Content, Videos 1 and 2, http:// links.lww.com/AA/B84, http://links.lww.com/AA/B85). This flow seemed to originate from the interatrial septum, although a patent foramen ovale by color-flow Doppler had not been previously identified. Further interrogation of the interatrial septum in different echocardiographic planes revealed no defect but intermittent identification of a twinkling artifact. The twinkling artifact demonstrated brilliant rapid alternating hues with a flame-like appearance, just distal to the location of the guidewire. Increasing the Nyquist limit did not appear to significantly diminish this artifact. Removing the guidewire before positioning the transseptal guiding introducer in the fossa ovalis resulted in the disappearance of this artifact. An uneventful atrial septal puncture was performed and the introducer advanced into the left atrium.