Michael E. Barron

Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass

BACKGROUND Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. METHODS Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA. RESULTS Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy. CONCLUSIONS In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA.

Factors affecting late survival after surgical remodeling of left ventricular aneurysms

OBJECTIVES Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods. METHODS From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch. RESULTS Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04). CONCLUSIONS Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.

A randomized, controlled trial on dexmedetomidine for providing adequate sedation and hemodynamic control for awake, diagnostic transesophageal echocardiography

OBJECTIVE Transesophageal echocardiography (TEE) has become established as a sensitive and accurate diagnostic method for the rapid assessment of myocardial function. It was theorized that dexmedetomidine (Precedex; Hospira, Inc, Lake Forest, IL) might prove to be useful for sedating patients while undergoing TEE. DESIGN A prospective, randomized trial was designed comparing dexmedetomidine versus standard therapy (eg, midazolam and opioids) for sedation. SETTING This trial was performed in a tertiary care, single-institution university hospital. PARTICIPANTS Males and females, American Society of Anesthesiologists I to IV, ages 18 to 65 years, requiring diagnostic TEE. Patients were excluded if pregnant, if they had taken benzodiazepines or opioids within 24 hours, or if they were deemed to be too unstable to receive any kind of sedation. INTERVENTIONS Patients were randomized to standard therapy or dexmedetomidine infusion groups. Sedation was assessed at 6 time points. Pulse oximetry, electrocardiogram, heart rate, noninvasive blood pressure, and respiratory rate were monitored. Additional variables measured were the amount of each drug given, the time of the TEE procedure, and the time to recovery. MEASUREMENTS AND MAIN RESULTS A survey about the quality of sedation, the level of comfort, and whether or not they would accept this type of sedation again was administered after recovery from sedation. Demographic data and patient questionnaire responses were reported as means and standard errors or percents and were analyzed with the t test and chi-square test. Twenty-two patients were enrolled. Hemodynamics were statistically different between the two groups at several time points. Both systolic and diastolic blood pressures (BP) were elevated in the standard therapy group, whereas the dexmedetomidine group had a lower BP. Heart rate was elevated significantly in the standard therapy group compared with the dexmedetomidine group. There was no statistical or clinical difference between the groups in terms of oxygenation or respiratory rate. CONCLUSIONS The authors concluded that dexmedetomidine appears equivalent in achieving adequate levels of sedation without increasing the rate of respiratory depression or decreasing oxygen saturation compared with standard therapy, and it may be better in achieving desired hemodynamic results.

Invasive Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus: Cardiac Anesthesia in Liver Transplant Settings

OBJECTIVES Resection of renal cell carcinomas (RCC) with tumor thrombus invasion into the inferior vena cava (IVC) is associated with significant perioperative morbidity and mortality. This study examined the intra- and inter-departmental collaboration among cardiac, liver transplantation, and urologic surgeons and anesthesiologists in caring for these patients. DESIGN After IRB approval, medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 in this institution, were reviewed. Data were collected and analyzed by one way-ANOVA and chi-square test. SETTING Major academic institution, tertiary referral center. PARTICIPANTS This was a retrospective study based on the medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-eight patients (82.9%) with level III thrombus and 12 patients (17.1%) with level IV thrombus were analyzed. Sixty-five (92.9%) did not require any extracorporeal circulatory support; 5 (2 with level III and 3 with level IV; 7.1%) required cardiopulmonary bypass. No patients required veno-venous bypass. Compared to patients with level III thrombus extension, patients with level IV had higher estimated blood loss (6978±2968 mL v 1540±206, p<0.001) and hospital stays (18.8±1.6 days v 8.1±0.7, p<0.001). Intraoperative transesophageal echocardiography (TEE) was utilized in 77.6% of patients with level III thrombus extension and in 100% of patients with level IV thrombus extension. Intraoperative TEE guidance resulted in a significant surgical plan modification in 3 cases (5.2%). Short-term mortality was low (n = 3, 4.3%). CONCLUSIONS Utilization of specialized liver transplantation and cardiac surgical techniques in the resection of RCC with extension into the IVC calls for a close intra-and interdepartmental collaboration between surgeons and anesthesiologists. The transabdominal approach to suprahepatic segments of the IVC allowed avoidance of extracorporeal circulatory support in most of these patients. Perioperative management of these patients reflected the critical importance of TEE-proficient practitioners experienced in liver transplantation and cardiac anesthesia.

Successful use of a custom-made paracorporeal total artificial heart as a bridge to retransplantation in adult and adolescent patients.

