BACKGROUND:Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified.METHODS AND RESULTS:TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001).CONCLUSION:Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Background: Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. Methods: We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. Results: Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 +/- 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P=.04) and baseline ejection fraction (57% +/- 6.7% vs 55% +/- 10%; P=.014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P=.001), 4 units fewer fresh-frozen plasma (P=.001), 6 units fewer platelets (P=.001), 1.3 units fewer cell-savers (P=.002), and 5 units fewer cryoprecipitate (P=.001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P=.046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P=.079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P=.13), 2 units fewer fresh-frozen plasma (P=.018), and 5 units fewer platelets (P=.001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P=.002), and intensive care length of stay was reduced by 3 days (P=.063) after intraoperative autologous platelet rich plasma use. Conclusions: The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.

We performed a retrospective chart review to investigate a potential relation between pulmonary artery (PA) diameter as measured by intraoperative transesophageal echocardiography and PA pressures measured by PA catheter with the aim of determining whether main PA diameter can aid clinicians in the diagnosis of PA hypertension. A total of 82 adult patients undergoing cardiac surgery were included in our study. Main PA diameter showed a moderate correlation with systolic and diastolic pressures, r = 0.576 (95% confidence interval [CI], 0.407-0.703), P < 0.001, and r = 0.504 (95% CI, 0.319-0.648), P < 0.001, respectively. The authors believe that although a moderate correlation exists between main PA diameter and PA pressure, confounding hemodynamic variables prevent main PA diameter from being an accurate and reliable means of diagnosing PA hypertension.

We thank Xue et al1Xue et al.Association of GI complications and adverse outcomes after cardiac surgery.JCVA. 2017; 31: 1268Google Scholar for their comments and welcome the opportunity to clarify the endpoints in question. Our study using an administrative database does not allow us access to patient information such as risk factors and a full list of comorbid conditions. We agree with Xue et al1Xue et al.Association of GI complications and adverse outcomes after cardiac surgery.JCVA. 2017; 31: 1268Google Scholar and attempted to elucidate in the original manuscript that this is indeed a limitation of our study because preexisting conditions could play a role in confounding the influence that gastrointestinal complications had on postoperative outcomes. Our team also believes that the concern raised regarding the odds ratios of known risk factors for mortality after cardiac surgery stems from this same limitation. We again agree that not being able to stratify based on preexisting conditions and functional status parameters plays a role in the “surprising” odds ratios of mortality caused by known risk factors. For example, the Continuous Improvement in Cardiac Surgery Program score exists as an algorithmic predictor of acute kidney injury in the cardiac surgery population.2Chertow G.M. Lazarus J.M. Christiansen C.L. et al.Preoperative renal risk stratification.Circulation. 1997; 95: 878-884Crossref PubMed Scopus (663) Google Scholar This score takes into account a wide variety of factors such as low ejection fraction (≤35%), New York Heart Association functional class, peripheral vascular disease, and creatinine clearance values, among others, to predict subgroups that are at risk for acute kidney injury after undergoing cardiac surgery. This illustrates the key role that the interactions between preexisting conditions play in potentially leading to various postoperative complications mentioned in the literature. As our respected colleagues state, all these factors would have to be taken into account to yield the most conclusive and informative data on postoperative outcomes. We currently acknowledge, as we did in our article, that additional prospective investigations are necessary to address the limitations mentioned in our study and, with that, the considerations raised by Xue et al.1Xue et al.Association of GI complications and adverse outcomes after cardiac surgery.JCVA. 2017; 31: 1268Google Scholar Thank you for the opportunity to share our perspective on these important points of discussion.

We present a case of severe systolic anterior motion developing intraoperatively after aortic valve replacement for aortic valve stenosis.

