Perioperative takotsubo cardiomyopathy: Implications for anesthesiologist

Takotsubo cardiomyopathy (TCM) is characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease that may be triggered by an acute medical illness or intense physical or emotional stress. TCM is often confused with acute myocardial infarction given the similar electrocardiographic changes, cardiac enzymes, hemodynamic perturbations, and myocardial wall motion abnormalities. In the perioperative setting, the clinical picture may be more confusing because of the effect of anesthesia as well as hemodynamic changes related to the surgery itself. However, awareness of various other diagnostic modalities may enable clinicians to distinguish between the two, more systematically and with greater certainty. Despite the large body of literature, there still seems to be an overall paucity in our understanding of the etiopathogenesis, clinical characteristics, natural history, and management of this syndrome, especially in the perioperative setting. This narrative review seeks to present and synthesize the most recent literature on TCM and to identify gaps in current knowledge which can become the basis for future research.

Iatrogenic atrio-esophageal fistula following a video-assisted thoracoscopic maze procedure: Is esophageal instrumentation justified even when the diagnosis is equivocal?

A 74-year-old female underwent an uneventful bilateral thoracoscopic maze procedure for persistent atrial fibrillation with continuous transesophageal echocardiographic (TEE) guidance. She presented six weeks later with persistent fever and focal neurological signs. Computed tomography of the thorax revealed air in the posterior LA, raising suspicion for an abscess versus an atrioesophageal fistula (AEF). Before undergoing an exploratory median sternotomy, an esophagogastroduodenoscopy (EGD) was performed by the surgeon to check for any esophageal pathology. This however, resulted in sudden hemodynamic compromise that required intensive treatment with vasopressors and inotropes. In this case-report, we review the various intraoperative risk factors associated with the development of AEF during cardiac ablation procedures as well as the potential hazards of esophageal instrumentation with TEE, naso- or oro- gastric devices, and/or an EGD when an AEF is suspected.

Anticoagulation dilemma in a high‑risk patient with On‑X valves.

Thromboembolism continues to be a major concern in patients with mechanical heart valves, especially in those with unsatisfactory anticoagulation levels. The new On‑X valve (On‑X Life Technologies, Austin, TX, USA) has been reported as having unique structural characteristics that offer lower thrombogenicity to the valve. We report a case where the patient received no or minimal systemic anticoagulation after placement of On‑X mitral and aortic valves due to development of severe mucosal arterio‑venous malformations yet did not show any evidence of thromboembolism. This case report reinforces the findings of recent studies that lower anticoagulation levels may be acceptable in patients with On‑X valves and suggests this valve may be particularly useful in those in whom therapeutic levels of anticoagulation cannot be achieved due to increased risk of bleeding.