K. Annette Mizuguchi

Thrombus or bilobar left atrial appendage? Diagnosis by real-time three-dimensional transesophageal echocardiography

Full Text Full Text (PDF) Diagnosis of a Bilobed Left Atrial Appendage and Pectinate Muscles Mimicking Thrombi on Real-time 3-Dimensional Transesophageal Echocardiography J Ultrasound Med June 1, 2010 29:975-980 Abstract Full Text Full Text (PDF)Full Text Full Text (PDF) PRO Editorial: PRO: Three-Dimensional Transesophageal Echocardiography Is a Major Advance for Intraoperative Clinical Management of Patients Undergoing Cardiac Surgery Anesth. Analg. June 1, 2010 110:1574-1578 Full Text Full Text (PDF) Thrombus or Bilobar Left Atrial Appendage? Diagnosis by Real-Time Three-Dimensional Transesophageal Echocardi...

Type A Aortic Dissection in a Patient on Dabigatran: Hemostasis Post Circulatory Arrest

We present a successful case of prevention of postoperative hemorrhage in a 70-year-old male on dabigatran, who developed an acute type A aortic dissection and subsequently underwent an emergent ascending aortic replacement.

Surgery of the Aortic Arch

A 60-year-old male is seen in the emergency room of a tertiary hospital. He complains of severe chest pain which is “tearing” in nature and localizes to the anterior chest. His past medical history is remarkable for hypertension, hypercholesterolemia, coronary artery disease and an aortic arch aneurysm. His aneurysm is 5.5 cm in diameter and he was scheduled to undergo an elective surgical repair 7 days from his present emergency room visit [1]. He had a left carotid endarterectomy in the past, which required placement of a shunt following carotid cross clamp application. On examination, his blood pressure is equal, bilaterally, in both the arms. Auscultation reveals a regular rhythm without a murmur. His EKG is unchanged from his most recent EKG performed for his scheduled, elective aneurysm repair, 2 weeks ago. His medications include atorvastatin, metoprolol, aspirin (81 mg) and lisonopril. The chest X-ray shows a widened mediastinum. After his blood pressure and chest pain were stabilized with a short-acting beta blocker, narcotics and sedatives, a CT angiogram was obtained. This revealed an aortic dissection with a tear located in the aortic arch. The dissection extends proximally to the sinus of valsalva and distally down the descending aorta.

Tricuspid and Mitral Valve Carcinoid Disease in the Setting of a Patent Foramen Ovale

59-yr-old-woman with an 8-yr history of carci-noid syndrome with hepatic metastasis presentedwith progressive shortness of breath. Transesophagealechocardiographic examination (TEE) revealed severetricuspid regurgitation, tricuspid stenosis, mild mitralstenosis, moderate mitral regurgitation, and a patentforamen ovale (PFO). She was referred for a tricuspidand mitral valve replacement.Intraoperative TEE confirmed the preoperative diag-nosis of mild tricuspid stenosis with leaflet and chordalthickening, severe tricuspid regurgitation by extent ofcolor flow jet area and hepatic vein flow reversal bypulse wave Doppler, severe right atrial and ventricularenlargement Video Clip 1; please see video clips avail-able at www.anesthesia-analgesia.org), mild mitral ste-nosis, and moderate mitral regurgitation with mitralleaflet thickening and posterior leaflet restriction (Figs. 1and 2; Video Clip 1). Agitated saline contrast injectionconfirmed a PFO. Mild pulmonary regurgitation wasalso noted but the aortic valve was uninvolved. Both themitral and tricuspid valves were replaced with pericar-dial bioprosthetic valves, and the PFO was repaired(Video Clip 2). The excised tricuspid valve was diffuselythickened and fibrotic and the mitral valve leafletsappeared white and smooth, consistent with carcinoidvalvular heart disease. The patient’s hospital course wascomplicated by recurrent carcinoid crises occurringwithin the first postoperative day. Her subsequent hos-pital course was uneventful and she was discharged onpostoperative day 10.Carcinoid tumors arise from the gastrointestinaltract. Malignant carcinoid syndrome occurs whenserotonin and other vasoactive substances are releasedfromcarcinoidtumorcellsandresultinoneormoreofa constellation of symptoms which include flushing,hypotension, diarrhea and bronchospasm. More thanhalf of patients with carcinoid syndrome develop carci-noid heart disease as a late complication and it isassociated with progressive disease.