Because the currently available total artificial hearts are rather bulky, the use of a custom-made paracorporeal total artificial heart constructed with 2 ventricular assist devices is an alternative for children and adults with small stature. This article reports our experience using this system in an adult and a pediatric patient. The advantages and disadvantages of this technique are discussed.

Factors Which Predict Safe Extubation in the Operating Room Following Cardiac Surgery

Abstract  Background: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. Methods: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co‐morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re‐exploration, surgical and OR times, and ICU and hospital lengths of stay. Results: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off‐pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off‐bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high‐risk procedures (2.5%). Conclusions: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR. (J Card Surg 2012;27:275‐280)

Controlled Ventilation Enhances Catheter Stability During Radiofrequency Ablation

Variations in the amplitude of the atrial and ventricular depolarization waves of the intracardiac electrogram occur during different phases of respiration. Therefore, we tested whether controlled ventilation would reduce ablation attempts and increase the rate of success in patients undergoing radiofrequency ablation with general anesthesia. Thirty‐eight children were divided into two groups: (1) controlled and (2) noncontrolled or cyclic ventilation. In the controlled ventilation group, the mapping electrogram was recorded during sustained inspiration, sustained expiration, and cyclic ventilation. Ablation was done in the phase of ventilation that had the least variability in atrial and ventricular amplitudes. Seventeen patients in the controlled ventilation group had tracings adequate for review. In eight patients, ablation was done during sustained inspiration with the percentage change of atrial and ventricular amplitudes (15%± 16% and 13%± 16%, respectively) being < that during sustained expiration (38%± 27%, P = 0.04 and 20%± 21 %) or during cyclic ventilation (57%± 27%, P < 0.01 and 54%± 26%, P = 0.003). In nine patients, ablation was done during sustained expiration with the percentage change of atrial and ventricular amplitudes (5%± 5% and 5%± 2%) being less than that during sustained inspiration (21%± 14%, P = 0.01 and 11%± 6%, P = 0.01) or during cyclic ventilation (68%± 23%, P < 0.001 and 48 ± 26%, P = 0.001). We achieved success with each patient in both groups, but the number of ablation attempts were less in the controlled ventilation group 1 (3 ± 2), as compared to the cyclic ventilation group 2 (8 ± 8; P < 0.02). We concluded that controlled ventilation reduced the number of ablation attempts and facilitated the ablation procedure.

Gas Exchange During Lung Perfusion/Ventilation During Cardiopulmonary Bypass: Preliminary Results of A Pilot Study

Lung perfusion/ventilation was introduced as a means to minimize cardiopulmonary (CPB)-related pulmonary ischemic injury. Current results in the literature are divergent, and the role of gas exchange during lung perfusion/ventilation during CPB, remains undefined. This report details a) the technique of continuous lung perfusion/ventilation during CPB, b) provides initial observations, and c) discusses gas exchange during CPB.

Transesophageal Echocardiography Images of an Inferior Wall Pseudoaneurysm: A Difficult Differential Diagnosis