We enjoyed the excellent paper by Patel et al describing the clinical classifications of aortic regurgitation (AR) in acute type A dissections1Patel P. Bavaria J. Ghadimi K. et al.Aortic regurgitation in acute type-A aortic dissection: A clinical classification for the perioperative echocardiographer in the era of the functional aortic annulus.J Cardiothoracic Vasc Anesth. 2017; Google Scholar and found it very interesting and relevant to our own practice. The functional aortic annulus does indeed provide a framework for understanding the mechanisms of AR in acute type A dissections, as well as a guide for facilitating surgical planning. Acute DeBakey type I aortic dissection (Stanford type A includes both DeBakey type I [ascending, arch, and possibly descending] and II [ascending only]) is a life-threatening emergency and requires immediate surgical intervention. For untreated DeBakey type I aortic dissection, mortality increases up to 50% in the first 24 hours and 75% within 2 weeks after the initial event.2Woo K.M. Schneider J.I. High-risk chief complaints I: Chest pain--the big three.Emerg Med Clin North Am. 2009; 27 (685–71)Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Surgical mortality for acute type A aortic dissection reported in different experiences from single centers or surgeons varied from 7% to 30%. The overall in-hospital mortality was 25.1%. Mortality in unstable patients was 31.4% compared with 16.7% in stable patients. Independent preoperative predictors of operative mortality were history of aortic valve replacement, migrating chest pain, hypotension as a sign of acute type A aortic dissection, shock, preoperative cardiac tamponade, and preoperative limb ischemia. Trimarchi et al note an incidence of aortic valve replacement of 23.1%.3Trimarchi S. Nienaber C.A. Rampoldi V. et al.Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience.J Thorac Cardiovasc Surg. 2005; 129: 112-122Abstract Full Text Full Text PDF PubMed Scopus (456) Google Scholar In our busy cardiac surgery practice, in which we see approximately 50 to 60 type A dissections each year, it has been our experience that type III AR (as described in the article—in which the intimal flap prolapses through the aortic valve during diastole to restrict cusp mobility) is the most common. Overall, in the hands of our surgeons, only about 5% of these type A dissections need aortic valve replacement. About another 5% to 10% of the patients benefit from aortic valve resuspension. Generally, the patients needing aortic valve replacement have at least 1 of the following: aortic root aneurysm (commonly seen with connective tissue disorders such as Marfan’s syndrome), diseased/heavily calcified bicuspid aortic valve, or dissection that has destroyed the aortic annulus. Many of these criteria are related to underlying valve or root issues and are not due to damage from the dissection itself. This correlates with the type of AR we typically see (type III, as shown in Figure 1 and Video clip 1), which usually only necessitates repair of the ascending aorta and possibly hemi-aortic arch replacement, but not aortic valve replacement. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMjA5ZTZiZDRmYjZmMjdmM2UzMzRmNzE0OTA3YTJmZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4OTcwMjQwfQ.XI0uCzrFSdMxJYd0kjWBVdl7mHkxoV_MVQohciB9aBDMSStewXAmSCxNFjtyF4ZYREUF1o_TXyLvFASm5ZQrFP_kCDNfAx5O1oPDlMRijfU1N_dW3c2hHyI5QNbqjKPuZHEKxM-5UZ534MZE9IcfcJ0tigTNMP2NnbZilGh1jXOpHVMelbPvl3FW0obMXJI01f0UJqiZ0uTrr-pRcTgdATBVgjnzcQLnaUuhXayd31fbzVhDcGGYbUUVhhoZfpwh0Fi6KW4BeBiCuLjWoCOgtR17Qyq2Mn1IKWy9w3knb5GPRKPE_2qHwy3hgKGV6IHR4YcdtgXlKC0x6NPeVtO5pg Download .mp4 (4.58 MB) Help with .mp4 files Video Clip 1. ME AV LAX view: Aortic dissection flap prolapsing through the aortic valve.

OBJECTIVE The authors aimed to evaluate the incidence, risk factors, and outcomes of gastrointestinal (GI) complications in cardiac and aortic surgery using recent versions of the National (Nationwide) Inpatient Sample (NIS) to provide clinicians with a better understanding of these uncommon but potentially serious complications. DESIGN Population-based study. SETTING NIS database 2010-2012. PARTICIPANTS Patients undergoing cardiac and aortic aneurysm repair surgeries. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS The most common GI complication was postoperative ileus, which also had the lowest mortality, followed by GI hemorrhage. Mesenteric ischemia demonstrated the highest mortality, followed by intestinal perforation. Mortality was highest in those with infective endocarditis (16.02%), followed by myocardial infarction (12.48%). GI complications were highest in patients undergoing repair of abdominal aortic aneurysm, followed by off-pump coronary artery bypass grafting. CONCLUSION In conclusion, this study demonstrated that GI complications after cardiac surgery occurred at a rate of 4.17%, which is similar to that reported in the NIS database from 1998 to 2002 in coronary artery bypass grafting patients, but higher than that previously described in single-center studies. GI complications after cardiac surgery increased inpatient mortality 3-fold and more than doubled length of stay. Improved recognition and understanding of the predisposing risk factors and complications elucidated in this study could serve to increase the necessity for timely diagnosis and treatment of patients at high risk for GI complications after cardiac surgery.