Transesophageal echocardiography imaging of the total artificial heart

October 2013 • Volume 117 • Number 4 A 57-year-old man presented with end-stage biventricular heart failure secondary to an infiltrative cardiomyopathy. Despite aggressive medical therapy, his health was deteriorating, and he was scheduled for a total artificial heart (TAH) implantation. The Total Artificial Heart (SynCardia, Inc., Tucson, AZ; formerly known as CardioWest) has been Food and Drug Administration-approved since 2004 for use as a bridge to transplant in heart transplant–eligible patients who have irreversible end-stage biventricular heart failure. In April 2012, the TAH was also approved for destination therapy. Because the left ventricular assist device implantation rate nearly doubled with the approval of the HeartMateII device (Thoratec Corp., Pleasanton, CA) for destination therapy,1 it is possible that the frequency of TAH implants will also rise. In this article, we review key features of the perioperative transesophageal echocardiographic (TEE) examination of patients being evaluated for or undergoing TAH implantation. To best use TEE to evaluate TAH patients, one must first understand the basic design of the TAH (Fig. 1). The TAH is an orthotopic pneumatic biventricular, pulsatile device that consists of 2 artificial ventricles. The native cardiac ventricles and arterioventricular valves are removed before implantation. Each artificial ventricle has a 27 mm inflow and a 25 mm outflow Medtronic-Hall single tilting disk valve (Medtronic, Inc, Minneapolis, MN)2 mounted on the rigid housings of the 2 artificial ventricles of the TAH. The inflow valve is attached via an atrial connector to the preserved native tricuspid or mitral valve annulus, and the outflow valve is attached to a short outflow graft that replaces the proximal segment of the aorta or pulmonary artery. Each TAH ventricle is connected to a pneumatically driven pump via a 4-layer polyurethane diaphragm. These diaphragms are interposed between a housing assembly superiorly and a base assembly inferiorly. After implantation, excursion of the air diaphragm via the pump allows the ventricles to fill and eject, thus moving blood in and out of the ventricles. Typically, output flows are maintained at 7 to 8 L/min with a central venous pressure of <15 mm Hg.2,3 TEE EXAMINATION BEFORE CARDIOPULMONARY BYPASS As with patients undergoing ventricular assist device implantation, a comprehensive TEE examination is helpful for guiding successful device implantation.4 Preoperative cardiac imaging and evaluation of the patient’s clinical status help determine whether TAH versus biventricular assist device (BiVAD) implantation is most likely to be successful. Cardiac pathologies that favor TAH versus BiVAD implantation include severe cardiomyopathies that result in biventricular hypertrophy with small intraventricular chamber size, failed Fontan procedure, myocardial infarction with related ischemic cardiomyopathy resulting in intractable biventricular failure coupled with pathologies such as postinfarct ventricular septal defects, large left ventricular apical aneurysm, or left ventricular thrombus, and severe aortic valve pathology such as aortic regurgitation or mechanical aortic valve prosthesis.2 Intraoperative TEE should be used for the following: (1) confirm that the tip of the patient’s central venous catheter is not in the right atrium (RA), as entrapment of a central venous catheter within the right TAH inflow valve can result in fatal malfunction of the TAH5; (2) assess the interatrial septum for a patent foramen ovale or atrial septal defect that could result in shunting or systemic embolic events after TAH implant; (3) check for thrombi in the atria and atrial appendages so that thrombus can be removed on cardiopulmonary bypass (CPB) to prevent thromboembolic events; (4) identify the inferior vena cava to establish a baseline size so that it can be readily compared to diagnose postoperative kinking or compression that could limit blood flow into the TAH. Kinking of the vena cava may be imaged as narrowing of the vena cava at the RA–caval junction (Video 1, see Supplemental Digital Content 1, http://links. lww.com/AA/A571); and (5) locate the pulmonary veins and assess for any pulmonary vein anomalies that could limit inflow to the TAH. Viewing the pulmonary veins preCPB can also facilitate ready localization of the pulmonary veins after TAH implantation (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A571). Since all 4 native cardiac valves will be removed, presence of significant valvular regurgitation or stenoses is not concerning for TAH placement and may actually be the reason the TAH was selected for the patient rather than a BiVAD.2

Use of Postoperative Creatinine to Predict Sustained Kidney Injury in Patients Undergoing Mesothelioma Surgery

BACKGROUND AND OBJECTIVESnAKI leads to increased morbidity and mortality and progression to chronic kidney injury is a frequent consequence of AKI. Surgical treatment of mesothelioma is associated with increased risk for kidney injury. However, sustained kidney injury may limit therapeutic options for treating residual cancer. This study hypothesized that patients with significant serum creatinine (sCr) elevation within 48 hours of surgery would be at risk for sustained kidney injury. The goal was to determine the best acute sCr measure predictive of sustained kidney injury defined as a 50% increase in sCr from baseline measured 2-4 weeks after surgery.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnIn a prospective, observational cohort of surgical patients with mesothelioma, receiver operator characteristic curves were generated for the 24- and 48-hour absolute difference and relative sCr change over baseline in the derivation cohort (n=279). The prediction was tested in a validation cohort (n=207). The ability of various other AKI definitions to predict sustained kidney injury was evaluated.nnnRESULTSnSustained kidney injury occurred in 9.8% of patients in the derivation cohort. A ≥59% increase in sCr 48 hours after surgery was most predictive of sustained kidney injury (c statistic=0.78). Among other AKI definitions, a sCr increase of 0.3 mg/dl in 24 hours or 0.5 mg/dl increase in 48 hours (Waikar and Bonventre criteria) also reliably predicted sustained kidney injury.nnnCONCLUSIONSnDevelopment of clinically significant sustained kidney injury can be predicted by acute postoperative sCr elevation in patients treated for mesothelioma.

Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter?

BACKGROUND: Waterless antiseptic surgical hand scrub (1% chlorhexidine gluconate and 61% ethyl alcohol, Avagard™; 3M Health Care, St. Paul, MN), alcohol-only cleanser (62% ethyl alcohol), and traditional surgical scrub (5-minute scrub with 4% chlorhexidine soap using a sterile scrub brush with water) are techniques used for hand cleansing and disinfection. We hypothesized that alcohol-only cleanser and waterless antiseptic scrub (Avagard) would be as effective as a traditional surgical scrub for hand cleansing before placement of central venous catheters. METHODS: Fingers of subjects were plate-cultured for 24 hours after 5 methods of hand cleansing: method 1: traditional surgical scrub (n = 49 plates produced by 14 subjects); method 2: traditional surgical scrub (5-minute scrub with water, brush, and 4% chlorhexidine soap) followed by a 15-minute break, then alcohol-only cleanser (62% alcohol) (n = 49 plates produced by 14 subjects); method 3: alcohol-only cleanser alone (n = 49 plates produced by 14 subjects); method 4: alcohol-only cleanser (62% alcohol), followed by a 15-minute break, then traditional surgical scrub (5-minute scrub with brush, and 4% chlorhexidine soap with water) (n = 49 plates produced by 14 subjects); and method 5: waterless surgical scrub (Avagard) alone (n = 116 plates produced by 38 subjects). The 15-minute break was introduced to allow a short period of recontamination, and to test for residual effects from prior cleansing. RESULTS: Alcohol-only cleanser alone (method 3) was significantly less effective than the traditional surgical scrub (method 1) (P < 0.001; 82% plate growth). Waterless surgical scrub (Avagard) (method 5) had a 0% observed difference (95% confidence interval [CI]: −14% to 11%) compared with the traditional 5-minute scrub (method 1) (P = 0.99; 16% plate growth). When a traditional surgical scrub was used first followed by a 15-minute period of recontamination, there was a 6% observed difference in method 2 from reference (method 1) (95% CI: −10% to 22%), and 0% observed difference in method 4 from reference (95% CI: −15% to 15%). CONCLUSION: As the initial cleansing method, the alcohol-only cleanser (method 3) was significantly less effective than the traditional surgical scrub (method 1) (P < 0.001).

Predicting kidney disease progression in patients with acute kidney injury after cardiac surgery

Objective: The study objective was to identify patients who are likely to develop progressive kidney dysfunction (acute kidney disease) before their hospital discharge after cardiac surgery, allowing targeted monitoring of kidney function in this at‐risk group with periodic serum creatinine measurements. Methods: Risks of progression to acute kidney disease (a state in between acute kidney injury and chronic kidney disease) were modeled from acute kidney injury stages (Kidney Disease: Improving Global Outcomes) in patients undergoing cardiac surgery. A modified Poisson regression with robust error variance was used to evaluate the association between acute kidney injury stages and the development of acute kidney disease (defined as doubling of creatinine 2–4 weeks after surgery) in this observational study. Results: Acute kidney disease occurred in 4.4% of patients with no preexisting kidney disease and 4.8% of patients with preexisting chronic kidney disease. Acute kidney injury predicted development of acute kidney disease in a graded manner in which higher stages of acute kidney injury predicted higher relative risk of progressive kidney disease (area under the receiver operator characteristic curve = 0.82). This correlation persisted regardless of baseline kidney function (P < .001). Of note, development of acute kidney disease was associated with higher mortality and need for renal replacement therapy. Conclusions: The degree of acute kidney injury can identify patients who will have a higher risk of progression to acute kidney disease. These patients may benefit from close follow‐up of renal function because they are at risk of progressing to chronic kidney disease or end‐stage renal disease.

