BACKGROUND The anesthetic management of patients with Charcot-Marie-Tooth disease (CMT) requires special deliberation. Previous literature has suggested that patients with CMT may have increased sensitivity to non-depolarizing neuromuscular blocking agents, and hyperkalemia associated with the administration of succinylcholine has been reported. The potential risk of malignant hyperthermia and underlying cardiopulmonary abnormalities, such as pre-existing arrhythmias, cardiomyopathy, or respiratory muscle weakness, must also be considered in patients with CMT. CASE REPORT We describe a case of a patient with a history of CMT and multivessel coronary artery disease who underwent coronary artery bypass grafting (CABG). Careful consideration was given to the anesthetic plan, which consisted of thorough pre- and perioperative evaluation of cardiac function, total intravenous anesthesia with propofol and remifentanil infusions, the use of a non-depolarizing neuromuscular blocking agent, and utilization of a malignant hyperthermia protocol with avoidance of volatile anesthetics to decrease the possible risk of malignant hyperthermia. Following a 3-vessel CABG, no anesthetic or surgical complications were noted and the patient was discharged on postoperative day 6 after an uneventful hospital course. CONCLUSIONS Exacerbation of underlying cardiac and pulmonary abnormalities associated with the pathophysiology of CMT, as well as patient response to neuromuscular blocking and volatile agents, should be of concern for the anesthesiologist when anesthetizing a patient with CMT. Therefore, CMT patients undergoing surgery require special consideration of their anesthetic management plan in order to ensure patient safety and optimize perioperative outcomes.

The COVID-19 PANDEMIC generated exponential demand for extracorporeal membrane oxygenation (ECMO) with an expanded array of indications.1 Our healthcare institution is a high-volume center with an area covering 55 counties and 5 states within the United States.2 As the COVID-19 pandemic progressed, we adjusted our approach to extracorporeal support, notably switching from cannulating patients in the intensive care unit to instead using the operating room to maintain higher standards of sterility, communication, and precision with the oversight of an anesthesiologist.

We read with great interest the recent letter by Ghulam et al.[1]Ghulam M, Ortoleva J, Hong E. Echocardiographic assessment of the coronary arteries: Seek and you shall find [e-pub ahead of print]. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca. Accessed February 22, 2023.Google Scholar As an institution with a considerable volume of minimally invasive robotic cardiac surgery, including the robotic aortic valve replacement, we regularly assess the left and right coronary arteries using transesophageal echocardiography to assist with the routine placement of coronary ostial cardioplegia cannulae. After an examination for anatomic abnormalities, we measure both ostial dimensions and share this information with our surgical colleagues to help size cannulae for optimal fit and cardioplegia delivery (Fig 1, Fig 2). Recently, we identified an early bifurcation of the left main coronary artery (Fig 3) that would have precluded complete left heart protection with a single coronary ostial cardioplegia cannula. Instead, 2 coronary ostial cannulae (Fig 4) were advanced into the area of the left main coronary and successfully placed into the left anterior descending and left circumflex coronary arteries for antegrade cardioplegia based on tactile feedback and flow characteristics. We believe that routine assessment of the coronary anatomy using transesophageal echocardiography will become increasingly relevant in minimally invasive cardiac surgery.Fig 2Modified midesophageal aortic valve short-axis view demonstrating a typical right main coronary ostial dimension of 4.7 millimeters.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Modified midesophageal aortic valve short-axis view demonstrating an early bifurcating left main coronary artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4Intraoperative photo during a minimally invasive robotic aortic valve replacement (as viewed through aortotomy), with 2 coronary ostial cannulae directed toward the area of the left main coronary artery, reaching the left anterior descending and left circumflex coronary arteries.View Large Image Figure ViewerDownload Hi-res image Download (PPT) None. Echocardiographic Assessment of the Coronary Arteries: Seek and You Shall FindJournal of Cardiothoracic and Vascular AnesthesiaPreviewThe latest guideline document for performing a comprehensive echocardiographic examination suggests that analysis of the coronary arteries may be neglected.1 We provide examples of how transesophageal echocardiography can be used to visualize coronary circulation. Manipulation of the transesophageal echocardiography probe from the midesophageal aortic valve short-axis view will reveal the left main coronary artery and its bifurcation into the left circumflex and the left anterior descending coronary arteries (Fig 1, A). Full-Text PDF

Leadless cardiac pacemakers were developed to reduce complications associated with conventional transvenous pacemakers. While this technology is still relatively new, devices are increasingly being implanted. The perioperative management of patients with these devices has been underreported; we thus seek to add to the limited body of knowledge of perioperative management of patients with leadless cardiac pacemakers. An elderly female patient with a Micra VR transcatheter pacing system leadless cardiac pacemaker placed for tachycardia-bradycardia syndrome with intermittent complete heart block was scheduled for elective tricuspid valve replacement for severe tricuspid regurgitation. Pacemaker interrogation was performed several hours prior to the scheduled surgery based on the electrophysiologist’s availability; the device was kept in its programmed VVIR mode, and the base rate was increased from 60 to 80 beats per minute in anticipation of the upcoming surgery. Upon preoperative evaluation, the anesthesiologist asked that the electrophysiology team be placed on standby intraoperatively due to the concern that either oversensing in the setting of pacemaker dependence and/or undesirable tachycardia from rate-responsive pacing could occur. The surgeon used monopolar electrocautery for the duration of the cardiac surgery. Despite the patient having evidence of pacemaker dependence in the intensive care unit preoperatively, no electromagnetic interference leading to oversensing nor rate modulation was detected during intraoperative electrocardiographic and intraarterial invasive monitoring. Evidence-based guidelines regarding perioperative management specifically of leadless cardiac pacemakers do not exist. As these devices become more prevalent, further evaluation will be paramount to determine whether existing guidelines for perioperative management of conventional transvenous pacemakers apply.