Marcello Fonseca Salgado Filho

Transesophageal Echocardiography in Ross Procedure

BACKGROUND AND OBJECTIVES Ross procedure is one of the surgical procedures for correction of severe congenital aortic insufficiency. Intraoperative transesophageal echocardiography is essential for optimal surgical evaluation. Furthermore, it is able to assess the blood volume profile and the need for administration of vasoactive drugs during surgery. CASE REPORT This is a 15-year old teenager with severe congenital aortic insufficiency scheduled for corrective surgery with the Ross procedure. In the operating room, the patient was monitored with electrocardiography and pulse oximeter, and he was premedicated with midazolam. After the administration of premedication, the left radial artery and right subclavian vein were punctured. Anesthetic induction was accomplished with etomidate, cisatracurium, and fentanyl while maintenance was achieved with sevoflurane. The probe of the transesophageal echocardiography equipment was introduced immediately after tracheal intubation, showing increased left ventricle; severe aortic insufficiency due to coaptation failure of the three leaflets; and competent pulmonary valve without anatomical and physiological changes. Intercurrences were not observed during surgery, with 120 minutes of extracorporeal circulation (ECC) and 8 hours of surgery. Immediately after removal from ECC the transesophageal echocardiography showed good function of both the auto- and homograft; however, the right ventricle presented hypocontractility, which was corrected with a bolus of milrinone followed by continuous infusion. The patient was transferred to the postanesthetic recovery unit intubated and hemodynamically stable with infusion of milrinone and sodium nitroprusside. CONCLUSIONS Ross procedure is one of the techniques for correction of congenital aortic insufficiency in which transesophageal echocardiography guides the surgeon precisely on the physiological and anatomical status of vascular grafts.

Impacto do ecocardiograma transesofágico intraoperatório na mortalidade em cirurgia de revascularização do miocárdio com circulação extracorpórea

OBJETIVO: avaliar as taxas de mortalidade e morbidade de doentes submetidos a revascularizacao do miocardio (RVM) com circulacao extracorporea (CEC) que utilizaram rotineiramente o ecocardiograma transesofagico intraoperatorio (ETEio). METODOS: estudo retrospectivo, observacional com avaliacao de prontuarios de 360 doentes no periodo entre abril de 2010 a abril de 2012. Foram analisados: idade, peso, altura sexo, EUROscore, diabete melito, fracao de ejecao e arterias acometidas. Os desfechos foram compilados no intra e no pos-operatorio (infarto do miocardio, acidente vascular cerebral, disfuncao renal, hemodialise, fibrilacao atrial, tempo de internacao no centro de tratamento intensivo). RESULTADOS: foram incluidos 53 doentes, com 27 recebendo a monitoracao. Foram excluidos 307 porque nao foram operados pela mesma equipe cirurgica. Os dois grupos foram homogeneos quanto a idade, peso e sexo, porem, a fracao ejecao foi menor no grupo que recebeu o ecotransesofagico (G ETEio: 56,3%; G Nao ETEio: 65,9% ± 11; p=0,01). Nos doentes em que nao foi utilizado o ETEio, a mortalidade foi maior (G ETEio: 0% e G Nao ETEio: 7,6%; p=0,01). Nao houve diferenca significativa entre os grupos quanto a incidencia de acidente vascular encefalico, infarto agudo do miocardio, fibrilacao atrial aguda e lesao renal. CONCLUSAO: a utilizacao do ecocardiograma transesofagico intraoperatorio em pacientes submetidos a revascularizacao do miocardio, com circulacao extracorporea, diminuiu a mortalidade perioperatoria; orientou quanto a utilizacao dos farmacos inotropicos e vasodilatadores e contribuiu para uma melhor evolucao dos doentes.

