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Seminars in Cardiothoracic and Vascular Anesthesia

Ramesh Singh, Katsuhiro Yamanaka, T Brett Reece
The extent and technique of resection for ascending aortopathies remains debated. The 2 main camps are divided into those who believe in the hemiarch resection utilizing hypothermic circulatory arrest and those who feel that the same goal can be accomplished with just an ascending aortic resection with an aortic cross clamp. While this debate continues to happen within groups and in some cases even in the same hospital, it certainly has not happened in the literature. There are no studies directly comparing the safety and efficacy of these 2 ideologies...
October 19, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Matthew S Mosca, George Justison, T Brett Reece
OBJECTIVE: The optimal strategy to deliver antegrade cerebral perfusion for cerebral protection during hypothermic circulatory arrest has not been established. The purpose of this review was to present our current clinical protocol utilizing selective antegrade cerebral perfusion during aortic arch surgery and to compare it to other published experience. CLINICAL PROTOCOL: Since 2013, our clinical protocol for aortic arch surgery has evolved to using selective antegrade cerebral perfusion via the innominate artery, moderate hypothermia, and ancillary strategies such as goal-directed perfusion (GDP)...
October 14, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Ryan C Shelstad, Justin G Reeves, Katsuhiro Yamanaka, T Brett Reece
We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique-each having its own advantages...
October 7, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Jeffrey E Keenan, Ehsan Benrashid, Emily Kale, Alina Nicoara, Aatif M Husain, G Chad Hughes
Circulatory management during replacement of the aortic arch is complex and involves a period of circulatory arrest to provide a bloodless field during arch vessel anastomosis. To guard against ischemic brain injury, tissue metabolic demand is reduced by systemically cooling the patient prior to circulatory arrest. Neurophysiological intraoperative monitoring (NIOM) is often used during the course of these procedures to provide contemporaneous assessment of brain status to help direct circulatory management decisions and detect brain ischemia...
October 4, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Faith J Ross, Denise Joffe, Gregory J Latham
Total anomalous pulmonary venous connection (TAPVC) is a potentially devastating form of congenital heart disease in which all pulmonary blood flow returns to the systemic venous circulation rather than the left atrium. Anomalous pulmonary venous flow may be obstructed at birth, and affected infants present with severe cyanosis and poor cardiac output unresponsive to standard resuscitation with prostaglandin. Obstructed TAPVC remains one of the few indications for emergent neonatal cardiac surgery. This review will discuss the physiology and perioperative management of isolated TAPVC without associated cardiac lesions...
September 29, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Maung Hlaing
Patients undergoing aortic arch surgery are at high risk for stroke, delirium, low cardiac output, respiratory failure, renal failure, and coagulopathy. A significantly higher mortality is seen in patients experiencing any of these complications when compared with those without complications. As surgical, perfusion, and anesthetic techniques improve, the incidence of major complications have decreased. A recent paradigm shift in cardiac surgery has focused on rapid postoperative recovery, and a similar change has affected the care of patients after arch surgery...
August 5, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Miklos D Kertai
No abstract text is available yet for this article.
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Keita Ikeda, Gregory Smith, John Renehan, James Isbell, Timothy McMurry, Mitchell Rosner, Robert Thiele
Introduction We hypothesize that respiratory variation in the pulmonary artery tracing predicts fluid responsiveness (primary hypothesis) and that inclusion of multiple physiologic waveforms as well as ventilator settings in a predictive model of fluid responsiveness would lead to improvements in the clinical utility of this class of metrics (secondary hypothesis). Methods Blood pressure tracings were prospectively recorded in 35 patients immediately following cardiac surgery. Fluid bolus administration data, ventilator settings, and cardiac output were recorded prospectively before and after fluid boluses given at the discretion of the treating physician...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Sang Kim, Samuel DeMaria, Edmond Cohen, George Silvay, Jeron Zerillo
We report the case of successful resuscitation after prolonged cardiac arrest during orthotopic liver transplantation. After reperfusion, the patient developed ventricular tachycardia, complicated by intracardiac clot formation and massive hemorrhage. Transesophageal echocardiography demonstrated stunned and nonfunctioning right and left ventricles, with developing intracardiac clots. Treatment with heparin, massive transfusion and prolonged cardiopulmonary resuscitation ensued for 51 minutes. Serial arterial blood gases demonstrated adequate oxygenation and ventilation during cardiopulmonary resuscitation...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Michael Stuart Green, Sankalp Sehgal, Rayhan Tariq
Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Peter H Ma, Ritu Sachdeva, Elizabeth C Wilson, Nina A Guzzetta
Polyvalvar myxomatous valve degeneration is a clinical pathology rarely encountered during cardiac anesthesia, but, when present, most commonly occurs in the context of a connective tissue disorder. Filamin A mutations have begun to be recognized as a source of progressive myxomatous mitral and tricuspid valve degeneration. These lesions can be diagnosed by echo, but their clinical presentation can be equivocal. We present a patient with significant echocardiographic findings of mitral and tricuspid valvar regurgitation, aortic dilatation, and intraoperative findings of aortic ectasia...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Nikil Patel, Jatinder S Minhas, Emma M L Chung
Since the advent of cardiac surgery, complications have existed in many forms. Recent work has focused on the safety of current cardiac surgery with particular emphasis on cognitive outcomes. Cardiopulmonary bypass has improved the safety of operative practice; however, increasing concern surrounds the measurable and immeasurable impact embolization has on the brain. New ischemic lesions have been associated with distant emboli, which intraoperatively enter the cardiovascular system. This has prompted better characterization of the nature of emboli manifesting as cognitive impairment postoperatively...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Marc Stone, Joseph Hinchey, Christopher Sattler, Adam Evans