LEFT ATRIAL DISSECTION is a rare complication of cardiac surgeries and usually is associated with mitral valve procedures. Typically, a false chamber is created through a tear of the mitral valve annulus extending into the left atrial wall. Transesophageal echocardiography (TEE) is used for diagnosis. The authors present a case of left atrial dissection that occurred after an ascending and transverse aortic arch aneurysm repair that was managed successfully conservatively.

The MitraClip procedure is an emerging endovascular technique for treating mitral regurgitation and an attractive alternative for patients who are at high risk for open heart mitral valve repair or replacement. We present the case of a failed redo MitraClip procedure that led to acute right ventricular failure in a patient with homozygous familial hypercholesterolemia and a preexisting secundum atrial septal defect. We highlight the sequelae of the failed redo MitraClip procedure and the anesthetic challenges associated with the emergent redo sternotomy and cardiopulmonary bypass procedure required to replace the mitral valve and repair the tricuspid valve and atrial septal defect.

EXTRA-ADRENAL CARDIAC paragangliomas are rare neuroendocrine tumors arising from the sympathetic chain or parasympathetic ganglia. 1 Knop G. Margaria R. Cardiac pheochromocytoma: A new case reported. J Thorac Cardiovasc Surg. 2006; 132: 1230-1231 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Cardiac paragangliomas can be the secreting or nonsecreting type. In the secreting type, anesthetic management begins preoperatively with pharmacologic alpha-receptor blockade followed by beta-blockade. However, the nonsecreting type tends to manifest clinically with cardiac compressive symptoms from the tumor bulk. This subset of cardiac tumor is hypervascular, with tumor-feeding vessels often originating from the coronary arteries.

Background. Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair.Methods. We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 +/- 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment arm. Because an anesthesiologist initiated the protocol, the surgeon was not aware of aPRP collection, as this occurred only after the sterile drape was in place. In addition, because cell salvage was performed on all cases, differentiation in perfusionist activities (during spinning of aPRP) was not evident. Platelet, fresh frozen plasma, and cryoprecipitate intraoperative transfusions were performed only after heparin was reversed and the patient was judged as coagulopathic on the basis of associated criteria: cryoprecipitate transfusion for fibrinogen level less than 150 mg/dL, platelet transfusion for platelet count less than 80,000, and fresh frozen plasma when thromboelastogram test was suggestive or a partial thromboplastin time was greater than 55 seconds, and prothrombin time was greater than 1.6 seconds.Results. Early mortality, stroke, and respiratory complications were similar between groups. Only acute renal failure was reduced in the aPRP group, 7% versus 0% (p < 0.014). Mean transfusion rate of packed red blood cells was reduced by 34%, fresh frozen plasma by 52.8%, cryoprecipitate by 70%, and platelets by 56.7% in the aPRP group (p < 0.02). Hospital length of stay (9.4 +/- 5.3 days versus 12.7 +/- 6.3 days; p < 0.014) and transfusion costs ($1,396 +/- $1,755 versus $2,762 +/- $2,267; p < 0.004) were reduced in the aPRP group.Conclusions. The use of aPRP reduced allogeneic transfusions during ascending and transverse aortic arch repair with deep hypothermic circulatory arrest. This translated to less acute renal failure, decreased length of stay, and lower transfusion costs. Further studies examining the coagulation factors of aPRP are required. (C) 2015 by The Society of Thoracic Surgeons

