Richa Dhawan

Multivessel beating heart robotic myocardial revascularization increases morbidity and mortality

OBJECTIVE The vast majority of reports describing beating heart robotic myocardial revascularization (total endoscopic coronary artery bypass) contain very small numbers of patients undergoing single-vessel bypass. We present a large series of patients undergoing multivessel total endoscopic coronary artery bypass. METHODS We performed a retrospective clinical review of 106 patients undergoing total endoscopic coronary artery bypass (72% multivessel) at 1 institution by 1 experienced cardiac surgeon/physician assistant team. These results were compared with the expected clinical outcomes from conventional coronary artery bypass grafting calculated using the Society of Thoracic Surgeons risk calculator. RESULTS Of the 106 patients, 1% underwent quadruple total endoscopic coronary artery bypass, 8% triple, 63% double, and 28% single. The emergent conversion rate for hemodynamic instability was 6.6%. The postoperative renal failure rate (doubling of baseline serum creatinine or dialysis required) was 7.5%. Overall, 23 patients (21.7%) exhibited at least 1 major morbidity/mortality (4 deaths). The number of vessels bypassed (single/double/triple/quadruple) correlated positively with the surgical/operating room time, the lung separation time, vasoactive medication use, blood use, a postoperative ventilation time longer than 24 hours, intensive care unit length of stay, and hospital length of stay. An increased surgical time was significantly associated with major morbidity (P = .011) and mortality (P = .043). A comparison with the Society for Thoracic Surgeons expected outcomes revealed a similar hospital length of stay but an increased incidence of prolonged ventilation (P = .003), renal failure (P < .001), morbidity (P = .045), and mortality (P = .049). CONCLUSIONS Our results suggest that addressing multivessel coronary artery disease using total endoscopic coronary artery bypass offers no obvious clinical benefits and might increase the morbidity and mortality.

Percutaneous closure of an incompetent aortic valve using an occluder device in a patient with left ventricular assist device.

November 2013 • Volume 117 • Number 5 CASE PRESENTATION A 56-year-old man with a history of ischemic cardiomyopathy status post–HeartMate II® axial-flow left ventricular assist device (LVAD) placement was admitted to our institution with symptoms of cardiogenic shock. His workup revealed newonset severe aortic insufficiency (AI) (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A589). Because of severe coagulopathy from hepatic failure, the patient was considered a poor candidate for surgical aortic valve (AV) closure. Instead, a novel procedure was devised using a percutaneous septal occluder device to anatomically close the AV. The patient consented to publication of this report. The patient underwent general anesthesia and endotracheal intubation. Intraoperatively before the procedure, a focused transesophageal echocardiography (TEE) examination revealed the following: (1) A continuous eccentric jet of severe AI; (2) An aortic annulus diameter of 24 mm; (3) A sinus of Valsalva diameter of 31 mm; (4) Patent left and right coronary ostia; (5) Moderately reduced right ventricular function; and (6) Severely dilated left ventricle with severely reduced function. After gaining femoral arterial access, a guidewire was advanced under fluoroscopy. Then using TEE, the delivery catheter containing a 25-mm diameter Amplatzer® cribriform septal occluder (St. Jude Medical Corp., St. Paul, MN) was visualized passing through the AV. Before deployment, LVAD flow was temporarily decreased to 1 L/min to reduce the trans-AV gradient and prevent shifting or embolization of the device. Next, the distal disk of the device was deployed within the left ventricular outflow tract (LVOT) (Fig. 1). Last, the proximal disk was deployed within the sinus of Valsalva and delivery catheter removed. After the procedure, repeat TEE examination revealed: (1) Proper device position, with the narrow waist of the double disk resting within the AV (Fig. 2/Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A590); (2) No residual AI identified via color flow Doppler (Fig. 3/Video 3, see Supplemental Digital Content 3, http://links.lww. com/AA/A591); (3) Normal mitral function; 4) Patent left coronary ostium but poorly visualized right coronary ostium because of acoustic shadowing from the device; (5) Unchanged right ventricular function; and (6) Reduced left ventricular dilation with unchanged function. After successful completion of the procedure, the patient was tracheally extubated and transported to the intensive care unit. He had complete resolution of his symptoms and was discharged home 5 days later. The patient continues to do well 6 months postprocedure.

Aortic valve anatomy and assessment by transesophageal echocardiography.

December 2013 • Volume 117 • Number 6 A 68-year-old woman is scheduled to undergo an abdominal aortic aneurysm repair. On her preoperative evaluation, she complains of occasional dyspnea with exertion, and on physical examination, she has a systolic murmur. Intraoperative transesophageal echocardiography (TEE) is planned to monitor the patient and evaluate valvular pathology, with a focus on the aortic valve (AV).

Powering the Heart to Recovery

From the Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Ill. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Feb 5, 2018; accepted for publication Feb 10, 2018. Address for reprints: Richa Dhawan, MD, MPH, Department of Anesthesia and Critical Care, University of Chicago Medical Center, 5841 S Maryland Ave, MC 4028, Chicago, IL 60637 (E-mail: rdhawan@dacc.uchicago. edu). J Thorac Cardiovasc Surg 2018;-:1-2 0022-5223/

Preoperative angiotensin system inhibitor use attenuates heparin-induced hypotension in patients undergoing cardiac surgery.

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.02.022

Percutaneous Closure of Mitral Paravalvular Leak

OBJECTIVE Both angiotensin system inhibitor (ASI) use and heparin are associated with hypotension. This study attempted to determine whether preoperative ASI therapy affected the hemodynamic response to heparin administered to patients undergoing cardiac surgery. DESIGN Sixty-two patients undergoing elective cardiac surgery requiring full (300 units/kg) systemic heparinization were studied prospectively. Thirty-three patients were receiving preoperative ASI therapy, whereas 29 patients were not. Anesthetic technique and mechanical ventilation parameters were standardized. Hemodynamics were recorded at 3 time points: baseline (just before the administration of heparin), 1-minute post-heparin administration, and 4-minute post-heparin administration. SETTING Single university hospital. PARTICIPANTS Patients undergoing elective cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 2 groups were similar regarding preoperative demographics and baseline hemodynamics. Baseline mean arterial pressure (MAP) in non-ASI patients was 82.0 mmHg, and it decreased significantly to 76.3 mmHg (1 min; p<0.05) and 70.7 mmHg (4 min; p<0.05) following heparin administration. MAP values in ASI patients were 81.9 mmHg, 81.8 mmHg, and 76.8 mmHg at baseline, 1-minute post-heparin, and 4-minute post-heparin administration, respectively (changes not significant).Within-group analysis revealed that non-ASI patients experienced significant decrease in MAP at 1-minute (-6.6%, p = 0.01) and 4-minute (-13.0%, p = 0.0011) post-heparin administration, whereas ASI patients did not (+1.9%, p = 0.52; -3.8%, p = 0.16, respectively). Between-group analysis revealed that differences in MAP values at 1 minute were significant (p = 0.03), whereas differences at 4 minutes were not significant (p = 0.05). CONCLUSIONS This prospective clinical study indicated that preoperative ASI therapy until the day before surgery may attenuate heparin-induced hypotension. Definitive mechanistic insight requires further clinical study.