Peter J. Neuburger

Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

OBJECTIVE Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. METHODS A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. RESULTS Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subclavian artery was used in 5 patients (4.6%) with contraindications to retrograde perfusion. An endoballoon clamp was placed by way of the femoral artery. In 105 of 108 patients (97.2%), endoaortic occlusion was successfully used; the mean crossclamp time was 87.4 minutes. The coronary sinus cardioplegia catheter was placed successfully in 81 of the 108 patients (75%). Postoperatively, no or mild inotropic support was needed in 94 (87%) and moderate support in 14 (13.0%). Of the 108 patients, 55 (50.9%) were extubated in the operating room. No hospital mortality, aortic injury, vascular complications, or wound infections occurred. Complications included 2 strokes (no residual deficit) (1.8%) and atrial fibrillation in 18 (16.7%). The median hospital stay was 4 days. Eighty patients (74.1%) were discharged by postoperative day 5. CONCLUSIONS A preoperative image-guided perfusion strategy and aortic balloon clamping permit routine TERMR with excellent myocardial preservation and minimal complications.

A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair.

OBJECTIVE The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. DESIGN A randomized, prospective trial. SETTING A single tertiary referral academic medical center. PARTICIPANTS 60 patients undergoing robotic mitral valve surgery. INTERVENTIONS Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. MEASUREMENTS AND MAIN RESULTS After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. CONCLUSIONS The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.

Anesthetic Techniques in Transcatheter Aortic Valve Replacement and the Evolving Role of the Anesthesiologist

The development of transcatheter aortic valve replacement (TAVR) has transformed the treatment of patients with aortic valve disease. This procedure now is used widely for patients at high and intermediate risk for surgical aortic valve replacement. The rapid acceptance and popularity of TAVR most clearly was enabled by advancements in device technology and procedural experience. Such a dramatic change to the standard medical practice is not without consequence to fields of medicine beyond cardiology and cardiac surgery. Anesthesiologists have witnessed this movement first hand, and while improved anesthetic techniques have contributed to the success of the procedure, in return these improved outcomes likely will result in further changes to perioperative anesthetic management. In this review the authors sought to evaluate the role and responsibility of the cardiac anesthesiologist in the development of TAVR. Future advancements in device technology and considerations of how the anesthetic technique for TAVR may continue to evolve in future years are discussed.

A Practical Approach to Managing Transcatheter Aortic Valve Replacement With Sedation.

Transcatheter aortic valve replacement is increasingly performed as a minimally invasive treatment option for aortic valve disease. The typical anesthetic management for this procedure was traditionally similar to surgical aortic valve replacement and involved general anesthesia and transesophageal echocardiography. In this review, we discuss the technological advances in transcatheter valve systems that have improved outcomes and allow for use of sedation instead of general anesthesia. We describe an anesthetic protocol that avoids general anesthesia and utilizes transthoracic echocardiography for procedural guidance.

Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate.

Objective In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. Methods Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4–0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. Results Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. Conclusions We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

Left Atrial Appendage Velocity as a Predictor of Atrial Fibrillation After Cardiac Surgery

OBJECTIVE To determine if there is an association between left atrial appendage velocity and the development of postoperative atrial fibrillation (POAF). DESIGN Single institution retrospective study performed between January 2013 and December 2013. SETTING Single-institution, university hospital. PARTICIPANTS Five hundred sixty-two adult patients undergoing cardiac surgery utilizing cardiopulmonary bypass. INTERVENTIONS No interventions for the purpose of this study. MEASUREMENTS AND MAIN RESULTS Left atrial appendage velocity, measured by transesophageal echocardiogram, ranged from 8 cm/sec to 126 cm/sec. The development of POAF within the first 3 days after cardiac surgery was 38.3%. The authors found that patients with a lower left atrial appendage velocity had a higher risk of developing POAF. In the adjusted logistic regression model, there was an 11% decrease in the odds of POAF for each 10-unit (cm/sec) increase in the left atrial appendage velocity (p = 0.044). CONCLUSIONS Decreasing left atrial appendage velocity is an independent predictor of risk for the development of POAF following cardiac surgery with cardiopulmonary bypass.

CASE 8—2015Paravertebral Catheter-Based Strategy for Primary Analgesia After Minimally Invasive Cardiac Surgery

ORT-ACCESS MINIMALLY INVASIVE cardiac surgery (PACS) has potential advantages when compared with traditional sternotomy techniques. These include smaller surgical incision, reduced trauma and blood loss, and shorter length of hospital stay. 1,2 Typically, PACS procedures are performed through a right anterior minithoracotomy or hemisternotomy, and postoperative pain commonly is managed primarily using intravenous analgesics, usually with an on-demand opioid or opioid-based patient-controlled analgesia (PCA). When an opioid is chosen as the primary strategy, particularly an intravenous PCA, benefits include ease of use, availability, and improved patient satisfaction, compared with on-demand pain treatment. Common adverse effects to opioidbased strategies include respiratory depression, delirium, and gastrointestinal dysfunction, which substantially can inhibit postoperative recovery and potentially cause harm to the aging and comorbid population that represents many cardiac surgery patients. In addition, minithoracotomy incisions used during PACS procedures also involve an increased risk of chronic pain, which is not prevented or reduced by an opioid-only strategy. 2–4 Analgesic strategies that reduce opioid consumption and improve long-term outcome after PACS, including regional or neuraxial anesthetic techniques, are desirable to reduce this complication and improve outcomes from PACS procedures. For thoracic surgery patients, regional analgesia delivered through thoracic paravertebral (PV) or epidural catheters provides high-quality analgesia for post-thoracotomy pain and is associated with reduced overall complication rates relative to parenteral opioids. 5–14 Published studies indicate that thoracic PV and epidural-based analgesia delivery of continuous local anesthetic infusions are approximately of equal value for pain control, but PV catheters are associated with fewer side effects, including hypotension. 15–17 The advantages of regional techniques involving the neuraxis always must be contrasted against their associated risk of epidural hematoma, particularly related to anticoagulation used during cardiopulmonary bypass (CPB). To avoid the risk of epidural hematoma, an alternate approach to neuraxial regional analgesia includes PV catheter placement. Although the usefulness of PV catheters have been confirmed for post-lung resection thoracotomy analgesia, their value for PACS patients is unclear. Here, the clinical course of 3 cardiac surgery patients undergoing PACS with PV catheters inserted for primary analgesia is described. These examples are reviewed in the context of existing literature and also serve to highlight the challenges of postoperative analgesia for PACS patients.

Is Extubating My Cardiac Surgery Patient Postoperatively in the Operating Room a Good Idea

Following multiple episodes of shortness of breath at home, a 66-year-old man with severe mitral regurgitation undergoes an elective mitral valve repair via mini-thoracotomy. His past medical history is significant for diabetes controlled with metformin and hypertension treated with metoprolol. In the past, he was a casual tennis player, but lately he has been feeling short of breath going up the flight of stairs in his house. It is the first case of the day. Induction, intubation, and line placement are uneventful, and the surgery proceeds without incident. At the end of the case, the surgeon jokes to his assistant, “This gas man over here has the easiest job; he just hits every patient over the head with his cookbook and hopes they wake up some point later in the day.”

SHORT- AND MID-TERM OUTCOMES AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT IN PATIENTS WITH RENAL INSUFFICIENCY NOT ON HEMODIALYSIS

Background: Outcomes after transcatheter aortic valve replacement (TAVR) in patients with renal insufficiency but not on dialysis remain uncertain. Methods: Retrospective chart review identified 209 patients who underwent TAVR between September 2014 and September 2015. Of these patients, 5 (2.4%)