Liem Nguyen

Case 13--2014: Management of pulmonary hemorrhage after pulmonary endarterectomy with venovenous extracorporeal membrane oxygenation without systemic anticoagulation.

From the *University of California, San Diego, Thornton Hospital, †University of Chicago, Chicago, IL, ‡University of Pittsburgh, Pittsburgh, PA; and §Duke University Medical Center, Durham, NC. Address reprint requests to Brett Cronin, MD, Dept. of Anesthesiology, University of California, San Diego, Thornton Hospital, 9300 Campus Point Drive #7770, La Jolla, CA 92037. E-mail: bcronin@ ucsd.edu

CASE 1--2015: left ventricular assist device insertion in a patient with heparin-induced thrombocytopenia and renal failure.

From the *University of California, San Diego, Sulpizio Cardiovascular Center, LaJolla, CA, †Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany; and ‡Department of Anesthesiology, Queen Fabiola Children’s University Hospital, Brussels, Belgium. Address reprint requests to Sonia Nhieu, MD, University of California, San Diego, Department of Anesthesiology, Thornton Hospital, 9300 Campus Point Drive #7770, LaJolla, CA 92023-7770. E-mail: snhieu@ucsd.edu Cardiac Anesthesia Fellow. UNFRACTIONATED HEPARIN (UFH) is the most widely used intravenous drug in the United States with as many as 60% of hospitalized patients receiving this agent. The incidence of heparin-induced thrombocytopenia (HIT) is approximately 2% of patients who receive UFH. HIT syndrome type II (HIT-II) is an immune-mediated reaction in which serum antibodies against heparin-platelet factor 4 (HPF4) complexes are produced in patients who receive heparin therapy. The reaction typically develops 5 to 10 days after exposure and leads to a decrease in platelet count of 50% or more and a paradoxical hypercoagulable state. No ideal method of anticoagulation exists for patients with HIT. In non-surgical patients requiring anticoagulation and medical management of HIT, approved therapies in the United States are limited to argatroban and lepirudin. Recommendations for anticoagulation for patients with HIT requiring cardiac surgery include delaying surgery until HIT antibodies are negative, administering platelet inhibitors in addition to heparin, or using an alternative anticoagulation strategy. Unfortunately, many patients, especially those requiring cardiac surgery, cannot delay the operation, and an alternative to heparin for intraoperative anticoagulation must be used. The use of cardiopulmonary bypass (CPB) further complicates the situation because of the higher levels of anticoagulation required. Use of bivalirudin for anticoagulation in patients with HIT undergoing cardiac surgery has increased and, in a few small studies, has demonstrated a similar safety and efficacy profile compared to UFH. Bivalirudin is a synthetic, direct thrombin inhibitor made up of twenty amino acids and is approved for patients undergoing percutaneous coronary intervention. Its elimination is predominantly dependent on thrombin active site-mediated proteolytic cleavage, resulting in a short half-life of 25 minutes. Approximately 20% of the drug is excreted unchanged by the kidney, leading to a doubling of the half-life in patients with severe renal impairment. The drug’s safety profile appears unchanged, even with respect to hemorrhagic complications, in patients with moderate impairment of renal function. However, in dialysis-dependent patients, the half-life increases markedly to approximately 3 to 5 hours. While the

Multidisciplinary Approach to Transvenous Lead Extraction: A Single Center’s Experience

OBJECTIVE To evaluate the success and complication rates of a single centers multidisciplinary approach to transvenous lead extraction. SETTING One university hospital. PARTICIPANTS One hundred ninety-five patients scheduled for transvenous lead extraction. INTERVENTIONS A multidisciplinary approach to transvenous lead extraction involving cardiac surgery, electrophysiology, perfusion, and cardiac anesthesiology. MEASUREMENTS AND MAIN RESULTS A case series of 351 lead extractions performed in 195 patients over a 42-month period. Indications, success rates, and complication rates were tracked and retrospectively evaluated and reported. Indications for lead extraction included 53.3% because of lead malfunction, 36.9% because of infection, with the remaining 9.7% from other categories such as venous stenosis. The lead extraction rate was 99.7%, with complete removal in 97.7%. The overall major complication rate was 3.08%. After an initial 1-year period of performing lead extractions, the overall major complication rate reduced to 1.23%. CONCLUSIONS Transvenous lead extraction generally is a safe procedure, but not without complications. A multidisciplinary approach involving cardiac surgery, electrophysiology, and cardiac anesthesiology allows for successful management and the ability to rapidly manage major complications.

Anesthetic management of the patient undergoing heart transplantation

Cardiac transplantation is the treatment of choice for patients with end-stage heart failure. Over the years, significant advances in patient selection, donor optimization and selection, and optimization of immunosuppression strategies have markedly improved outcomes. In this review, we highlight patient selection, donor management and procurement, heart transplantation procedure, and intraoperative and postoperative management of heart transplants.

Plasma Vasopressin Levels in Patients With Right-Sided Heart Dysfunction and Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

OBJECTIVES Patients with left-sided heart dysfunction and volume overload often have associated elevations in vasopressin from neuroendocrine activation. The authors investigated perioperative levels of vasopressin in patients with isolated right-sided heart dysfunction from chronic thromboembolic pulmonary hypertension. DESIGN Prospective, observational study. SETTING Single center, tertiary hospital. PARTICIPANTS Patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy. INTERVENTIONS Vasopressin levels were measured in 22 patients during the perioperative period. MEASUREMENTS AND MAIN RESULTS Vasopressin was undetectable in 8/22 patients at baseline. As a group, vasopressin levels at baseline and after induction of anesthesia were 0.8 pg/mL (median; 0.5-1.5, interquartile range of 25% and 75%) and 0.7 pg/mL (median; 0.5-1.4, interquartile range of 25% and 75%), respectively. During cardiopulmonary bypass (CPB), vasopressin increased to 13.9 pg/mL (median; 6.7-19.9, interquartile range of 25% and 75%). Vasopressin remained elevated after deep hypothermic circulatory arrest (DHCA) at 10.5 pg/mL (median; 6.5-19.9 interquartile range of 25% and 75%) and after CPB at 19.9 pg/mL (median; 11.1-19.9 interquartile range of 25% and 75%). CONCLUSIONS Vasopressin levels in PTE patients are in the low-to-normal range at baseline and may be a clinically relevant issue in the hemodynamic management of PTE.