Joerg Ender

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

Background:The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. Methods:All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. Results:A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 ± 13 vs. 64 ± 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation–predicted risk of mortality (4.8 ± 6.1% vs. 4.6 ± 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45–110] vs. 900 min [600–1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0–5] vs. 20 h [16–25]), intermediate care unit (21 h [17–39] vs. 26 h [19–49]), and hospital (10 days [8–12] vs. 11 days [9–14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). Conclusion:The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

Anesthesia Management for Transapical Transcatheter Aortic Valve Implantation: A Case Series

OBJECTIVE The purpose of this study was to review the management of anesthesia for transapical transcatheter aortic valve implantation. DESIGN Retrospective review of collected data. SETTING University-affiliated heart center. PARTICIPANTS One hundred consecutive patients with severe aortic stenosis. INTERVENTIONS General anesthesia followed by an established fast-track protocol. MATERIALS AND METHODS A total of 100 patients with significant AS received transapical transcatheter aortic valve implantation. The patients were treated following a fast-track protocol. The mean arterial pressure was maintained above 65 mmHg by volume and/or inotropes during the procedure. The mean arterial pressure was increased above 75 mmHg to avoid hemodynamic deterioration before starting rapid ventricular pacing for the balloon valvuloplasty and the valve implantation. Transesophageal echocardiography was used to assess valve size and for hemodynamic monitoring. Eighty-one patients were treated completely off pump. There was a significant decline in mean arterial pressure from pre- to postvalvuloplasty (74.7 +/- 9.1 mmHg v 63.6 +/- 11.3 mmHg, p < 0.001) and from pre- to postimplantation (76.5 +/- 12.6 mmHg v 67.2 +/- 12.7, p < 0.001). The first 10 patients in the study intentionally were placed on cardiopulmonary bypass, and 9 patients required cardiopulmonary bypass because of hemodynamic deterioration. CONCLUSION A well-designed anesthetic plan as well as an understanding of the surgical procedure and the hemodynamic effects of rapid ventricular pacing are required to ensure successful outcomes in this new surgical option for high-risk patients.

Transapical Beating Heart Mitral Valve Repair

Repair of mitral valve (MV) leaflet prolapse using chordal replacement is an established procedure in open heart surgery for the treatment of mitral regurgitation (MR). The technique has proven high reproducibility and excellent long-term outcomes for posterior leaflet prolaspe, with freedom from valve-related reoperation of >95%.1, 2 Striving toward a less-invasive treatment for structural heart disease, the concept of transapical beating heart chordae replacement for MV repair using the NeoChord DS1000 device (NeoChord Inc; Minnetonka, Minn) has been introduced and proven in acute and chronic animal studies.3 The rationale of this approach is to imitate native valve anatomy by replacing ruptured or elongated chordae tendineae of the MV that cause prolapse of the MV leaflet with subsequent MR. The aim of this report is to elucidate this new therapy while presenting our initial experience with this procedure in humans. ### Patient Screening The primary selection criteria, including morphological characteristics of …

Awake Transapical Aortic Valve Implantation Using Thoracic Epidural Anesthesia

Transapical aortic valve implantation is a minimally invasive, beating-heart procedure that normally requires a general anesthetic. We herein report an 85-year-old patient with impaired pulmonary function who underwent successful transapical aortic valve implantation while awake, using a thoracic epidural anesthetic.

A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: early experience.