A 72-year-old man was transferred from an outside hospital after a cardiac catheterization revealed total occlusion of his right coronary artery, an inferior wall aneurysm, and a ventricular septal defect (VSD) 3 weeks after a myocardial infarction. Emergent coronary revascularization and VSD repair were planned. Informed consent for this presentation was obtained from the patient. Intraoperative transesophageal echocardiography (TEE) revealed a mildly dilated left ventricle (LV), with basal inferolateral, inferior, and inferoseptal akinesis (Video 1, loop 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A160; see Appendix for video legend). In transgastric (TG) midpapillary shortaxis view, a large aneurysmal cavity broadly connected to the inferior wall medial to the posteromedial papillary muscle was identified (Video 1, loop 2, http://links.lww.com/AA/A160). In TG mid short-axis and deep TG long-axis views, the walls of the aneurysmal sac were seen comprising connective tissue and lined with thrombotic material (Figs. 1 and 2) (Video 1, loops 2, 3, and 4; http://links.lww.com/AA/A160). Echographically, the thrombotic material appeared well circumscribed, homogeneously soft, with irregular borders and multiple mobile fibrillary projections into the aneurysmal cavity, markedly distinct from the LV myocardium and from the highly echo-reflective pericardium. Blood flow between the LV and the aneurysmal cavity appeared laminar based on color Doppler study (Video 1, loop 5, http://links.lww.com/AA/A160). Upon further examination in the deep TG view, this aneurysm appeared to communicate with the right ventricle through a defect in the inferior septum (Video 1, loop 6, http://links.lww.com/AA/A160); pulse-wave and color Doppler examination confirmed left-to-right systolic flow through this defect (Fig. 3) (Video 1, loop 7, http://links.lww.com/AA/A160). These data were communicated to the surgical team. Upon entry into the mediastinum, extensive dense pericarditis was noted, and a large LV inferior wall pseudoaneurysm, contained by the adherent pericardium and communicating with the right ventricle through the postinfarct VSD, was identified. The patient underwent coronary revascularization and closure of the defects in the interventricular septum and LV inferior wall with bovine pericardium and BioGlue Surgical Adhesive (CryoLife Inc., Kennesaw, GA). He made an uneventful recovery and was discharged in satisfactory condition. Myocardial infarction can result in rupture of a free LV wall in 4% of patients. Overlying adherent pericardium may contain the defect, giving rise to a false (pseudo) aneurysm. Lacking the structural support of myocardium, an LV pseudoaneurysm carries a significant risk of expansion and fatal rupture. This entity needs to be differentiated from a true LV aneurysm, arising in an area of a thinned or scarred myocardium. Both true and false LV aneurysms may result in heart failure, thromboembolic events, and ventricular arrhythmias secondary to sluggish blood flow in a noncontractile aneurysmal cavity and disrupted ventricular conduction. Distinguishing between true and false LV aneurysms is essential in determining the appropriate therapeutic approach and prognosis. Pseudoaneurysms specifically require urgent surgical intervention. The most important fundamental feature differentiating true and false aneurysms is the presence of a continuous surrounding myocardial wall in the former, and its absence in the latter. Demonstration of myocardial wall discontinuity may be confounded by the presence of thrombotic material lining the adherent pericardium. Pseudoaneurysmal wall composition (pericardium with mural thrombus) should be carefully distinguished from a true aneurysm’s myocardium. Analysis is greatly facilitated by the use of appropriately focused zoomed images of the aneurysmal neck and sack walls. Only if myocardial continuity and aneurysmal wall composition are uncertain should secondary characteristics be used. Traditionally, an LV pseudoaneurysm is described as a globular, echo-free cavity connected to the ventricular chamber via a relatively narrow orifice (neck), with a ratio of the maximum neck diameter to the maximum aneurysm diameter (Gatewood and Nanda index) 0.5. Turbulent blood flow through the neck or within the cavity is another secondary characteristic of pseudoaneurysms. Conversely, true LV aneurysms are usually characterized by laminar flow through a mouth as wide as or wider than their internal diameter. Significantly, these surrogate criteria may not be universally applicable, because pseudoaneurysms resulting from inferior wall myocardial infarctions (posterior descending artery distribution in our case) are From the *Department of Anesthesiology, CVT Division, and ‡Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami; and †Department of Anesthesia, Memorial Regional Hospital East, Hollywood, Florida.

Pulmonary artery catheter in cardiac surgery revisited.

To the Editor We believe that the findings of Schwann et al. are not applicable to patients undergoing cardiac surgery in general, title notwithstanding, because they studied outcomes of only a narrow and nonrepresentative segment: coronary revascularization with the use of extracorporeal circulatory support and without transesophageal echocardiography guidance. The presumed cause-and-effect conclusions and the discussion of various potential etiologies of detrimental outcomes in patients in whom pulmonary artery catheters (PACs) were used were based on the statistical analysis of outcomes of propensity-matched patients. The logical absurdity of this approach could be illustrated by the following “thought experiment”: substitute the procedure in question (placement of PAC) with another (for example, performance of cardiopulmonary resuscitation [CPR]). State-of-the-art statistical analysis would show higher mortality and morbidity rates in those patients to whom CPR was administered, compared with propensity-matched patients to whom CPR was not administered. Should we call for a reassessment of CPR as a procedure associated with worse outcomes? In addition to the many concerns and limitations discussed in the accompanying editorial, two sources of potential bias stand out: first, the absence of pulmonary hypertension and right ventricular dysfunction, arguably the most important indications for perioperative pulmonary arterial catheterization from the list of covariates used for propensity matching analysis. The second is a significant heterogeneity of perioperative surgical care introduced by noninclusion of specific institutions and surgeons as analysis covariates. It remains entirely plausible that institutions with low frequency of pulmonary artery catheterizations also have more experienced and proficient surgeons, shorter cardiopulmonary bypass times, “better” intensive care unit care, and achieve lower morbidity and mortality rates in otherwise propensity-matched populations. This possibility might explain the mysterious doubling of mortality in patients monitored with PACs despite very modest changes in fluid balance and/or use of vasoactive support statistically attributed to PACs. We applaud the efforts to establish parameters for the perioperative use of invasive hemodynamic monitoring in cardiac surgery, but caution against extrapolating the potentially biased outcomes of on-bypass coronary revascularization in low-risk population to the entire field.