Jonathan Frogel

Transesophageal echocardiography diagnosis of coronary sinus thrombosis.

A 36-yr-old man with a medical history significant for anabolic steroid abuse initially presented to the operating room with aortic valve endocarditis with a focal perforation of the anterior leaflet of the mitral valve secondary to a prolapsing aortic valve vegetation. The patient underwent uneventful aortic valve replacement with a 25 mm On-X (MCRI, Austin, TX) mechanical valve and repair of the mitral valve perforation with a bovine pericardial patch. Throughout the procedure, he received intermittent retrograde cardioplegia via a coronary sinus catheter that was placed without difficulty under transesophageal echocardiography (TEE) guidance in the prebypass period. The patient’s postoperative course was complicated by persistent high grade fevers and respiratory failure. A repeat TEE examination on postoperative day 10 revealed an ejection fraction (EF) of 45% and multiple echodense masses adherent to both the atrial and ventricular aspects of the patient’s mitral valve. In addition, an elliptical sessile mass was discovered adhering to the lateral wall of the right atrium and impinging on the anterior leaflet of the tricuspid valve. There was moderate tricuspid regurgitation secondary to leaflet restriction. The mechanical aortic valve appeared to be functioning normally. No abnormalities of the coronary sinus were noted at the time. The patient returned to the operating room for reexploration and debridement of presumed recurrent endocarditis. Intraoperative TEE once again revealed a low normal EF and echogenic masses adherent to the mitral valve (Fig. 1A) and to the lateral wall of the right atrium (Fig. 1B). In addition, a dilated coronary sinus was noted in the midesophageal views (Fig. 1A). Further inspection of the coronary sinus in a modified four-chamber view demonstrated the presence of thrombus with near complete occlusion of the coronary sinus which measured nearly 2 cm in diameter (Figs. 2A and B, Video Clip 1; please see video clips available at www.anesthesia-analgesia.org). Surgical exploration confirmed the presence of multiple thrombi that did not seem infectious in origin. Examination of the coronary sinus verified complete occlusion of the sinus with thrombus. The patient underwent thrombectomy of the tricuspid valve, mitral valve, and coronary sinus without complication. Postcardiopulmonary bypass TEE demonstrated normal mitral and tricuspid valve function. The postprocedure left ventricular function was markedly improved, with an EF of 65%, compared to 45% before operation (Video Clip 2; please see video clips available at www.anesthesia-analgesia.org). Pathologic examination confirmed noninfectious organized thrombus recovered from the mitral valve, tricuspid valve, and coronary sinus. The coronary sinus is responsible for the venous drainage of the heart under normal conditions. It receives contributions from the small, middle, oblique and great cardiac veins, courses through the coronary sulcus and empties into the right atrium between the inferior vena cava inlet and the septal leaflet of the tricuspid valve. On TEE examination, the coronary sinus is reliably visualized in a modified midesophageal fourchamber view (with slight insertion and retroflexion of the probe) and in the bicaval view (where it can be seen adjacent to the junction of the inferior vena cava and the right atrium). In one study, the coronary sinus was successfully visualized in 100% of patients using TEE and the mean maximum diameter measured 9 2 mm. Coronary sinus dilation may be encountered in patients with persistent left superior vena cava, congenital abnormalities, and elevated right atrial pressures with right atrial dilation. Coronary sinus thrombosis, as described in this case, is a rare complication of heart transplantation, This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Thoracic epidural steroid injection for rib fracture pain.

Treatment for rib fracture pain can be broadly divided into pharmacologic approaches with oral and/or parenteral medication and interventional approaches utilizing neuraxial analgesia or peripheral nerve blocks to provide pain relief. Both approaches attempt to control nociceptive and neuropathic pain secondary to osseous injury and nerve insult, respectively. Success of treatment is ultimately measured by the ability of the selected modality to decrease pain, chest splinting, and to prevent sequelae of injury, such as pneumonia. Typically, opioids and NSAIDs are the drugs of first choice for acute pain because of ease of administration, immediate onset of action, and rapid titration to effect. In contrast, neuropathic pain medications have a slower onset of action and are more difficult to titrate to therapeutic effect. Interventional approaches include interpleural catheters, intercostal nerve blocks, paravertebral nerve blocks, and thoracic and lumbar epidural catheters. Each intervention has its own inherent advantages, disadvantages, and success rates. Rib fracture pain management practice is founded on the thoracic surgical and anesthesiology literature. Articles addressing rib fracture pain are relatively scarce in the pain medicine literature. As life expectancy increases, and as healthcare system modifications are implemented, pain medicine physicians may be consulted to treat increasing number of patients suffering rib fracture pain and may need to resort to novel therapeutic measures because of financial constraints imposed by those changes. Here we present the first published case series of thoracic epidural steroid injections used for management of rib fracture pain.

CASE 8—2012 Intraoperative Embolization of Renal Cell Tumor Thrombus During Radical Nephrectomy

ATIENTS PRESENTING FOR resection of renal cell carcinoma with supradiaphragmatic vena cava or right atrial extension offer a host of challenges to both their surgeons and anesthesiologists. The need to perform a complete resection while minimizing the risk of embolization and metastases, which classically calls for median sternotomy and cardiopulmonary bypass (CPB), with or without deep hypothermic circulatory arrest (DHCA), must be balanced against the risks of coagulopathy, bleeding, and neurologic insult often encountered with this approach. Recently, some have advocated sternotomy and CPB-sparing techniques that do not compromise the goal of complete tumor resection. 1 A case of attempted resection of renal cell carcinoma with level III (suprahepatic, supradiaphragmatic, infra-atrial) extension is presented.

Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm

Audrey Spelde, MD n , Toby Steinberg, MD n , Prakash A. Patel, MD n , Harry Garcia, MD n , Jeremy D. Kukafka, MD n , Emily MacKay, DO n , Jacob T. Gutsche, MD n , Jonathan Frogel, MD n , Michael Fabbro, DO † , Jessie M. Raiten, MD ‡ , John G.T. Augoustides, MD, FASE, FAHA n,1 Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis

Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA