José A. Sastre

Hemodynamic performance of the Medtronic Mosaic and Perimount Magna aortic bioprostheses: five-year results of a prospectively randomized study

OBJECTIVE Clinical outcomes of patients undergoing aortic valve replacement may be influenced by the presence of residual gradients and patient-prosthesis mismatch. The aim of this study was to compare hemodynamic performance and clinical outcomes at 5 years after prospectively randomized porcine versus bovine aortic valve replacement. We also aimed to determine the effects of valve hemodynamics on left ventricular (LV) mass regression. METHODS A total of 108 patients undergoing aortic valve replacement were randomized to receive either the Medtronic Mosaic (MM) porcine (n=54) or the Edwards Perimount Magna (EPM) bovine pericardial prosthesis (n=54). Clinical outcomes, mean gradients, effective orifice area and LV mass regression were evaluated at 1 and 5 years after surgery. Follow-up echocardiograms were performed on 106 (98%) and 87 (92%) patients, respectively. RESULTS Preoperative characteristics were similar between groups. Mean aortic annulus diameter and mean implant size were comparable in both groups. At 1 and 5 years, mean transprosthetic gradients were lower in the EPM group: EPM 10.3±3.4mmHg versus MM 16.3 ± 7.6 mmHg (p<0.0001) and EPM 9.6 ± 3.5 mmHg versus MM 16.8 ± 8.7 mmHg (p<0.0001), respectively. Similarly, indexed effective orifice areas (IEOA) at 1 and 5 years were significantly greater in the EPM group: EPM 1.10 ± 0.22 cm(2)m(-2) versus MM 0.96 ± 0.22 cm(2)m(-2) (p<0.004) and EPM 1.02 ± 0.25 cm(2)m(-2) versus MM 0.76 ± 0.19 cm(2)m(-2) (p<0.0001), respectively. At 5 years, the incidence of patient-prosthesis mismatch (IEOA ≤0.85 cm(2)m(-2)) was significantly lower in the EPM group: EPM 22.9% vs MM 73.9% (p<0.0001). Such differences were similar when analysis was stratified by surgically measured annular size and implant valve size. During the first year after surgery, both groups demonstrated similar regression of LV mass index (MM -26.3 ± 43 gm(2) vs EPM -30.1 ± 36 gm(-2); p=0.8); however, at 5 years, regression of LV mass index was significantly greater in the EPM group: (EPM -47.4 ± 35 gm(-2) vs -4.4 ± 36 gm(-2); p<0.0001). Five-year survival was 79.6 ± 4.1% in the MM group and 94.4 ± 2.2% in the EPM group (p=0.03). CONCLUSIONS At 5 years, the EPM valve was significantly superior to the MM prosthesis with regard to hemodynamic performance, incidence of patient-prosthesis mismatch and regression of LV mass index. The hemodynamic superiority of the EPM prostheses in comparison to MM-prostheses demonstrated at 1 year, increased significantly over time.

Management of a transbronchial cryobiopsy using the i-gel ® airway and the Arndt endobronchial blocker