We would like to comment on the potential for broader adoption of autologous platelet-rich plasma sequestration, as described by Zhou and colleagues [1Zhou S.F. Estrera A.L. Loubser P. et al.Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial.Ann Thorac Surg. 2015; 99: 1282-1290Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. Existing evidence suggests that the yield should exceed 2.5 × 1011 platelets (∼0.5 to 0.75 standard apheresis units, which have a required yield of >3 × 1011 platelets) to avoid allogeneic transfusion, mostly platelets and plasma, after routine cardiac operations [2Carless P.A. Rubens F.D. Anthony D.M. O'Connell D. Henry D.A. Platelet-rich-plasmapheresis for minimising peri-operative allogeneic blood transfusion.Cochrane Database Syst Rev. 2011; : CD004172PubMed Google Scholar]. By sequestering and processing approximately 1 liter of whole blood, the platelet yield can be estimated at ∼2 × 1011(<1 apheresis unit), which is less than the dose associated with avoidance of allogeneic platelet transfusions [2Carless P.A. Rubens F.D. Anthony D.M. O'Connell D. Henry D.A. Platelet-rich-plasmapheresis for minimising peri-operative allogeneic blood transfusion.Cochrane Database Syst Rev. 2011; : CD004172PubMed Google Scholar]. It is unexpected, therefore, that this dose of autologous platelets could promote sufficient hemostasis to significantly reduce the use of allogeneic platelets, plasma, cryoprecipitate, and red blood cell units. This raises the possibility of ineffective blinding and treatment bias. Of note, the surgeon was present while the platelets were obtained and the anesthesiologist was aware of group allocation. The current study [1Zhou S.F. Estrera A.L. Loubser P. et al.Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial.Ann Thorac Surg. 2015; 99: 1282-1290Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] was well designed for whole blood sequestration to succeed, for two reasons. First, previous studies have failed to show benefit because of a limited requirement for platelets in the control group, whereas platelet use after aortic operations is typical. Second, yield is dependent on the preoperative platelet count and the volume processed. Large patient size (average weight ∼90 kg), high hemoglobin/hematocrit (∼0.40), and normal ventricular function likely facilitated tolerating a large-volume whole blood removal. In contrast, we repurposed a blood donor apheresis device (TRIMA, Terumo BCT, Lakewood, CO) [3Alberts M. Bandarenko N. Gaca J. et al.Reduced use of allogeneic platelets through high-yield perioperative autologous plateletpheresis and reinfusion.Transfusion. 2014; 54: 1348-1357Crossref PubMed Scopus (2) Google Scholar] to concentrate platelets, broadening suitable participants to small or anemic patients with impaired cardiac function, who may not have tolerated the removal of 15 to 20 mL/kg whole blood. These concerns aside, any process to reduce allogeneic platelet usage is likely to reduce cost and transfusion-related adverse events and is to be commended. Although the simplicity of repurposing a cell saver for autologous platelet removal is very appealing, we would caution the reader when considering the application of this technique beyond large patients with high hemoglobin concentrations and preserved left ventricular ejection fraction undergoing procedures in which routine allogeneic platelet requirement is typical. Autologous Platelet-Rich Plasma Reduces Transfusions During Ascending Aortic Arch Repair: A Prospective, Randomized, Controlled TrialThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewBlood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 100Issue 5PreviewWe appreciate the constructive comments from the group from Duke [1] regarding our randomized clinical trial on autologous platelet-rich plasma (aPRP) [2]. Doctors Welsby and Poisson questioned whether the quantity of aPRP harvested was adequate to provide sufficient hemostasis during proximal thoracic aortic surgery and whether the observed reduced transfusion requirements were the result of “ineffective blinding.” In addition, they suggested that our approach to aPRP harvesting was limited to only larger patients, ie, greater than 90 kg, as smaller patients would not provide a great enough yield for benefit. Full-Text PDF