BACKGROUND The HeartWare (HeartWare International, Inc. Framingham, MA) ventricular assist device (HVAD) is approved for implantation through a sternotomy with cardiopulmonary bypass. We report on our initial experience with this device implanted off-pump via thoracotomy. METHODS A total of 26 patients were included in this review. All patients were Interagency Registry for Mechanically Assisted Circulatory Support categories 2 or 3 and underwent implantation of an HVAD as an elective procedure via thoracotomy and mini sternotomy approach. Three-dimensional echocardiography was used to assess the ventricle and was also used to facilitate proper pump positioning. Patients were managed during follow-up using anti-coagulants at a target international normalized ratio 2.0 to 2.5 as well as anti-platelet agents. RESULTS Implantation was performed without the use of cardiopulmonary bypass, but 1 patient did require conversion to on-pump surgery. There were no perioperative deaths or right heart failure events. The mean intensive care unit stay was 1.5 days. Transfusions of 1 to 3 units of packed red blood cells were required in 16 patients, whereas 10 patients maintained a stable perioperative hematocrit of at least 30% and did not require transfusion. Survival through 90 days was 100%, and survival through 180 days was 87%. CONCLUSIONS Our experience was favorable in respect to outcome, safety, and use of blood products. Our technique can be used as an alternative approach for left ventricular assist device implantation using the HVAD.

Value of augmented reality-enhanced transesophageal echocardiography (TEE) for determining optimal annuloplasty ring size during mitral valve repair.

BACKGROUND Mitral valve (MV) annuloplasty is an integral part of MV repair, but sizing under direct vision is occasionally challenging. Furthermore, traditional sizing is not possible for percutaneous MV repair techniques. This study compared augmented reality-enhanced three-dimensional (3D) transesophageal echocardiography (TEE) for determining MV annuloplasty size with conventional surgical sizing. METHODS In patients undergoing elective MV repair, a 3D MV reconstruction was performed using TEE. Modified 4D valve assessment software was used to create 3D computer-aided design models of standard annuloplasty rings (28 to 36 mm), which were stored in a digital database. These virtual 3D annuloplasty ring templates were superimposed on the preoperative 3D TEE reconstructions of the MV, and results were compared with conventional sizing under direct vision. A post hoc validation of the 3D models was performed using the implanted rings as a control. The echocardiographer was blinded to the implanted ring size. RESULTS The study included 50 patients. The correlation between the selected 3D annuloplasty ring template and the implanted annuloplasty ring size was 0.83. Thirty ring templates (60%) were the same size as the implanted annuloplasty ring, 19 templates (38%) differed by +/-2 mm in size, and 1 template differed by +4 mm. Postoperatively, the validation protocol revealed a correlation of 0.94 between the size of the ring templates and the implanted annuloplasty prostheses. CONCLUSIONS Augmented reality-enhanced TEE for determining optimal annuloplasty ring size during MV repair correlates well with conventional surgical sizing and may facilitate future percutaneous MV repair techniques.

Controversies and complications in the perioperative management of transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is performed with increasing frequency in the United States since Food and Drug Administration approval in 2011. The procedure involves the replacement of a severely stenosed native or bioprosthetic aortic valve with a specially constructed valvular prosthesis that is mounted onto a stent, without the use of cardiopulmonary bypass and the complications of a major open surgical procedure. TAVR has been performed mostly in elderly patients with multiple comorbidities or who have undergone previous cardiac surgery. The most commonly used access routes are the femoral artery (transfemoral) or the cardiac apex (transapical), but the transaortic and transubclavian approaches are also used with varying frequency. Conscious sedation may be used in patients undergoing transfemoral TAVR, but the use of general anesthesia has not been shown to carry greater risk and permits the use of transesophageal echocardiography to assist in valve positioning and diagnose complications. Cardiovascular instability during TAVR is relatively common, necessitating invasive monitoring and frequent use of vasoactive medications. Complications of the procedure are still relatively common and the most frequent is vascular injury to the access sites or the aorta. Cardiovascular collapse may be the result of major hemorrhage pericardial effusion with tamponade or coronary occlusion due to incorrect valve placement. Persistent hypotension, myocardial stunning, or injury requiring open surgical intervention may necessitate the use of cardiopulmonary bypass, the facilities for which should always be immediately available. Ongoing and planned trials comparing conventional surgery with TAVR in lower risk and younger patients should determine the place of TAVR in the medium- to long-term future.