To the Editor, The practice of anesthesiology is moving beyond the operating room and increasingly into the venue of various interventional medical specialties, including cardiology, radiology, gastroenterology, and pulmonology. Interventional pulmonologists are frequently performing transbronchial cryobiopsy procedures that often require various degrees of sedation or general anesthesia. Initially, this procedure was mainly used in the treatment and excision of endobronchial lesions, particularly in cases of bronchial obstruction. Nevertheless, it is now an emerging technique performed by pulmonologists to diagnose focal and diffuse lung diseases, including neoplastic and interstitial lung diseases as well as pulmonary infections and lung rejection following transplantation. The use of the cryotherapy probe allows sampling of well-preserved tissue that tends to be superior quality to that obtained through traditional forceps biopsy via a flexible bronchoscope. For example, the tissue is often devoid of the crush artifact commonly seen with a traditional forceps technique. Cryobiopsy offers additional advantages as it may reduce operative time, improve diagnostic yields, and potentially decrease complications. Additionally, the cryotherapy probe may facilitate the sampling of airway lesions positioned tangentially to the bronchoscope. The disadvantage of cryobiopsy is that tracheal intubation is often recommended because the samples attached to the cryoprobe cannot be retracted through the bronchoscope and thus requires removal of both cryoprobe and bronchoscope as a single unit. For that reason, it is important to have a secure airway in place to facilitate rapid control of any potential bleeding. Absolute contraindications to cryobiopsy include severe hypoxia, status asthmaticus, poor patient cooperation, massive hemoptysis, and uncorrectable bleeding diathesis. In our institution, we carry out cryobiopsy under general anesthesia. This facilitates better conditions for performing the technique, including an optimized field of view in a non-combative patient. In addition, it allows for better control of the airway in case of a bleeding emergency. For these procedures, we use standard intraoperative monitors as well as the bispectral index (BIS). Anesthesia induction is performed with propofol 2.5-3 mg kg and remifentanil 1 lg kg, both administered slowly over one minute. Once an adequate depth of anesthesia has been achieved, an i-gel supraglottic airway (Intersurgical Ltd, Berkshire, UK) is inserted according to the manufacturer’s instructions. Next, an Arndt endobronchial blocker with spherical balloon (C-AEBS-9.0-78-SPH-AS; Cook Medical Inc, Bloomington, IN, USA) is advanced through the blocker port of the Arndt Multiport Adapter , and a 6.0-mm diameter fibreoptic bronchoscope (with a 3.0-mm operating channel), which had been introduced through the fibreoptic port, is passed J. A. Sastre, MD, PhD (&) Department of Anesthesiology, Salamanca University Hospital and IBSAL, Salamanca, Spain e-mail: josealfsastre@hotmail.com

Left-sided cardiac gas embolism produced by hydrogen peroxide: intraoperative diagnosis using transesophageal echocardiography.

IMPLICATIONS We present a case of an adult who suffered a left-sided gas embolism after surgical lavage of the thoracic cavity with hydrogen peroxide. An intraoperative diagnosis was made using transesophageal echocardiography.

Influence of uridine diphosphate-glucuronyltransferase 2B7 (UGT2B7) variants on postoperative buprenorphine analgesia.

Genetic factors are known to influence individual differences in pain and sensitivity to analgesics. Different genetic polymorphisms in opioid‐metabolizing enzymes that can affect the analgesic response to opioids have been proposed. This study investigates a possible difference in the response to postoperative buprenorphine analgesia related to the presence of different isoforms (cytosine or thymine substitution at nucleotide 802) of UGT2B7 gene.

Bone cement implantation syndrome during spinal surgery requiring cardiac surgery.

During a posterior segmental spinal fusion procedure, a 71-year-old woman developed cardiac and pulmonary embolism characterized by nonsustained ventricular tachycardia during cement injection, rapid and severe hypoxemia, and hemodynamic instability. Management included exploratory cardiotomy under cardiopulmonary bypass and removal of the emboli from the pulmonary vessels. Postoperative recovery was successful, and the patient was discharged without sequelae. We discuss the pathophysiology of bone cement implantation syndrome during spinal fusion, possible causative factors, and treatment alternatives.

Changes in density spectral array of bilateral BIS during carotid external compression in cardiac surgery