Venous-venous extracorporeal membrane oxygenation [ECMO] can be life saving in clinical situations where awake, fiberoptic intubation or tracheostomy were indicated but were not feasible because of critical airway obstruction in the lower airways. We present a case of unusual airway obstruction by a neck mass extending in the mediastinum in a young adult. A flexible fiberoptic bronchoscope was used to confirm the extent of external compression and airway obstruction. The nature of invasion was concerning for bleeding and obstruction of the airway if we attempted to manipulate the airway by fiberoptic intubation. The extension of the mass into the chest prevented other methods for securing the airway such as retrograde intubation or awake tracheostomy. There was also a concern that the use of standard induction and neuromuscular blocking drugs would cause irreversible tracheal compression or cardiovascular compromise. ECMO was utilized to provide safe oxygenation while establishing a definitive airway. Central Davide et al. (2014) Email: Int J Clin Anesthesiol 2(1): 1022 (2014) 2/4 Superior extent of the mass was at the lower pole of left thyroid lobe and the lower limit was not palpable. She exhibited increased work of breathing with suprasternal retractions. Fiberoptic nasal endoscopy showed paralyzed left true vocal fold in an abducted position. No lesion was visualized in the subglottis. Contrastenhanced CT scan of the neck and chest revealed a 4.5 x 3.9 x 4.3 cm homogenously enhancing mass displacing the left inferior pole of thyroid gland, compressing the extrathoracic trachea to a slit like appearance with possible erosion in the trachea. There was significant mass effect on the esophagus with compression at the C7-T1 level. The patient was immediately transferred from the clinic, which was connected to the hospital, to the intensive care unit due to progressive dyspnea. The patient was treated with intravenous dexamethasone and nebulized racemic epinephrine to optimize her ventilation. The patient was started on a mixture of helium 79% and oxygen 21 % [Heliox]. Heliox, having a lower density than room air reduces resistance of turbulent/orifice flow, and indeed subjective fatigue of ventilation immediately improved based on patient’s experience. However the relief was temporary and due to the patient’s deteriorating respiratory status she was taken to the operating room [general OR] to assess the airway in a protected environment and possibly secure it by mean of endotracheal intubation. We attempted an awake flexible fiberoptic bronchoscopy [FFB] with the intent of proceeding to an oral endotracheal intubation. After topicalization of the oropharynx and trachea with lidocaine 4%, mild sedation by midazolam 2 mg and 50 mcg of fentanyl, the bronchoscope was placed through the glottic opening. FFB revealed that the tumor was eroding through the left tracheal wall 5 cm below the level of the vocal cords with about 90% occlusion of the trachea. Most of the concern [that was also raised intitially at the CT scan images review], was the extension of the airway invasion, up to 3-5 cm below the initial visualization. We decided not to proceed with immediate intubation and consider a tracheostomy surgically impossible [as per assessment of ORL surgeon]. Even though placement of an endotracheal tube into the larynx would likely be uneventful, there was concern that ventilation may be difficult due to subglottic compression or significant bleeding may occur as result of shaving and scraping the irregular mucosal surface of the trachea, surely could have ended up in hypoxia/asphyxia. A consult was made for cardiothoracic surgery to initiate ECMO. Our patient was then transferred to the cardiothoracic operating room. While awake, but comfortably sedated [midazolam 2 mg] she was placed in a semi-recumbent position and local anesthetic infiltration was used prior to placement of a left subclavian vein which was verified by fluoroscopy [that was decided by the CV surgeon, a skilled clinician expert and director of the ECMO adult and pediatric program at our institution]. The time span from placing local anesthetic to initiating ECMO was approximately 15 minutes. Venous-venous flow was initiated at approximately 2.4 L/min/meter 2 and the perfusionist titrated flows to maintain normal blood pressure. The patient was anesthetized smoothly titrating 100 mcg of fentanyl, propofol 150 mg and Rocuronium 50 mg. Continuous general anesthesia was provided by propofol and fentanyl. After obtaining adequate oxygen saturation and hemodynamic stability [20 minutes were necessary], a rigid bronchoscopy was performed by a thoracic surgeon. The surgeon sequentially dilated the trachea and tumor to 11mm with an esophageal dilator [Savory, Cook Medical, IN, USA]. Bleeding was controlled by irrigation of the tumor with saline and 1:10,000 epinephrine. Orotracheal intubation was successfully performed after several dilatations, over an exchange catheter [Soft tipped exchange catheter, Cook Medical, IN, USA]. The patient was intubated with a 7mm internal diameter, wire reinforced, cuffed endotracheal tube [about 25 minutes from the start of the procedure]. Flexible bronchoscopy and a chest x-ray were utilized to confirm the placement of the endotracheal tube 3.5 cm above the carina. ECMO was discontinued after mechanical ventilation was commenced and there was confirmation of adequate oxygenation [about 1 hour from the beginning of the artificial oxygenation]. At the end of the case an ultrasound guided core needle biopsy of the mass was performed through the left lower neck. Biopsy results were inconclusive for undifferentiated epidermal carcinoma. The patient returned to the OR 3 days later for left subtotal thyroidectomy, mediastinal mass resection and prophylactic tracheostomy which were performed under general anesthesia. The patient did not experience any complications with this procedure. The patient was discharged from the hospital within a few weeks of the initial surgery. She survived approximately four months post resection. The histology confirmed the mass not being thyroid tissue, but a highly undifferentiated epidermal carcinoma.

