Norman E. Torres

Percutaneous Endocardial and Epicardial Ablation of Hypotensive Ventricular Tachycardia with Percutaneous Left Ventricular Assist in the Electrophysiology Laboratory

Ventricular tachycardia (VT) in the setting of structural heart disease is challenging to treat with percutaneous catheter ablation due to the presence of complex substrate, multiple morphologies, hemodynamic instability, and epicardial circuits. When substrate‐based approaches fail, however, it may be impossible to map and ablate hemodynamically unstable arrhythmias. We describe a novel approach to endocardial and epicardial mapping and ablation of hypotensive VT using a percutaneous left ventricular assist device in the electrophysiology laboratory, permitting near‐surgical access to cardiac structures.

Spinal Cord Protection During Open Repair of Thoracic and Thoracoabdominal Aortic Aneurysms Using Profound Hypothermia and Circulatory Arrest

BACKGROUND Reduced risk of paraplegia is argued as an advantage of endovascular repair of descending thoracic aortic aneurysms (DTA) and thoracoabdominal aortic aneurysms (TAAA); however, paraplegia rates with open repair vary widely. STUDY DESIGN We identified consecutive patients undergoing open repair of TAAA or DTA with or without arch replacement using profound hypothermia and circulatory arrest as a spinal cord protection strategy on a single surgical service between June 1, 2001 and September 20, 2010. RESULTS Ninety-nine procedures were performed in 94 patients with a mean age of 59 years (range 19 to 84 years), 56 of whom were male (60%). The extent of repair was TAAA in 37 (Crawford extent I in 6, extent II in 28, and extent III in 3), DTA in 37, and DTA plus arch in 25. Surgery was urgent or emergent in 25 patients (25%). Operative mortality (30-day) was 10% (10 of 99), including a mortality of 12% for arch DTA (3 of 26), 11% for TAAA (4 of 25), and 5% for isolated DTA (2 of 37). There were 11 (11%) strokes and 11 patients experienced renal failure (7 with dialysis). There were 15 late deaths and survival at 5 years was 74% (95% CI, 62.4-88.2%). No patients experienced paraplegia, although one had delayed paraparesis thought to be secondary to refractory hypotension postoperatively. CONCLUSIONS Although the mortality and stroke risks for patients undergoing repair of DTA or TAAA using profound hypothermia and circulatory arrest are substantial, the risk for paraplegia is low. In appropriately selected patients, profound hypothermia and circulatory arrest should be the preferred technique for spinal cord protection for DTA and TAAA.

Use of Paravertebral Blockade to Facilitate Early Extubation after Minimally Invasive Cardiac Surgery

We retrospectively reviewed the first 14 patients who received preoperative paravertebral blockade prior to minimally invasive cardiac surgical procedures. The use of paravertebral blockade along with an anesthetic technique designed to facilitate rapid recovery allowed early extubation in the operating room or intensive care unit in all but one patient. Extubated patients leaving the operating room were comfortable. No postoperative respiratory complications occurred.

Thoracoabdominal Aortic Aneurysm Repair: Reducing the Incidence of Paraplegia

Paraplegia is a major complication associated with repair of thoracoabdominal aortic aneurysms (TAAA). A number of therapies have been tried over the years, none of which has been successful. Recently, regional lumbar epidural cooling has been tried in an attempt to prolong the safe ischemic time during aortic cross- clamping. In approximately 90 patients in whom the authors have tried this technique, there was no de crease in the incidence of paraplegia in patients with type II TAAAs. This is perhaps not unanticipated be cause the paraplegia is related to a number of factors including the duration of the aortic cross-clamping, the adequacy of collateral circulation, embolization during the procedure, and perhaps thrombosis in situ. Given the multimodal cause of paraplegia, perhaps it is naive to think that a single therapy would be of benefit. Additional studies are necessary to explore the mecha nisms and to prove efficacy or lack of benefit of any techniques designed to decrease the incidence of paraplegia in patients undergoing TAAA repair.

Bivalirudin and transcatheter aortic valve replacement: a cautionary tale.

Bivalirudin is an accepted alternative to heparin for anticoagulation during select cardiac procedures. Its use has not been well described during transcatheter aortic valve replacement. Herein is the report of a transcatheter valve replacement case that was complicated by catastrophe and need for emergent cardiopulmonary bypass. A successful outcome was achieved. However, the inability to rapidly reverse the anticoagulation effect of bivalirudin proved troublesome, and that provides for a cautionary tale about its use during transcatheter valve replacement.

Hypoxemia after an axial flow pump Jarvik-2000 implantation: Catheter induced

Left ventricular assist devices (LVADs) are now being implanted frequently as a bridge therapy to transplant or a destination therapy. Device technology is also changing in that nonpulsatile axial flow pumps are being used as frequently as pulsatile pumps at many centers. LVADs are effective in restoring circulation and unloading the left heart. LVAD support could result in a potential problem of right to left shunt through the patent foramen ovale (PFO), and the practice of performing transesophageal echocardiography (TEE) looking for PFO at the time of surgery has been well established. We describe an unusual case of significant hypoxemia resulting from a defect in the interatrial septum (IAS) created iatrogenically at the time of an electrophysiologic procedure in a patient who subsequently underwent an axial flow pump implantation.

Whole-lung lavage in a patient with pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.