M. Megan Chacon

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events

OBJECTIVE The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING Single university hospital. PARTICIPANTS A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair.

OBJECTIVE The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. DESIGN A randomized, prospective trial. SETTING A single tertiary referral academic medical center. PARTICIPANTS 60 patients undergoing robotic mitral valve surgery. INTERVENTIONS Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. MEASUREMENTS AND MAIN RESULTS After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. CONCLUSIONS The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.

Perioperative management of two patients with left ventricular assist devices presenting for noncardiac surgery in the prone position.

Ventricular assist devices (VADs) provide mechanical circulatory support for patients with advanced heart failure. Patients with VADs are presenting for noncardiac surgery with increasing frequency. Understanding anesthetic management of patients with VADs is timely and necessary for perioperative physicians. We present 2 patients supported by left VADs who required intraoperative prone positioning, and how transesophageal echocardiography and VAD variables can be used to guide management.

Is Regional Anesthesia for Cardiac Surgery a Good Idea

High thoracic epidural anaesthesia (HTEA) has been used successfully in cardiac surgery and has many potential advantages. However, its safety and practicality have been called in to question because of the need for full heparinization prior to cardiopulmonary bypass, the risks associated with heparin use and neuraxial anaesthesia, and the need to delay cardiac surgery in the event of traumatic epidural placement. HTEA is excellent for postoperative pain control, and there is evidence HTEA can have a positive impact on short-term mortality.

Dilemmas for the Cardiac Anesthesiologist: Managing Conflicting Fluid Management Strategies During Combined Heart-Kidney Transplantation

IT IS WELL-DESCRIBED that patients undergoing heart transplantation with coexisting renal dysfunction have higher morbidity and mortality than those without renal impairment. A glomerular filtration rate (GFR) of 30 mL/min is considered to be a relative contraindication for heart transplantation alone. In the past, patients with concurrent heart and kidney failure were not considered as candidates for heart transplantation. With thoracic-only transplantation, patients have an unacceptably high mortality rate. Similarly, significant heart or lung disease excluded patients with renal disease from kidney transplantation alone. Several studies have shown that in selected patients, combined heart-kidney transplantation (HKT) or lung-kidney transplantation is safe to perform and demonstrates similar survival outcomes as for those who undergo a heart or lung transplantation alone. According to the United Network for Organ Sharing national database, 1,445 HKTs had been performed in the United States through September 30, 2017. Much less common are lung-kidney transplantations and combined heart-lung-kidney transplantations, of which there have been 47 and 5, respectively. Kidney transplantation is the recognized treatment of choice for chronic renal failure. Transplantation recipients often have comorbid conditions that require optimization before surgery. In addition, proper intraoperative anesthetic and hemodynamic management are vital for successful graft function. Historically, the most important intraoperative measure to ensure immediate graft function has been adequate intravascular volume. The anesthesiologist is tasked with optimization of hemodynamic status before kidney reperfusion. Hypotension after reperfusion predisposes the recipient to delayed graft function and is associated with increased incidence of renal failure and recipient complications. It has been welldemonstrated that infusion of intravenous fluids (up to 100 mL/kg) and maintenance of elevated central venous pressures (10-15 mmHg) are associated with improved immediate graft function. The intraoperative mean arterial pressure should be maintained between 60 and 70 mmHg. Optimized volume therapy is essential to ensuring renal graft viability,

Heart Failure With Preserved Ejection Fraction: A Perioperative Review

HEART FAILURE (HF) with preserved ejection fraction (HFpEF) presents significant challenges for anesthesiologists. Nearly 50% of patients presenting with HF have HFpEF, defined as having clinical HF with a left ventricular ejection fraction (LVEF) 450% and abnormal left ventricular diastolic dysfunction (LVDD). Even though HFpEF is a strong predictor of negative postoperative outcomes, it often is difficult to diagnose and the management strategies are unclear. Although there have been specific articles published with regard to the echocardiography descriptors, diagnosis, and relationship of LVDD with HF, the authors believed it was timely to present a review article for clinicians on the subject of perioperative HFpEF. This article reviews what is known about the pathogenesis, diagnosis, management options, and implications of HFpEF in the perioperative arena.

Intraoperative Transesophageal Echocardiography–Guided Placement of Bicaval Dual-Lumen Extracorporeal Membrane Oxygenation Cannula

Graphical abstract