Nathaen S. Weitzel

Left Ventricular Assist Device Outflow Cannula Obstruction by the Rare Environmental Fungus Myceliophthora thermophila

Left ventricular assist devices are used to provide mechanical circulatory support during end-stage heart failure either as a destination therapy or as a bridge to heart transplantation. Perioperative transesophageal echocardiography is becoming an invaluable tool to investigate device function during implantation and in case of mechanical malfunction. Most malfunctions are due to inflow graft occlusion, or device malfunction, while outflow graft dysfunction is rare. Here, we present a case of severe outflow conduit obstruction by a rare environmental fungus, Myceliophthora thermophila. After replacement of the infected device and intensive antifungal treatment, heart transplantation was performed 2 yr later.

Detection of Left Ventricular Apical Thrombus With Three-Dimensional Transesophageal Echocardiography:

Objective. Left ventricular (LV) thrombosis persists as a clinical challenge in echocardiographic diagnosis and is an important risk factor for perioperative embolic events in cardiac surgery. Appropriate detection and monitoring when thrombus is suspected is critical in surgical planning and in avoiding catastrophic patient outcomes. Case Presentation. The authors present a case of a laminated LV apical thrombus, which was discovered intraoperatively by real-time 3-dimensional (3D) transesophageal echocardiography. Clinical Challenges. The clinical challenges were (a) LV thrombosis impact on surgical management, (b) key echocardiographic challenges in diagnosing LV thrombosis, and (c) role of 3D echocardiography in the diagnostic algorithm. Conclusion. Because of the lack of a gold standard, 2D transthoracic echocardiography remains the imaging modality of choice in assessment; however, there is increasing evidence that 3D technology can be more accurate in intracardiac mass detection and should be considered in the diagnostic algorithm.

Approaches to Perioperative Care for Esophagectomy

DESPITE ITS LONGSTANDING RECOGNITION, esophageal carcinoma remains a highly lethal disease that affects thousands of patients annually. The United States Centers for Disease Control and Prevention reports heterogenous development of mortality from esophageal cancer over time (Fig 1). Although improvements over time have been made in the mortality rates of black women and men, the mortality for white men actually has increased in the last decade of the 20th century. In 2010, death rates from esophageal cancer were approximately 40/100,000 for men Z 65 years of age and about 10/100,000 for women Z 65 years of age. In 1990, death rates were significantly higher for black than for white patients; in 2010 the death rates were similar (Fig 1). Perioperative mortality for esophagectomy is the highest among elective procedures, and has been reported from 1% to 3% in contemporary single-center studies and between 3.4% high-volume hospitals and 17.3% in low-volume hospitals in a large multicenter retrospective study assessing cancer outcomes from 1984 to 1993 in patients older than 65. A recent study looking at trends and outcomes of esophageal surgery in the United States examined the national inpatient sample database to analyze results for patients with esophageal cancer treated with either total or partial esophagectomy. Between 2001 and 2010 in the United States, 15,190 esophagectomies were performed. Although numbers increased progressively during this period, mortality decreased from 8.3% to 4.2%.

Postreperfusion Syndrome During Liver Transplantation

Each Roundtable Discussion involves discussion of a clinical case scenario with various experts in the field. This issue will be a discussion regarding postreperfusion syndrome and involves 3 anesthesiologists and a liver transplant surgeon as our discussants. Matthew Fiegel, MD, is an Associate Professor of anesthesiology at University of Colorado Denver. He is a liver transplant specialist as well as the head of the Acute Pain Service. Sara Cheng MD, PhD, is an Assistant Professor of anesthesiology at the University of Colorado Denver. She is an active research scientist with interest in liver transplant and coagulation studies, as well as a specialist in liver transplantation. Micheal Zimmerman, MD, is an Associate Professor of surgery in the Transplant Surgery Division of the University of Colorado Denver. He is an active research scientist, with a clinical and research interest in liver transplant. Tamas Seres MD, PhD, is an Associate Professor of anesthesiology and the Chief of the Cardiothoracic Anesthesiology Service at the University of Colorado Denver. He has an active interest in transesophageal echocardiography applications in both cardiac surgery and transplant.