Background. Coagulopathy is a common complication after ascending and transverse arch aortic surgery with profound hypothermic circuit arrest (PHCA). Blood conservation strategies to reduce transfusion have been ongoing and involve multiple treatment modalities in modern cardiac surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet-rich plasma (aPRP) as a blood conservation technique to reduce blood transfusion in ascending and arch aortic surgery.Methods. Between 2003 and 2009, we retrospectively reviewed 685 cases of ascending aorta and transverse arch repair using PHCA. A total of 287 patients in which aPRP was used (aPRP group) were compared with 398 patients who did have aPRP (non-aPRP group). Perioperative transfusion requirements and clinical outcomes that included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay were analyzed. The data were analyzed by mean and frequency for continuous variables and qualitative variables. To account for potential selection bias, 2 types of propensity analysis were performed.Results. In both unadjusted and adjusted analysis, perioperative transfusions were fewer in the aPRP group compared with the non-aPRP group: (3.9 units fewer packed red blood cells, 4.5 units fewer fresh frozen plasma, 7.9 units fewer platelets, and 6.8 units fewer cryoprecipitate). In all analyses, postoperative morbidity (stroke, duration of mechanical ventilation, and intensive care unit stay) were significantly improved. Hospital mortality rate was not significantly decreased.Conclusions. The utilization of aPRP was associated with a reduction in allogeneic blood transfusions as well as a decrease in early postoperative morbidity during repairs of the ascending and transverse arch aorta using PHCA. (C) 2013 by The Society of Thoracic Surgeons

Background: This study examined outcomes of endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) using general, spinal, epidural, and local/monitored anesthesia care (MAC) in a multicenter North American hospital database reflecting contemporary anesthesia and surgical practices.Methods: Elective EVAR cases performed between 2005 and 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Excluded were emergency cases and patients with concomitant procedures requiring general anesthesia. Patient-level comorbidities, characteristics, and intraoperative and postoperative details were examined. Complications were analyzed individually and in aggregate categories, including wound, pulmonary, renal, venous thromboembolic, cardiovascular, operative, and septic. Length of stay (LOS) and 30-day mortality were examined. Characteristics and outcomes were described using mean +/- standard deviation or count (%), and comparisons were evaluated for statistical significance using chi(2), Fisher exact test, and univariate linear regression. LOS was analyzed with linear regression techniques using a log transformation. Associations between anesthesia type and outcomes were examined using univariable and multivariable regression techniques.Results: We identified 6009 elective EVAR procedures for analysis. General anesthesia was used in 4868 cases, spinal anesthesia in 419, epidural anesthesia in 331, and local/MAC in 391. Defined morbidity occurred in 11% of patients. Median LOS was 2 (interquartile range, 1-3) days, and mean LOS was 2.8 +/- 4.3 days. The 30-day mortality rate was 1.1%. Significant multivariate associations were observed between anesthesia type, pulmonary morbidity, and log-LOS. General anesthesia was associated with an increase in pulmonary morbidity vs spinal (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3-12.5; P = .020) and local/MAC anesthesia (OR, 2.6; 95% CI, 1.0-6.4; P = .041). Use of general anesthesia was associated with a 10% increase in LOS for general vs spinal anesthesia (95% CI, 4.8%45.5%; P = .001) and a 20% increase for general vs local/MAC anesthesia (95% CI, 14.1%-26.2%; P < .001). Trends toward increased pulmonary morbidity and LOS were not observed for general vs epidural anesthesia. No significant association between anesthesia type and mortality was observed.Conclusions: In contemporary North American anesthetic and surgical practice, general anesthesia for EVAR was associated with increased postoperative LOS and pulmonary morbidity compared with spinal and local/MAC anesthesia. These data suggest that increasing the use of less-invasive anesthetic techniques may limit postoperative complications and decrease the overall costs of EVAR. (J Vasc Surg 2011;54:1273-82.)

