ABSTRACT
Background With the COVID-19 pandemic and referral from out-reach centers, there has been a change in practice of assessing left atrial appendage (LAA) via TEE on the day of LAA closure (LAAC). We present a challenging case of inadequate LAAC with WATCHMAN FLX due to suboptimal TEE images. Follow up TEE and CT revealed a much larger LAA ostium that was mostly uncovered. Case An 84 yo male with AF and recent hepatic hematoma, was referred for LAAC. LAA dimensions were measured using a technically difficult intraprocedural (IP) 2D TEE and a 24mm Watchman FLX was successfully implanted. Follow up 3D TEE at 45 days revealed incomplete LAAC with a large PDL. Retrospective review of fluoroscopic images revealed unrecognized filling of a posterior LAA lobe. Decision-making Anticoagulation (AC) was continued for 3 more months, and Cardiac CT was performed which showed persistent under-coverage of the LAA with large PDL of 16.5 x 11.3 mm (159mm2). A much larger ostium was measured on 45 days TEE (27 mm max 2 D dimension) and 145 days CT (18 X 25 mm) vs. 12.9 mm on IP-TEE. AC was continued with consideration of a 2nd adjacent device placement in future. Conclusion TEE on the day of LAAC although implemented in several centers, has its limitations. In the presence of sub-optimal image quality, it can lead to incorrect device sizing and incomplete LAAC as in our case. Cardiac CT with 3D evaluation or 3D TEE are crucial for pre-planning to achieve successful device implantation. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
ABSTRACT
BACKGROUND: Neuraxial blocks is the recommended mode of analgesia and anesthesia in parturients with Coronavirus 19 (COVID-19). There is limited data on the hemodynamic responses to neuraxial blocks in COVID-19 patients. We aim to compare the hemodynamic responses to neuraxial blocks in COVID-19 positive and propensity-matched COVID-19 negative parturients. METHODS: We conducted retrospective, cross-sectional case-control study of hemodynamic changes associated with neuraxial blocks in COVID-19 positive parturients in a Tertiary care academic medical center. Fifty-one COVID-19 positive women confirmed by nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR), were compared with propensity-matched COVID negative controls (n = 51). Hemodynamic changes after neuraxial block were recorded by electronic medical recording system and analyzed using paired and unpaired T- test and Wilcoxon-Mann-Whitney Rank Sum tests. The primary outcome was ≥ 20% change in MAP and HR after neuraxial block placement. RESULTS: In the epidural group, 7% COVID-19 positive parturients had > 20% decrease in mean arterial pressure (MAP) from baseline compared to 15% COVID-19 negative parturients (P = 0.66). In the spinal group, 83% of COVID-19 positive parturients had a decrease in MAP more than 20% from baseline compared to 71% in control (P = 0.49). MAP drop of more than 40% occurred in 29% COVID positive parturients in the spinal group versus 17% in COVID-19 negative parturients (P = 0.5465). In COVID-19 positive spinal group, 54% required vasopressors whereas 38% in COVID-19 negative spinal group required vasopressors (P = 0.387). We found a significant correlation between body mass index (BMI) > 30 and hypotension in COVID ( +) parturient with odds ratio (8.63; 95% CI-1.93 - 37.21) (P = 0.007). CONCLUSION: Incidence and severity of hypotension after neuraxial blocks were similar between COVID-19 positive and COVID-19 negative parturients. BMI > 30 was a significant risk factor for hypotension as described in preexisting literature, this correlation was seen in COVID-19 positive parturients. The likely reason for parturients with BMI > 30 in COVID negative patients not showing similar correlation, is that the sample size was small.