Use of intraoperative transesophageal echocardiography to evaluate positioning of tandemheart® percutaneous right ventricular assist device cannulae

January 2014 • Volume 118 • Number 1 A 67-year-old woman presented to our operating room (OR) for planned removal of a TandemHeart® percutaneous right ventricular assist device (pRVAD; Cardiac Assist, Pittsburgh, PA) that was placed at an outside hospital as a bridge to recovery from severe right ventricular (RV) dysfunction after coronary artery bypass graft surgery. When she presented to our OR, her pRVAD support had been weaned to <2 L/min of outflow. Before presenting to our OR, a pulmonary artery (PA) catheter that had been placed became dysfunctional, and a second PA catheter was floated under fluoroscopic guidance. The dysfunctional PA catheter was left in place to avoid inadvertent snaring and withdrawal of the pRVAD cannulae. We performed a full transesophageal echocardiographic (TEE) examination intraoperatively, focusing on confirming the correct position of the pRVAD cannulae. A right ventricular assist device (RVAD) is an extracorporeal pump that drains blood from the right atrium (RA) via an inflow cannula (flow into the RVAD) and then delivers that blood to the PA via an outflow cannula (flow out of the RVAD). RVADs do not provide gas exchange, but they provide circulatory support that takes over some or all the work of the RV in the setting of RV failure. While TandemHeart support of the left ventricle is well described,1 the TandemHeart is used less frequently to support a failing RV. Several publications describe technical placement as well as medical and surgical management of pRVADs.2–4 However, while a published description of TEE evaluation of percutaneous left ventricular assist devices is available,1 there is a paucity of literature describing how to use TEE to evaluate pRVAD cannulae positioning and the related integrity and function of right heart structures that can be affected by the pRVAD.5 Our examination demonstrated the following: in the midesophageal RV inflow–outflow view, the pRVAD outflow cannula was seen traversing the pulmonary valve (PV) in conjunction with 2 PA catheters (Video 1, Clip 1, see Supplemental Digital Content 1, http://links.lww.com/ AA/A683). Addition of Color flow Doppler (CFD) imaging (Fig. 1; Video 1, Clip 2, Supplemental Digital Content 2, http://links.lww.com/AA/A684) demonstrated mild, cannula-associated pulmonic regurgitation (PR). The tip of the outflow cannula was well positioned in the main PA (Video 1, Clip 1, Supplemental Digital Content 1, http:// links.lww.com/AA/A683). Midesophageal bicaval and 4-chamber views demonstrated the pRVAD inflow cannula appropriately positioned in the mid RA (Video 1, Clip 2, Supplemental Digital Content 2, http://links.lww.com/ AA/A684). Biventricular function was assessed, and the device was weaned to off and successfully explanted.

Echocardiographic features of pulmonary atresia with intact ventricular septum.

A 36 wk, 2.1 kg girl prenatally diagnosed by echocardiography with pulmonary atresia with intact ventricular septum, (PA/IVS) and coronary sinusoids was started on a prostaglandin E1 infusion immediately after birth. Postnatally, a transthoracic echocardiogram revealed PA/IVS, severe tricuspid and right ventricular (RV) hypoplasia, RV hypertrophy, RV to coronary artery sinusoids, a secundum atrial septal defect with bidirectional flow, and a large patent ductus arteriosus as the sole source of pulmonary blood flow. (Figs. 1 and 2 and Videos 1 and 2; please see video clips available at www.anesthesia-analgesia.org). Cardiac catheterization on day of life two revealed suprasystemic RV pressures, RV to coronary artery fistulae and ostial coronary stenoses (Fig. 1 and Video 2). In the intensive care unit on day of life 15, anemia and associated hypovolemia produced myocardial ischemia, which resolved after transfusion of packed red blood cells (Video 2). The patient was listed for cardiac transplantation (status 1A), and underwent cardiac transplantation at age 3 mo. Gross pathologic examination of the explanted heart revealed: PA/IVS with RV hypoplasia, tricuspid stenosis, RV hypertrophy, narrow coronary arteries, and areas of fibrosis consistent with myocardial infarction (Video Clip 3; please see video clip available at www.anesthesia-analgesia.org). Intraoperative management was complicated by recurrent episodes of myocardial ischemia with ST depression. Management of these patients is challenging. Optimization of myocardial oxygen delivery focuses on maintenance of RV pressure. Avoiding hypovolemia, anemia, and anything that decreases RV pressure is essential. However, maintaining this physiologic end-point may result in increases in myocardial oxygen consumption. Ultimately, any interventions to reduce myocardial oxygen consumption by reducing preload, afterload, or contractility must be undertaken with caution as they may result in a reduction in RV pressure. The time from induction of anesthesia to institution of cardiopulmonary bypass must also be minimized. Due to the increased risk of airway, great vessel, and left atrial compression with probe insertion and manipulation in a small infant, we elected to forgo use of intraoperative transesophageal echocardiography (TEE) during the transplant procedure in this hemodynamically tenuous patient.