Treatment of Acute Silicoproteinosis by Whole-Lung Lavage

Acute silicoproteinosis is a rare disease that occurs following a heavy inhalational exposure to silica dusts. Clinically, it resembles pulmonary alveolar proteinosis (PAP); silica exposure is thought to be a cause of secondary PAP. We describe a patient with biopsy-confirmed acute silicoproteinosis whose course was complicated by acute hypoxemic respiratory failure requiring mechanical ventilation. Without clinical improvement despite antibiotic and steroid treatment, the patient was scheduled for whole-lung lavage under general anesthesia. Anesthetic challenges included double-lumen tube placement and single-lung ventilation in a hypoxic patient, facilitating lung lavage, and protecting the contralateral lung from catastrophic spillage.

Right Ventricular Longitudinal Strain In Left Ventricular Assist Device Surgery – A Retrospective Cohort Study☆☆☆

OBJECTIVES Right ventricular (RV) failure is common after left ventricular assist device (LVAD) surgery and is associated with higher mortality. Measurement of longitudinal RV strain using speckle-tracking technology is a novel approach to quantify RV function. The authors hypothesized that depressed peak longitudinal RV strain measured by intraoperative transesophageal echocardiography (TEE) examinations would be associated with adverse outcomes after LVAD surgery. DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. PARTICIPANTS Following Institutional Review Board approval, the authors retrospectively identified adult patients who underwent implantation of non-pulsatile LVAD. Exclusion criteria included inadequate TEE images and device explantation within 6 months for heart transplantation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The postoperative adverse event outcome was defined as a composite of one or more of death within 6 months, ≥14 days of inotropes, mechanical RV support, or device thrombosis. Intraoperative TEE images were analyzed for peak RV free wall longitudinal strain by two blinded investigators. Simple logistic regression was used to assess the relationship between adverse outcome and the mean of the strain measurements of the two raters. Agreement between the raters was assessed by intra-class correlation (0.62) and Pearson correlation coefficient (0.63). Of the 57 subjects, 21 (37%) had an adverse outcome. The logistic regression indicated no significant association between RV peak longitudinal strain and adverse events. CONCLUSIONS In this retrospective study of patients undergoing non-pulsatile LVAD implantation, peak longitudinal strain of the RV free wall was not associated with adverse outcomes within 6 months after surgery. Additional quantitative echocardiographic measures for intraoperative RV assessment should be explored.

Postoperative Management for Patients With Durable Mechanical Circulatory Support Devices.

Mechanical circulatory support devices have been approved as bridge to transplantation, as bridge to recovery, or as destination therapy to treat end-stage heart failure. The perioperative challenges for the anesthesiologist and the intensivist caring for these patients include device-related complications, hemodynamic instability, arrhythmias, right ventricular failure, and coagulopathy. Perioperative management in this high-risk population has a significant impact on patient outcomes. This review focuses immediate postoperative intensive care unit management of device-related complications.

Anesthetic Considerations for Surgery on the Aortic Arch

Aortic arch surgery requires meticulous teamwork in the true perioperative sense. Planning and communication at all phases from preoperative evaluation, through intraoperative management, to postoperative care should be well coordinated between surgical, anesthesia, perfusion, and intensive care unit teams. This review discusses intraoperative management from the anesthesiologist’s perspective, with particular emphasis on transesophageal echo evaluation and coagulation management.

Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function

Preclinical Research

Mediastinal mass with superior vena cava syndrome.

Corresponding Author: Ramin Jamshidi, Children’s Hospital of Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI 53226, USA Email: rjamshidi@chw.org Each quarter, the Roundtable Discussion explores a clinical case with experts in the field, aiming to present topics with a multidisciplinary approach. This issue’s article features contributions from 2 expert surgeons and 2 anesthesiologists, discussing preoperative, intraoperative, and postoperative management decisions.