Michael Fabbro

Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm

Audrey Spelde, MD n , Toby Steinberg, MD n , Prakash A. Patel, MD n , Harry Garcia, MD n , Jeremy D. Kukafka, MD n , Emily MacKay, DO n , Jacob T. Gutsche, MD n , Jonathan Frogel, MD n , Michael Fabbro, DO † , Jessie M. Raiten, MD ‡ , John G.T. Augoustides, MD, FASE, FAHA n,1 Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Cardiorespiratory Stability of Patients Undergoing Transcatheter Aortic Valve Replacement Is Not Improved During General Anesthesia Compared to Sedation: A Retrospective, Observational Study

ABSTRACT Purpose: To evaluate whether general anesthesia (GA) provides improved cardiorespiratory stability compared to sedation during TAVR. Methods: A retrospective analysis at a single center, university hospital. Patients undergoing TAVR were given either routine GA or deep sedation with dexmedetomidine for TAVR. Results: The superiority of GA versus deep sedation was evaluated statistically by testing if any of the following were lower in the GA patient group; the incidence of cardiorespiratory perturbations (hypotension, bradycardia, or hypoxemia), the amount of volume resuscitation (crystalloid, colloid, or allogeneic blood administration), or the doses of drugs needed to control blood pressure (epinephrine, norepinephrine, calcium, and nitroglycerine). A total of 206 TAVR patients were studied. Of these, 150 patients underwent TAVR via the transfemoral approach and were included for comparative analysis. In total 58 (39%) received sedation. Sedation patients were older than those who received GA. There were not less cardiorespiratory perturbations in the GA group. No less vasocactive agents were administered in the GA patients. Volume resuscitation was also not less in the patients receiving GA. All broad indices of stability were not lower in GA patients. Patients in the GA group were also more likely to receive a packed red blood cell transfusion. In all, 8 (13.8%) of the patients required conversion of sedation to GA. Patients who received GA were almost twice as likely to be transferred to the ICU intubated. Conclusion: Transfemoral TAVR patients who received GA did not have more cardiorespiratory stability compared to those receiving sedation.

A Narrative Review for Perioperative Physicians of the 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants

In 2017 the American College of Cardiology issued an Expert Consensus Decision Pathway dedicated specifically to the management of bleeding in patients on anticoagulants. The consensus document is both timely and important as indications for more novel anticoagulants expand rapidly. The document reviews in detail recommendations for interruption, management and re-initiation of anticoagulation in bleeding scenarios. Numerous points within the document are relevant to perioperative physicians managing patients on anticoagulation with either bleeding complications or undergoing surgical procedures. The intent of this narrative review is to highlight the salient points within the expert consensus for perioperative physicians.

ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Review of the 2017 Document for the Cardiac Anesthesiologist

Chronic mitral regurgitation (MR) is the most prevalent valvular lesion in the adult US population. Appropriate patient selection for mitral intervention and selection of the appropriate interventional strategy and optimal periprocedural management rely on thorough clinical evaluation, accurate echocardiographic input, and in-depth understanding of chronic MR pathophysiology on the part of the cardiac anesthesiologist. The recently published Expert Consensus Decision Pathway on the management of MR was designed to provide tools to help the clinician with broad clinical decision-making, including patient referral, and the present review focuses and elaborates on the key aspects relevant to the cardiac anesthesiologist in the peri-interventional setting.

Comparing Factor Concentrates for Post-Bypass Coagulopathy: Is There One Best Option?

TRADITIONAL MANAGEMENT of post-bypass coagulopathy often relies on the transfusion of fresh frozen plasma and platelets in order to achieve acceptable hemostasis. However, this can often be detrimental to both cardiac function and hemodynamic stability due to the volume overload from excessive transfusion. Furthermore, an increase in red blood cell transfusion is common due to dilution. The rising use of factor concentrates for factor repletion has aided in providing therapy that can be given in much smaller volumes, along with more concentrated amounts of coagulation factors. These concentrates include recombinant activated Factor VII (rFVIIa), fibrinogen concentrates, and prothrombin complex concentrates (PCC). Certainly, the off-label use of these concentrates in cardiac surgery has demonstrated sufficient clinical benefits leading to their inclusion in blood management guidelines; however, their use does not come without safety concerns and thrombosis risk. Additionally, each of these concentrates has been well studied against standard transfusion approaches described above, but there are far fewer direct comparisons of the effectiveness of factor concentrates when compared with other factor concentrates in the cardiac surgery setting. As we continue to explore these therapies for optimal dosing, timing of administration, and safety profiles, we must keep in mind that each of these targetspecific agents works differently with different intended goals, and therefore, any direct comparisons of factor concentrates may not be as straightforward as we would like. Initial comparisons of one factor concentrate to another actually date back to more than a decade ago, although studies did not involve cardiac surgical patients directly. In the setting of sustained anticoagulation (ie, vitamin K antagonist), 4-factor PCC (Factors II, VII, IX, X) compared to rFVIIa, an animal model demonstrated that PCC was more effective in restoring hemostatic function. Interestingly, a comparison of 3-factor PCC (Factors II, IX, X) and low-dose rFVIIa in patients requiring emergent warfarin reversal revealed that 1.0 to 1.2 mg of rFVIIa was more effective at achieving an international normalized ratio (INR) less than 1.5 when compared with 3-factor PCC (average dose 20 U/kg). Next, a direct comparison of 4-factor PCC to 3-factor PCC in an

Hypertrophic Cardiomyopathy and Left Ventricular Outflow Tract Obstruction: Expecting the Unexpected

Hypertrophic cardiomyopathy is an increasingly recognized clinical disease that carries perioperative risk. Patients may or may not carry a preoperative diagnosis, but provocable left ventricular outflow tract gradients place them at risk for hemodynamic compromise under surgical conditions. Early recognition of obstructive patterns and rapid management alterations in the face of instability are imperative for the treatment of these patients. This review focuses on the diagnostic criteria, risk factors, and management strategies for the perioperative hypertrophic cardiomyopathy patient. Finally, novel diagnostic modalities are discussed.

Technology: Is there sufficient evidence to change practice in point-of-care management of coagulopathy

Currently, hemostasis is one of the most widely researched topics in perioperative medicine. As investigators learn more about the complexity of coagulation, developing tests with the ability to rapidly monitor coagulation and guide targeted therapy is the key to optimizing hemostasis management. There is mounting evidence that algorithmic transfusion using point-of-care (POC) testing can reduce red cell and platelet transfusions and major bleeding after cardiac surgery. Integrating these tests during cardiac surgery and trauma management is especially important because these groups use the most blood products within a health system and the risks of transfusion are well documented. Currently, numerous POC tests are available for evaluating hemostasis. The purpose of this review is to provide a comprehensive evaluation of the current evidence surrounding the most common POC testing devices in practice for managing coagulation.

Acute Type B Aortic Dissection in Pregnancy – Therapeutic Challenges in a Multidisciplinary Setting ☆ ☆☆

Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston-Salem, NC Cardiothoracic Anesthesiology, Department of Anesthesiology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL