Mona Momeni

Hypnosis in the Perioperative Management of Breast Cancer Surgery: Clinical Benefits and Potential Implications

The aim of this review is to summarize data published on the use of perioperative hypnosis in patients undergoing breast cancer surgery (BCS). Indeed, the majority of BCS patients experience stress, anxiety, nausea, vomiting, and pain. Correct management of the perioperative period and surgical removal of the primary tumor are clearly essential but can affect patients on different levels and hence have a negative impact on oncological outcomes. This review examines the effect of clinical hypnosis performed during the perioperative period. Thanks to its specific properties and techniques allowing it to be used as complementary treatment preoperatively, hypnosis has an impact most notably on distress and postoperative pain. During surgery, hypnosis may be applied to limit immunosuppression, while, in the postoperative period, it can reduce pain, anxiety, and fatigue and improve wound healing. Moreover, hypnosis is inexpensive, an important consideration given current financial concerns in healthcare. Of course, large randomized prospective studies are now needed to confirm the observed advantages of hypnosis in the field of oncology.

Aortic regurgitation after left ventricular assist device placement.

A 1 60-YEAR-OLD man with a history of recent heart failure caused by both primitive and ischemic dilated cardiomypathy underwent the successful implantation of a left ventriclar assist device (Novacor LVAS; WorldHeart, Ottawa, ON, anada) under cardiopulmonary bypass. Intraoperative transsophageal echocardiography (TEE) performed immediately fter implantation showed the correct placement of both the nflow and the outflow grafts (Fig 1) and the absence of any ortic regurgitation or aortic valve pathology. His immediate postoperative course was uneventful, and no ight ventricular assistance was needed. A routine follow-up ransthoracic echocardiogram performed in the intensive care nit on postimplantation day 9 disclosed mild central aortic egurgitation along with a mild pericardial effusion. Another ransthoracic echocardiogram performed on postimplantation ay 15 showed an aggravation of both the aortic regurgitation nd the pericardial effusion. Clinically, the patient was asymptomatic and had no fever or igns of peripheral hypoperfusion. Because the magnitude of he aortic insufficiency could preclude the correct functioning t

The dose of hydroxyethyl starch 6% 130/0.4 for fluid therapy and the incidence of acute kidney injury after cardiac surgery: A retrospective matched study

The safety of hydroxyethyl starches (HES) is still under debate. No studies have compared different dosing regimens of HES in cardiac surgery. We analyzed whether the incidence of Acute Kidney Injury (AKI) differed taking into account a weight-adjusted cumulative dose of HES 6% 130/0.4 for perioperative fluid therapy. This retrospective cohort study included all adult patients undergoing elective or emergency cardiac surgery with or without cardiopulmonary bypass. Exclusion criteria were patients on renal replacement therapy (RRT), cardiac trauma surgery, heart transplantation, patients with ventricular assist devices, subjects who required a surgical revision for bleeding and those whose medical records were incomplete. Primary endpoint was AKI following the creatinine based RIFLE classification. Secondary endpoints were 30-day mortality and RRT. Patients were divided into 2 groups whether they had received a cumulative HES dose of < 30 mL/kg (Low HES) or ≥ 30 mL/kg (High HES) during the intra- and postoperative period. A total of 1501 patients were analyzed with 983 patients in the Low HES and 518 subjects in the High HES group. 185 (18.8%) patients in the Low HES and 119 (23.0%) patients in the High HES group developed AKI (P = 0.06). In multivariable regression analysis the dose of HES administered per weight was not associated with AKI. After case-control matching 217 patients were analyzed in each group. AKI occurred in 39 (18.0%) patients in the Low HES and 50 (23.0%) patients in the High HES group (P = 0.19). In conditional regression analysis performed on the matched groups a lower weight-adjusted dose of HES was significantly associated with a reduced incidence of AKI [(Odds Ratio (95% CI) = 0.825 (0.727–0.936); P = 0.003]. In the absence of any safety study the cumulative dose of modern HES in cardiac surgery should be kept less than 30 mL/kg.

Detection by NeuroSENSE(®) Cerebral Monitor of Two Major Neurologic Events During Cardiac Surgery

From the Departments of *Anesthesiology, †Cardiac Intensive Care Unit, ‡Neurology; and §Cardiac Surgery, Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium. Address reprint requests to Mona Momeni, MD, PhD, Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Department of Anesthesiology, Avenue Hippocrate 10/1821 1200, Brussels, Belgium. E-mail: mona.momeni@uclouvain.be

Papillary Fibroelastoma of the Pulmonary Valve: The Value of Three-Dimensional Transesophageal Echocardiography.

January 2016 • Volume 122 • Number 1 www.anesthesia-analgesia.org 31 A previously healthy and physically active 48-year-old man presented to our hospital for the resection of a mass at the level of the pulmonary valve (PV). The patient’s symptoms were dyspnea and increasing fatigue. Preoperative transthoracic echocardiography (TTE) had shown a mass at the level of the PV with moderate left ventricular dysfunction. There were no signs of right ventricular outflow tract obstruction. Preoperative tests were negative for tumor markers. There was no evidence of chronic thromboembolic disease. The blood cultures were negative. Positron emission tomography showed hyperfixation at the level of the main pulmonary hilus. The decision to resect the mass was made. Intraoperative 3-dimensional (3D) transesophageal echocardiography (TEE) was performed. Full-volume (FV) acquisition of the midesophageal right ventricular inflow–outflow tract view revealed a well-defined, nonmobile mass in the proximal right ventricular outflow tract adjacent to the PV (Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/B241). No pedicle was observed. Only trivial pulmonary regurgitation was present (Supplemental Digital Content 2, Video 2, http:// links.lww.com/AA/B242). Video 3 (Supplemental Digital Content 3, http://links.lww.com/AA/B243) helped analyze the mass and its relationship to the pulmonary cusps in several multiplanar reconstruction views. Figure 1 illustrates the absence of attachments to any pulmonary cusp. The mass showed a specific appearance with the presence of cavities. This typical aspect with the areas of different echogenicity inside the mass is seen in Figure 2. After exclusion of a patent foramen ovale, the mass was resected under cardiopulmonary bypass with beating heart. The size of the mass was 17 mm × 15 mm. It showed the characteristic “sea anemone” shape once put into a water solution. Its histologic examination revealed a papillary cystic myxoid stroma surrounded by endothelial cells. The diagnosis of a papillary fibroelastoma was made. The patient was discharged on postoperative day 5. TTE after 1 month showed a normal functioning PV. DISCUSSION The differential diagnosis of a mass at the level of the PV includes endocarditis, a noninfective thrombus, or the presence of a primary valve tumor. In an analysis of 22 autopsy series, Reynen1 reported a frequency of 0.02% of primary cardiac tumors. The most common histologic type of cardiac valve tumors are papillary fibroelastomas and myxomas.2 Cardiac papillary fibroelastomas are small, benign tumors derived from the normal components of the endocardium. They are usually attached to the endocardium by a short pedicle. The analysis of 725 cases of

Transcatheter aortic valve implantation (TAVI): short- and long-term outcomes with respect to the type of procedure and the anaesthetic management

Results and discussion: 44patients were classified into two groups according to 75% quartile of RT(85.5sec): ER (RT < 85.5 sec, n=33) and DR (RT> 85.5sec, n=11). The DR group had significantly smaller body surface area (p< 0.05) and lef t ventricular diameter (p< 0.05), and more complicated with intraventricular out flow obstruction, and lower SvO2 immediately before RP. The multivariate logistic regression model identified SvO2 as an independent predictor of the delayed recovery af ter RP (OR 0.767, CI 0.4830.928). During TAVI, maintaining systemic oxygen supply-demand balance during surgery may overcome the preoperative disadvantageous factors.

The patient with a history of congenital heart disease who is to undergo ambulatory surgery

Purpose of review There is a strong pressure to widen the indications of ambulatory anaesthesia in children. Making a decision concerning a child with a history of cardiac disease is often difficult. The aim of this review is to give practical recommendations to help the anaesthesiologist recognize potentially dangerous situations in children with a history of cardiac disease. Recent findings The anaesthetic care of a child with a history of heart disease presenting for an ambulatory procedure includes three steps: understanding the pathophysiology of the childs current haemodynamic status, checking whether he/she is actually eligible for outpatient anaesthesia and planning the safest anaesthetic plan, accordingly. The concept of congenital heart disease nowadays includes not only congenital heart defects but also congenital dysrythmias such as congenital long QT and Brugada syndromes, and acquired lesions such as sequellae of Kawasaki disease. Children with a partially corrected or palliated cardiac defect tolerate poorly hypovolaemia, systemic hypotension and hypoxaemia. They should thus not undergo on an ambulatory basis procedures during or after which such problems can occur. Moreover, postoperative analgesia should be carefully planned with the parents. Summary A child whose cardiac disease has been corrected, who is developing well, has no exercise restriction and undergoes regular cardiologic follow-up does not present more risks than any normal American Society of Anesthesiologists physical status 1–2 child. Any other situation requires close communication with the childs paediatric cardiologist to evaluate the risks of both anaesthesia and outpatient care, and make an individualized decision accordingly.

Acute Normovolemic hemodilution during CABG induces diastolic dysfunction: A perioperative transesophageal echocardiographic study

Background and Goal of Study: A previous study has shown that Acute Normovolemic Hemodilution (ANH) during CABG improves diastolic function.1 It is however based on transmitral doppler indices that are preload dependent.2 Tissue doppler imaging (TDI) could overcome this problem. Materials and Methods: Af ter Ethical approvement and informed consent, 51 patients (subgroup of another study) with normal systolic function and hemoglobin values were prospectively randomized to ANH group or C (control) group. In ANH group, a precalculated amount of blood was withdrawn and replaced with colloids af ter the induction of anesthesia. Hemodynamic and echocardiographic parameters were recorded af ter anesthesia induction (T0), af ter ANH (T1) and 15 minutes post sternotomy (T2). Af ter the confirmation of normal distribution, student t-test was used. Results and Discussion: The demographic data of the patients are shown in table 1.