The importance of transesophageal echocardiography in heart harvesting for cardiac transplantation

BACKGROUND AND OBJECTIVES The use of transesophageal echocardiography (TEE) during heart harvesting for transplantation can guide the heart assessment, as harvesting a marginal heart can jeopardize the cardiac transplantation. CASE REPORT Male, 30 years old, suffered a car crash that resulted in a severe traumatic brain injury (TBI) that evolved to brain death. The patient was intubated and ventilated with a fraction of inspired oxygen of 0.6, presetting Vt 500 mL, RR 14 bpm, PEEP of 3 mm Hg, 99% O(2) saturation, and normal blood gases. He was also hypovolemic, with urine output of 9,300 mL.day(-1), sodium level of 157 mEq.L(-1), hematocrit of 27%, and BP 90/60 mm Hg maintained by infusion of norepinephrine 0.5 mcg.kg.min(-1). The patient was clinically optimized and evaluated by TEE, which showed normal size cardiac chambers, ejection fraction 66%, anatomical and functional heart valves with no changes, and foramen ovale integrity. Immediately after the confirmation of cardiac viability and clinical stabilization, the patient was taken to the operating room and the harvest began. The ischemic period lasted two hours and the heart was successfully transplanted. CONCLUSIONS In most heart transplant services, the cardiac assessment is made subjectively by the surgeon who often does not have the anesthesiologist support to clinically optimize the donor. At the Instituto Nacional de Cardiologia (INC/MS), the anesthesiologist is part of the harvesting team in order to perform intraoperative TEE, evaluating objectively the harvested heart. In doing so, it provides greater chances of heart transplantation success with lower costs for the Brazilian public health system.

Intraoperative Transesophageal Echocardiography to Evaluate PediatricPatients Undergoing Atrial Septal Defect Procedure

Introduction: Atrial septal defects (ASD) are a type of congenital heart disease that are characterized by a communication between the left atrium with the right atrium. Preoperative intraoperative transesophageal echocardiography (TEE) evaluates cardiac anatomy and function. The objective of this paper was to compare the use of intraoperative TEE in corrective surgeries for ASD in pediatric patients. Material and Methods: After approval by the local Ethics Committee for Research, a retrospective descriptive study was conducted in children aged 3 to 18 years who underwent an ASD repair between January 2011 and January 2015 divided in two groups: TEE group (n=24) and No-TEE group (n=28). Were assessed the demographic data, Qp/Qs ratio, pulmonary hipertension (PH), left ventricle ejection fraction (EF), and major clinical outcomes. Results: There were differences between the two groups in demographics data in age and wieght that were higher in the No-TEE group. There were no differences between the two groups in pulmonary infection, renal dysfunction, congestive heart failure, time of extubation in the ICU and intra-hospital mortality. There was 4% atrial arrhythmias in the TEE group and 0% in the No-TEE group (p=0.46). The No-TEE group showed more time to wean from CPB (35.1 ± 17.3 minutes vs 43.6 ± 27.2 minutes; p=0.01) and more time to release from ICU than TEE-group (42 ± 13.2 hours vs 58.9 ± 30.4 hours, p=0.01). Conclusions: We concluded that the use of intraoperative TEE is safe and economically feasible. It enables an assessment of cardiac anatomy and functions in the pre-CPB period and guide the weaning from CPB with lower time of CPB and ICU length stay than No-TEE group.

Comparison between Ultrasound-Guided and Anatomic Landmark Puncture of the Right Internal Jugular Vein

Introduction: Central venous puncture guided by Ultrasound (US) is considered the technique of choice by the Society of Cardiovascular Anesthesiologists (SCA), and performing central venous puncture without employing US is considered poor medical practice. Methods: After approval by the Research Ethics Committee of the National Institute of Cardiology a randomized clinical trial was conducted electronically with 40 patients (of both genders) who were between 45 and 65 years old and were scheduled to undergo Coronary Artery Bypass Surgery (CABG). The patients were electronically randomized (GraphPad 5.0 OS for Macintosh) divided into two groups of 20: the Ultrasound Group (USG) and the Blind Group (BG). The BG subjects were punctured according to anatomical definitions, and the USG subjects were punctured with US guidance. Results: There were no differences in the demographic data. The duration of the puncture procedure was equal for the two groups (USG=130.7 ± 57.1 sec and BG=149.4 ± 98.1 sec; p=0.78). The incidence of carotid puncture was the same for the two groups (USG=0 (0%) and BG=2 (8.5%); p=0.48). The USG had a lower incidence of changing the puncture site (USG=0 (0%) and BG=4 (23%); p=0.03) and a higher incidence of catheter implantation in a single attempt (USG=16 (100%) and BG=10 (58%). Conclusions: The use of US for insertion of central venous catheters is associated with a higher incidence of performing venous puncture in a single attempt, a lower incidence of vascular complications and a lower incidence of changing the puncture site.

A importância do ecocardiograma transesofágico na captação do coração para transplante cardíaco

JUSTIFICATIVA Y OBJETIVOS: La utilizacion del ecocardiograma transesofagico en la captacion para el transplante cardiaco, puede orientar la evaluacion del corazon, porque si captamos un corazon marginal podremos poner en riesgo el exito del transplante cardiaco. RELATO DEL CASO: Hombre de 30 anos, que sufrio un accidente automovilistico que le causo un TCE grave, y que fallecio por muerte cerebral. El paciente estaba entubado, ventilando con la ayuda de un respirador 0,6 de fraccion inspirada de oxigeno, VC 500 ml, FR 14 irpm, PEEP de 3 mmHg, con 99% de saturacion periferica de O2 y gasometria normal. Tambien estaba hipovolemico, con debito urinario de 9.300 mL.dia-1, sodio de 157 meq.L-1, hematocrito de 27% y PAI 90x60 mmHg mantenida por infusion de noradrenalina al 0,5 mcg. kg.min-1. Fue optimizado clinicamente y evaluado por el ETE, que arrojo cavidades cardiacas de tamano normal, fraccion de eyeccion de un 66%, valvulas cardiacas anatomicas y sin alteraciones funcionales y foramen oval integro. Justo despues de la confirmacion de la viabilidad cardiaca y de la estabilizacion clinica, el paciente fue derivado al quirofano y se inicio la captacion. El periodo de isquemia tuvo una duracion de dos horas y el corazon fue transplantado con exito. CONCLUSIONES: En la mayoria de los servicios de transplante cardiaco, la evaluacion del corazon se hace de forma subjetiva por parte del cirujano, que muchas veces no cuenta con la ayuda del anestesista para optimizar clinicamente el donante. En el Instituto Nacional de Cardiologia (INC/MS), el anestesista forma parte del equipo de captacion para poder realizar el ETE intraoperatorio, evaluando, de forma objetiva, el corazon captado. Asi, tenemos mas chances de exito del transplante cardiaco con un menor coste para el sistema publico de sanidad en Brasil.

O ecocardiograma transesofágico na cirurgia de Ross

JUSTIFICATIVA Y OBJETIVOS: Una de las cirugias correctivas para la insuficiencia aortica congenita grave es la cirugia de Ross. El ecocardiograma transesofagico intraoperatorio es indispensable para una buena evaluacion quirurgica. Ademas, es capaz de evaluar el perfil volemico y la necesidad de administrar farmacos vasoactivos durante la operacion. RELATO DEL CASO: Adolescente de 15 anos, que presentaba insuficiencia aortica grave de origen congenito, citado para la correccion quirurgica por la tecnica de Ross. En quirofano, el paciente fue monitorizado con electrocardiograma y oximetro de pulso, recibiendo premedicacion con midazolan. Despues de la premedicacion, se puncionaron la arteria radial izquierda y la vena subclavia derecha. La induccion anestesica se hizo con etomidato, cisatracurio y fentanil, y el mantenimiento anestesico con sevoflurano. La sonda del aparato del ecocardiograma transesofagico fue introducida inmediatamente despues de la intubacion traqueal e indicaba aumento del ventriculo izquierdo; insuficiencia aortica grave por falla de coaptacion de las tres capas; valvula pulmonar competente sin alteraciones anatomicas y fisiologicas. La cirugia trascurrio sin intercurrencias, con 120 minutos de circulacion extracorporea (CEC), y 8 horas de cirugia. Inmediatamente despues de la salida de CEC, el ecocardiograma transesofagico mostraba un buen funcionamiento tanto del auto como del homoinjerto, sin embargo, el ventriculo derecho estaba hipocontractil, lo que fue corregido con un bolo de milrinona, seguido de infusion continua. El paciente fue derivado al postoperatorio intubado, estable hemodinamicamente, y con infusion de milrinona y nitroprusiato de sodio. CONCLUSIONES: Una de las tecnicas de correccion de la insuficiencia aortica congenita es la cirugia de Ross, en que el ecocardiograma transesofagico intraoperatorio orienta al cirujano de manera precisa sobre el status fisiologico y anatomico de los injertos vasculares.