Transesophageal Echocardiography for Verification of the Position of the Electrocardiographically-Placed Central Venous Catheter

OBJECTIVE Compare changes in P-wave amplitude of the intra-atrial electrocardiogram (ECG) and its corresponding transesophageal echocardiography (TEE)-controlled position to verify the exact localization of a central venous catheter (CVC) tip. DESIGN A prospective study. SETTING University, single-institutional setting. PARTICIPANTS Two hundred patients undergoing elective cardiac surgery. INTERVENTIONS CVC placement via the right internal jugular vein with ECG control using the guidewire technique and TEE control in 4 different phases: phase 1: CVC placement with normalized P wave and measurement of distance from the crista terminalis to the CVC tip; phase 2: TEE-controlled placement of the CVC tip; parallel to the superior vena cava (SVC) and measurements of P-wave amplitude; phase 3: influence of head positioning on CVC migration; and phase 4: evaluation of positioning of the CVC postoperatively using a chest x-ray. MEASUREMENTS AND MAIN RESULTS The CVC tip could only be visualized in 67 patients on TEE with a normalized P wave. In 198 patients with the CVC parallel to the SVC wall controlled by TEE (phase 2), an elevated P wave was observed. Different head movements led to no significant migration of the CVC (phase 3). On a postoperative chest-x-ray, the CVC position was correct in 87.6% (phase 4). CONCLUSION The study suggests that the position of the CVC tip is located parallel to the SVC and 1.5 cm above the crista terminalis if the P wave starts to decrease during withdrawal of the catheter. The authors recommend that ECG control as per their study should be routinely used for placement of central venous catheters via the right internal jugular vein.

Four-dimensional modelling of the mitral valve by real-time 3D transoesophageal echocardiography: proof of concept

OBJECTIVES The complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Assessing the dynamic movement and interaction of MV components to define MV physiology during the complete cardiac cycle remains a challenge. We herein describe a novel semi-automated 4D MV model. METHODS The model applies quantitative analysis of the MV over a complete cardiac cycle based on real-time 3D transoesophageal echocardiography (RT3DE) data. RT3DE data of MVs were acquired for 18 patients. The MV annulus and leaflets were semi-automatically reconstructed. Dimensions of the mitral annulus (anteroposterior and anterolateral-posteromedial diameter, annular circumference, annular area) and leaflets (MV orifice area, intercommissural distance) were acquired. Variability and reproducibility (intraclass correlation coefficient, ICC) for interobserver and intraobserver comparison were quantified at 4 time points during the cardiac cycle (mid-systole, end-systole, mid-diastole and end-diastole). RESULTS Mitral annular dimensions provided highly reliable and reproducible measurements throughout the cardiac cycle for interobserver (variability range, 0.5-1.5%; ICC range, 0.895-0.987) and intraobserver (variability range, 0.5-1.6%; ICC range, 0.827-0.980) comparison, respectively. MV leaflet parameters showed a high reliability in the diastolic phase (variability range, 0.6-9.1%; ICC range, 0.750-0.986), whereas MV leaflet dimensions showed a high variability and lower correlation in the systolic phase (variability range, 0.6-22.4%; ICC range, 0.446-0.915) compared with the diastolic phase. CONCLUSIONS This 4D model provides detailed morphological reconstruction as well as sophisticated quantification of the complex MV structure and dynamics throughout the cardiac cycle with a precision not yet described.

A specialized post-anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial

IntroductionFast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end points in adult patients after elective cardiac surgery.MethodsIn a prospective, single-blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new-onset cardiac arrhythmia, low cardiac output syndrome, need for cardiopulmonary resuscitation, stroke, acute renal failure, and death.ResultsMedian time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P <0.001). Median length of stay in the PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P <0.001). Of the adverse events examined, only the incidence of new-onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups.ConclusionsTreatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step-down unit, without compromising patient safety.Trial registrationhttp://ISRCTN71768341. Registered 11 March 2014.