Kent H. Rehfeldt

Robotic Mitral Valve Repair for All Categories of Leaflet Prolapse: Improving Patient Appeal and Advancing Standard of Care

OBJECTIVE To characterize the early outcomes of robotic mitral valve (MV) repair using standard open techniques. PATIENTS AND METHODS We prospectively studied 100 patients with severe mitral regurgitation due to leaflet prolapse who underwent robot-assisted MV repair using conventional open-repair techniques between January 1, 2008, and December 31, 2009, at Mayo Clinic, Rochester, MN. RESULTS The mean age of the patients was 53.9 years; 77 patients (77%) were male. Fifty-nine patients (59%) had posterior leaflet prolapse, 38 (38%) had bileaflet disease, and 3 (3%) had isolated anterior leaflet prolapse. Median cross-clamp and bypass times decreased significantly during the course of the study (P<.001). Median postoperative ventilation time was 0 hours for the last 25 patients, with most patients extubated in the operating room. No deaths occurred. Reexploration for postoperative bleeding occurred in 1 patient (1%); 3 patients (3%) required percutaneous coronary intervention. Median hospital stay was 3 days. One patient (1%) underwent mitral reoperation for annuloplasty band dehiscence. Residual regurgitation was mild or less in all patients at dismissal and 1 month postoperatively. Significant reverse remodeling occurred by 1 month, including decreased left ventricular end-diastolic diameter (-7.2 mm; P<.001) and left ventricular end-diastolic volume (-61.0 mL;P<.001). CONCLUSION Robot-assisted MV repair using proven, conventional open-repair techniques is reproducible and safe and hastens recovery for all categories of leaflet prolapse. One month after surgery, significant regression in left ventricular size and volume is evident.

Transesophageal Echocardiography in a Patient in Hemodynamic Compromise After Jarvik 2000™ Implantation : The Suckdown Effect

A 39-yr-old man presented with decompensated heart failure for placement of a Jarvik 2000TM (Jarvik Heart Inc., New York, NY) left ventricular (LV) assist device (LVAD) as a bridge to transplant. He was inotrope-dependent with a LV ejection fraction of 14% and severe right ventricular (RV) dysfunction. The device was placed at the LV apex with the outflow cannula anastomosed to the ascending aorta. He was weaned from cardiopulmonary bypass (CPB) to LVAD support without hemodynamic instability. However, his course was complicated by persistent nonsurgical bleeding. Nine hours after his initial operation he returned to the operating room in hemodynamic distress for emergent exploration. The patient was tachycardic to 140 bpm with a mean arterial blood pressure of 42–55 mm HG, despite support from the LVAD at setting 3 (approximately 10,000 revolutions per minute [RPM]). Considering the persistent postoperative bleeding, his hemodynamic compromise was likely due, in part, to hypovolemia despite aggressive resuscitation in the intensive care unit. Cardiac tamponade also needed to be excluded. Intraoperative transesophageal echocardiography (TEE) demonstrated no evidence of pericardial fluid or clot accumulation. However, his LV enddiastolic volume was markedly reduced with near collapse of the ventricular walls adjacent to the LVAD inflow site (Fig. 1, Video 1; please see video clip available at www.anesthesia-analgesia.org). Based on the TEE images, LVAD flow was transiently reduced to lower settings and additional resuscitative fluids were administered resulting in adequate LV filling (Fig. 2, Video 2), a mean arterial blood pressure of 75 mm Hg and a heart rate of 90 bpm. Of note, neither the pulmonary artery diastolic pressure nor central venous pressure changed significantly before, during, or after this episode. He was discharged from the hospital without any deficits and subsequently underwent successful orthotopic heart transplantation.

The perioperative management of patients undergoing combined heart-liver transplantation.

Background Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease. Methods A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed. Results Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT. Conclusion Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.

Robotic Mitral Valve Repair: A Review of Anesthetic Management of the First 200 Patients

OBJECTIVE The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. DESIGN A retrospective review. SETTING A single tertiary referral academic hospital. PARTICIPANTS Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. CONCLUSIONS Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

Robot-Assisted Mitral Valve Repair

p i n p s t BASED LARGELY ON THE success of laparoscopic surgery in the 1990s, minimally invasive surgical approaches have gained widespread acceptance among many surgical specialties; cardiac surgery is no exception. In addition, the lay press and Internet are replete with reports of cardiac valve repair or replacement through small incisions with reportedly improved recovery times and cosmesis. Perhaps the most dramatic change to the surgical approach of valvular repair is with the use of robotic assistance (Fig 1). Many surgeons find that robotic assistance provides superior dexterity compared with thoracoscopic instruments. In addition, the dramatic and futuristic sounding nature of this approach leads many patients to seek out centers that offer robotic approaches to mitral surgery. Currently, a minority of mitral valve (MV) operations in the United States are conducted with robotic assistance and randomized trials comparing this minimally invasive approach with standard, open techniques are lacking. However, hospital stays and recovery times appear to be shorter with robotic assistance, and cosmesis undoubtedly is improved compared with an open approach via median sternotomy. These observations combined with the growing awareness of the availability of this operation among patients continue to fuel growth in this practice.

Use of Paravertebral Blockade to Facilitate Early Extubation after Minimally Invasive Cardiac Surgery

We retrospectively reviewed the first 14 patients who received preoperative paravertebral blockade prior to minimally invasive cardiac surgical procedures. The use of paravertebral blockade along with an anesthetic technique designed to facilitate rapid recovery allowed early extubation in the operating room or intensive care unit in all but one patient. Extubated patients leaving the operating room were comfortable. No postoperative respiratory complications occurred.

Prosthetic Valve Malfunction Masked by Intraoperative Pressure Measurements

IMPLICATIONS We describe a case in which intraoperative echocardiography recorded an abnormally high pressure gradient across a newly implanted mechanical heart valve. However, inserting pressure-transducing needles on each side of this prosthesis did not confirm the echocardiographic findings. The prosthesis was later confirmed to be malfunctioning and was replaced.

Anesthetic pharmacology and perioperative considerations for heart transplantation.

From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.

The Diagnosis of Left Ventricular Hypertrabeculation/Noncompaction by Intraoperative Transesophageal Echocardiography

Fig 1. Intraoperative transgastric LV short-axis view obtained apical to the papillary muscles showing a dilated apex. The anterior and lateral walls display changes consistent with left ventricular hypertrabeculation/noncompaction, including characteristic thickening with a 2-layer appearance and deep recesses between prominent trabeculations.

Digital gangrene after radial artery catheterization in a patient with thrombocytosis

A nesthesiologists often perform radial artery catheterization, to facilitate both close hemodynamic monitoring and repeated blood sampling. Many possible complications, including infection, bleeding, dissection, and pseudoaneurysm, have been identified (1). Thromboembolism, occasionally leading to amputation of a limb or digits, has also been reported (2,3). We present the case of a patient with thrombocytosis who developed gangrene and subsequent autoamputation of the distal index finger after ipsilateral radial artery cannulation. This case may serve to identify a group of patients who are at increased risk of one of the most serious sequelae of arterial catheterization.