Comparison between the hemodynamic parameters of rigid laryngoscopy and lighted stylet in patients with coronariopathies.

BACKGROUND AND OBJECTIVES Anesthesiologists are responsible for airway management whenever they assume the anesthesia of a patient. In this study, we compare the hemodynamic parameters of rigid laryngoscopy and lighted stylet in patients with coronariopathies. PATIENTS AND METHODS This randomized clinical trial included 40 patients undergoing myocardial revascularization assigned into two groups: lighted stylet and rigid laryngoscope. Besides time of tracheal intubation in each group, heart rate, mean arterial pressure, changes in ST segment, and central venous pressure were evaluated during patient preparation, 1 minute and 5 minutes after anesthetic induction, and 1 minute after tracheal intubation. RESULTS Both groups were homogenous regarding demographic data. Time of tracheal intubation in the rigid laryngoscope group (24 ± 5 sec) was lower than that of the lighted stylet group (28 ± 7 sec), but without significance. Heart rate showed a reduction in both groups during anesthetic induction (p < 0.05), but 1 minute after tracheal intubation the heart rate increased to levels close to baseline levels in both groups (p > 0.05). In the rigid laryngoscope group mean arterial pressure increased after tracheal intubation to levels close to those observed during patient preparation (p > 0.05), while in the lighted stylet group mean arterial pressure remained below baseline levels (p < 0.05). Central venous pressure increased on both groups at all times (p < 0.05). CONCLUSIONS It was possible to observe that both techniques are safe for tracheal intubation in patients with coronariopathies. However, lighted stylet has fewer repercussions on mean arterial pressure.

Avaliação dos parâmetros hemodinâmicos entre a laringoscopia rígida e o estilete luminoso em pacientes coronariopatas

JUSTIFICATIVA Y OBJETIVOS: El anestesiologo esta en contacto con el manejo de la via aerea siempre que aplica una anestesia. En este estudio, estamos evaluando los parametros hemodinamicos entre el laringoscopio rigido y el estilete luminoso en pacientes con coronariopatias. PACIENTES Y METODOS: Este ensayo clinico randomizado fue llevado a cabo con la participacion de 40 pacientes sometidos a la revascularizacion del miocardio, y divididos en dos grupos: estilete luminoso y laringoscopio rigido. Se evaluaron la frecuencia cardiaca, la presion arterial promedio, alteraciones del segmento ST y la presion venosa central durante la preparacion del paciente, 1 minuto despues de la induccion anestesica, 5 minutos despues de la induccion anestesica y 1 minuto despues de la intubacion traqueal, ademas del tiempo de intubacion traqueal en cada grupo. RESULTADOS: Los grupos fueron homogeneos con relacion a los datos demograficos. El tiempo de intubacion traqueal para el grupo laringoscopio rigido (24 ± 5 seg), fue menor que en el grupo estilete luminoso (28 ± 7 seg), sin embargo con p > 0,05. La frecuencia cardiaca se reduce en los dos grupos durante la induccion (p 0,05). En el grupo laringoscopio rigido la presion arterial promedio aumento despues de la intubacion traqueal para valores proximos al momento de la preparacion del paciente (p > 0,05), mientras que en el grupo estilete luminoso la presion arterial promedio quedo por debajo de los valores basales con p < 0,05. La presion venosa central aumento en ambos grupos durante todos los momentos (p < 0,05). CONCLUSIONES: En este estudio, pudimos observar que ambas tecnicas son seguras para la intubacion traqueal en pacientes con coronariopatias. Sin embargo, el EL presenta una menor repercusion en la presion arterial promedio.