To the editor, Ischemic stroke is one of the more common perioperative complications after cardiac surgery, with an overall incidence close to 2% [1, 2]. Aortic manipulation including cannula insertion and placement and removal of the aortic clamp are critical factors for microembolization. Some strategies have been proposed in order to reduce cerebral embolism such as transient external compression of the common carotid arteries or a brief reduction in the flow of the cardiopulmonary bypass pump [3]. An experimental study suggest that carotid compression for 10–20 s may reduce the number of emboli entering the carotid arteries by over 73% [in patients with normal mean arterial pressure (MAP)], and by over 85% (in patients with high MAP) during aortic cross clamping [4]. Anesthetics act at specific receptors in specific neural circuits and induce changes in the power of the frequency bands of the spectrum giving rise to characteristic patterns in the spectrogram [5]. When general anesthesia is maintained by a propofol infusion in a surgical plane, the electroencephalogram signatures of this drug are robust slow-delta (red band between 0 and 4 Hz) and alpha oscillations (red band between 9 and 12 Hz) (Fig. 1, upper part of spectrogram). There is a strong correlation between the decrease in cerebral blow flow (CBF) and the electrogenesis pattern. When the CBF is less than 25–35 mL/100 g min, disappearance of fast α and β waves is detected in the following seconds. At a more advanced stage, there is a marked slowing down of the electrogenesis linked to the appearance of δ waves. When the CBF is less than 8–10 mL/100 g min, burst suppression or an isoelectric trace appears [6]. Some monitors like INVOSTM 5100C (Somanetics, Inc., Troy, MI, USA) and BISTM Complete 4-Channel Monitor (Medtronic, Boulder, CO, USA) are used in cardiac surgery for detecting cerebral desaturations and for assessing the hypnotic effects of general anesthetics respectively; moreover, both can be useful for detecting global cerebral ischemia [7–9]. In our hospital, aortic cross clamping is performed after a combined maneuver in which the flow of the cardiopulmonary bypass pump is minimized up to 0.5 lpm while external carotid compression is performed simultaneously. This maneuver is held for a few seconds until the clamp has been properly positioned (approximately 10–15 s). The efficacy of this maneuver is shown both in bilateral rSO2 tendencies (abrupt desaturation) and in the bilateral color density spectral array of BIS monitor system (sudden slowing of the electrogenesis) with loss of the band corresponding to the α oscillation (9–12 Hz) (outermost red band in both hemispheres) showing global cerebral ischemia. (Fig. 1A). The second alteration in rSO2 and in color density spectral array of BIS showed in the image is due to a transient decrease in cardiac output due to cardiac manipulation for the placement of the venous cannula in the right atrium (Fig. 1B). The BIS value also decreased during both events. There were no changes in dosage of anesthetics during this period. This image shows a novel utility of the color density spectral array as a tool to assess the efficacy of an induced substantial decrease in cerebral blood flow for preventing embolic phenomena related to aortic cannulation; this finding has not been described previously. In conclusion, changes in bilateral color density spectral array of BIS could be an indicator of the efficacy of the external compression of the common carotid arteries for reducing the cerebral blood flow during aortic cannulation; however, more prospective studies are needed to support the real effectiveness of this maneuver. * José A. Sastre jasastre@saludcastillayleon.es

Diagnosis of Aortic Dissection by a Subtle Wall Thickening in Transesophageal Echocardiography

2017 by The Society of Thoracic Surgeons Published by Elsevier Inc. 53-year-old man with no previous medical problems, Apresented with 12 hours of worsening abdominal pain associated with vomiting, diarrhea, and hemodynamic instability, requiring admission to the intensive care unit and intravenous noradrenaline. Laboratory tests demonstrated impaired renal and liver function with coagulopathy. Computed tomography (CT) with contrast medium ruled out acute mesenteric ischemia (suspected diagnosis) but revealed an unsuspected ascending aortic aneurysm (8.9 7.4 cm), calcification of the aortic valve, and pericardial effusion (1.9 cm) without an intimal flap or extravasation of contrast material (Fig 1). Transesophageal echocardiography (TEE) showed enlargement of the aortic root (7.2 cm) and minimal separation of a smooth hypoechoic layer within the wall of the ascending aorta (AsAo) (Figs 2A, 2B), severe valve stenosis, and cardiac tamponade. An emergent cardiac operation was ordered, and a Bentall-Bono procedure was performed. Sternotomy showed an aortic intramural hematoma and a small linear tear in the sinotubular junction immediately above the left coronary sinus (Fig 3). Some variants of aortic dissection have been described, and diagnosis of this entity can be a challenge. Intramural hematomas may weaken the aorta and progress to an inward disruption of

Young Adult With Abdominal Pain

A 23-year-old woman with anorexia nervosa, binge/purge subtype, presented to the hospital after a binge episode with diffuse abdominal pain, nausea, and inability to vomit. On physical examination, the abdomen was extremely distended and firm. Initial treatment consisted of decompression by gastric endoscopy; patchy areas of dark ischemic tissue along the stomach were noted but no full-thickness perforation was identified. Abdominal computed tomography (CT) was performed (Figures 1 and 2).