To the Editor: Vaughn et al. are to be commended for their excellent educational case report on anesthesia for thoracoabdominal aortic aneurysm repair. However, there is one area that we believe merits clarification, because it does not bring “completeness” to a full discussion of the subject. In their report, they tend to minimize the relative value and utility of neurophysiologic monitoring during thoracoabdominal aortic aneurysm (TAAA) surgery, while citing a small sample of studies and citing “drawbacks and limitations for the use of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs).” One is immediately reminded of the debate on cerebrospinal fluid drainage that raged for many years. As early as 1988, Hollier’s group had provided evidence of the neuroprotective action of cerebrospinal fluid drainage in canine studies. However, skepticism prevailed among surgeons for many years. Crawford himself was highly skeptical of the modality, stating in 1991, “Thus cerebrospinal fluid drainage as we used it, was not beneficial in preventing paraplegia.” But, only in 1994, when Safi et al. demonstrated the association between cerebrospinal fluid drainage and reduced postoperative neurologic deficits in TAAA patients, did the surgical community relent. Several published reports have identified neurophysiologic monitoring as highly useful in the prediction and amelioration of neurologic complications occurring after TAAA surgery. In a study of 233 patients undergoing TAAA surgery, in which paired SSEP and MEP monitoring was conducted, our group demonstrated that SSEPs and MEPs were highly correlated when intraoperative changes were irreversible. These irreversible changes were significantly associated with immediate neurologic deficits. In contrast, normal SSEP and MEP findings had a strong negative predictive value for neurologic deficits. These findings confirm the results of Shine at al., who reported a negative predictive value of 96% for MEPs, in the absence of any changes for 20 min after aortic cross-clamp application. In a further refinement, our group examined 108 patients undergoing TAAA surgery, citing loss of SSEPs and MEPs, in 26% and 50% of patients, respectively. Active intraoperative measures, which included intercostal artery reattachment in 85% of patients and judicious management of distal aortic and cerebrospinal fluid pressure, produced a return of SSEPs in all patients and a return of MEPs in all but one patient, (who awoke with an immediate neurologic deficit). MEPs can be highly reactive to spinal cord perfusion, as reported by Koeppel et al., who demonstrated rapid temporal changes of MEP loss and recovery, with interruption and restoration of distal aortic perfusion. Why do Vaughn et al. and ostensibly other surgical groups not embrace neurophysiologic monitoring during TAAA surgery? Well, they require an experienced team of a surgeon, neurologist, anesthesiologist, and perfusionist to ensure that they are effective and accurate. Coselli and Tsai recently questioned the validity of MEPs, citing interference by anesthesia agents and other potential factors. Our experiential track record has been quite the opposite. Indeed, we limit our use of inhalation agents to approximately 0.5 minimum alveolar concentration, but this is not a novel technique in cardiac anesthesia. We have transitioned to the use of shorter acting muscle relaxants such as rocuronium and cisatracurium. However, in some instances, we have found it necessary to suppress MEPs with a small dose of muscle relaxant to minimize MEP interference of the SSEP signal. Because MEPs actually produce muscle contraction and subtle patient movement, electrode detachment can occur at any time during the procedure and must be detected rapidly by the neurophysiology technician. What was not borne out in Vaughn’s article was the synergy of effort that is needed when cortical sensory evoked potentials, and in particular, when MEPs degrade during TAAA surgery, consisting of improving distal aortic perfusion (perfusionist), reducing cerebrospinal fluid pressure (anesthesiologist), and intercostal artery reattachment (surgeon). Likened to the aviation industry’s “Crew Resource Management,” the team caring for the TAAA patient must all work aggressively and rapidly in an attempt to reverse these changes and mitigate neurologic complications. Based on the lessons learned from cerebrospinal fluid drainage, and in the interest of patient safety, we should view neurophysiologic monitoring during TAAA surgery not as an obscure modality as Vaughn et al. impugn, but as a “standard-of-care.”

Survey of Anesthesiology: June 2012 - Volume 56 - Issue 3 - p 107-108 doi: 10.1097/01.SA.0000413396.46395.05