In our institution, the vast majority of patients presenting for noncardiac surgery (NCS) while supported by a left ventricular assist device (LVAD) are now cared for by noncardiac-trained anesthesiologists as the result of a decade of educational intervention to effect this transition. This represents a significant departure from the published experiences of other institutions. With institutional review board approval, we queried the database of our anesthesia record keeping system (CompuRecord) to determine various aspects of the perioperative management of these patients from July 1, 2003, through June 30, 2013, during which time 271 NCS procedures were performed on adult patients supported by LVADs...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Michael Stuart Green, Sankalp Sehgal, Naomi Smukler, LaDouglas Jarod Suber, Pooven Saththasivam
The anatomy of the coronary circulation is well described with incidence of congenital anomalies of approximately 0.3% to 1.0%. Although often incidental, 20% are life-threatening. A 25-year-old woman with syncopal episodes collapsed following a 10-km run. Coronary anatomy evaluation showed an anomalous left main coronary artery originating from the right sinus of valsalva and following a course between the aorta and the pulmonary outflow tract. Percutaneous coronary intervention was followed by eventual surgical revascularization...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Priya A Kumar, Susan M Martinelli, Robert W Kyle, Harendra Arora
A double-walled interatrial septum is a rare congenital cardiac anomaly characterized by a distinct echolucent cavity between the atria formed by 2 separate interatrial septae. It may be a variant of other well-recognized cardiac anomalies such as persistent venous valve of the sinus venosus or cor triatriatum. Although uncommon, it may be associated with thromboembolic disease due to stagnant flow in the septal cavity. Awareness of this rare entity and its clinical significance along with a thorough echocardiographic examination to rule out similarly presenting or coexisting conditions are the key to an accurate diagnosis and appropriate management...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Elif Doğan Bakı, Nilgün Kavrut Ozturk, Rauf Umut Ayoğlu, Mustafa Emmiler, Bilge Karslı, Hanife Uzel
Background Sternotomy causes considerable postoperative pain and postoperative pain management encompasses different analgesic regimens. In this study, we aimed to investigate the effect of peroperative parasternal block with levobupivacaine on acute and chronic pain after coronary artery bypass graft surgery. Materials and Methods A total of 81 patients undergoing coronary artery bypass graft surgery were included in this study. Patients were randomly allocated by opening an envelope to receive either parasternal block with pharmacologic analgesia (group P; before sternal wire placement: sternotomy and mediastinal tube sites were infiltrated with local anesthetics) or pharmacologic analgesia alone (group C) for postoperative pain relief...
September 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Ibrahim Sultan, Joseph E Bavaria, Wilson Szeto
Open repair of the aortic arch remains the gold standard for aortic aneurysms and dissections. However, in elderly patients with comorbidities, and in patients where prolonged cardiopulmonary bypass time and circulatory arrest may pose a significant risk, hybrid techniques in repairing the aortic arch have become quite attractive. Hybrid arch surgery includes a combination of endovascular and open surgery that allows surgeons to operate on the arch in a safe and expeditious manner with potential decrease in morbidity and mortality...
July 13, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Kim I de la Cruz, Susan Y Green, Ourania A Preventza, Joseph S Coselli
The progressive expansion of residual, chronic DeBakey type I dissection often necessitates repair of the aortic arch and the distal aorta (ie, descending thoracic and thoracoabdominal aorta). The vast majority of patients with chronic aortic dissection facing aortic arch surgery are survivors of emergent proximal aortic repair for acute dissection, and thus, these patients now face a reoperative procedure necessitating a redo median sternotomy. One approach for repairing the chronic type I aortic dissection incorporates total transverse aortic arch replacement with and without an elephant trunk extension; an elephant trunk extension is a useful strategy, because the proximal descending thoracic aorta is commonly ectatic or aneurysmal at the time of aortic arch repair-using an elephant trunk approach facilitates subsequent repair in the distal aorta...
July 13, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Akiko Tanaka, Anthony L Estrera
Background Since Borst and colleagues first applied the elephant trunk technique more than 30 years ago, it has become a standard method in approach for staged repair of an extensive thoracic aneurysm. While the original technique was cumbersome, a number of innovations have significantly improved the results over the past 3 decades. Conclusions Today, total arch replacement with elephant trunk provides simplified staged surgery but, nonetheless, remains a complex surgical procedure. Although many proximal aortic procedures may be addressed with ascending and partial transverse arch replacement, when total or complete transverse arch replacement is required, then the use of the elephant trunk technique, whether standard or frozen, should be considered...
July 12, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
S Michael Roberts, Trey Banbury, Anand Mehta
Anomalous left coronary artery from the pulmonary artery (ALCAPA), or Bland-White-Garland syndrome, is a rare congenital coronary anomaly that results in altered myocardial perfusion and a left to right shunt. It occurs in 1:300000 live births and represents 0.24% to 0.46% of all congenital cardiac diseases. Despite its rarity, it is one of the most common causes of ischemia and infarction in children. Ninety percent of these patients will die within the first year of life if untreated and diagnosing this abnormality in adulthood is extremely rare...
July 9, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
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