Endovascular Vena Cavae Occlusion Technique in Minimally Invasive Tricuspid Valve Surgery in Patients With Previous Cardiac Surgery.

OBJECTIVES: The aim of the present study was to describe a bicaval endovascular occlusion technique in minimally invasive tricuspid valve (TV) surgery in patients with previous cardiac surgery. DESIGN: Case series. SETTING: Single tertiary university center. PARTICIPANTS: The study comprised ten patients. INTERVENTIONS: Endovascular occlusion of vena cavae for minimally invasive TV redo surgery. MEASUREMENTS AND MAIN RESULTS: Between 2008 and 2017, ten patients with previous cardiac surgery underwent TV minimally invasive surgery (repair or replacement; isolated or with concomitant procedures) using the Coda balloon catheter (Cook Medical, Bloomington, IN) to occlude both vena cavae. Data were collected retrospectively from electronic medical records. Superior and inferior vena cava occlusion with Coda balloon catheters was successful with no complications. The drainage of the vena cavae was optimal with excellent surgical exposure. Cardiopulmonary bypass time was 131 ± 119 minutes, with 30% of patients undergoing aortic clamping (two with a Chitwood clamp, one with an endoaortic balloon). Intensive care unit length of stay was 3.9 ± 2.7 days, and the in-hospital mortality rate was 30%. CONCLUSION: Bicaval endovascular occlusion of vena cavae is a feasible and effective technique in patients with previous cardiac surgery who are undergoing a minimally invasive TV procedure. The high mortality rate is associated with the inherent risk of a redo surgery involving the TV.

Combined endoscopic and transcatheter treatment of native mitral stenosis.

This report describes an approach for the treatment of high-risk native mitral valve stenosis. It incorporates the deployment of a transcatheter valve in the mitral position under full endoscopic vision, combined with endoscopic mitral repair techniques that secure valve positioning and reduce the risk of paravalvular leak. This approach could be used as a rescue procedure in centres with experience in transcatheter and endoscopic valve techniques.

Management of tight intraoperative glycemic control during off-pump coronary artery bypass surgery in diabetic and nondiabetic patients.

OBJECTIVES: To optimize intra- and postoperative insulin management in cardiac surgical patients. DESIGN: A prospective, randomized, open-label, single-center study. SETTING: A large nonuniversity hospital. PARTICIPANTS: Sixty diabetics and 60 nondiabetics undergoing off-pump cardiac bypass surgery. INTERVENTIONS: Intra- and postoperative tight glycemic control were achieved using different approaches with a modified insulin protocol. MEASUREMENTS AND MAIN RESULTS: Nondiabetics were divided randomly: in the ND-ind group (n = 30), insulin was started at induction according to preinduction blood glucose (BG) concentrations. In group ND >110 (n = 30), insulin was started when BG concentrations exceeded 110 mg/dL during surgery. Up to 85% of the ND >110 group started on insulin intraoperatively. Intraoperatively, the ND-ind group had more BG within target (80-110 mg/dL) (p = 0.002), less BG >130 mg/dL (p = 0.015), and more BG between 70 and 79 mg/dL (p = 0.002). In diabetics, BG concentration was checked every 30 (DM-30), n = 30) versus 60 minutes (DM-60, n = 30) to improve the protocol's performance. Intraoperatively, there were more BG concentrations within target (80-110 mg/dL) (p = 0.02) and less >130 mg/dL (p = 0.0002) in the DM-30 group. During surgery, the hyperglycemic index and the glycemic penalty index were lower in the ND-ind group (p < 0.05). Postoperatively, the mean BG concentrations, hyperglycemic index, and glycemic penalty index in diabetics and nondiabetics were comparable between groups (p < 0.05). In the overall 2,641 BG samples, the lowest BG concentration in the operating room was 71 and in the intensive care unit (ICU) it was 61 mg/dL. CONCLUSIONS: In diabetics and nondiabetics undergoing off-pump coronary artery bypass surgery, tight perioperative glycemic control is feasible and efficient, with minimal risks for hypo- and hyperglycemia. In nondiabetics, starting insulin therapy from induction onwards results in more measurements within target, without affecting the mean BG. In diabetics, decreasing the sampling interval from 60 to 30 minutes results in more measurements within target and in a mean blood glucose within target at ICU arrival.

Right atrial tumor: a contraindication to minimally invasive surgery?

Cardiac tumors are rarely observed. The incidence of primary cardiac tumors in autopsy series ranges from 0.0017% to 0.19%. Surgical resection is the main therapy for the majority of the cardiac tumors. Surgical treatment of these tumors carries an operative mortality rate of 3% or less. In this article, we present our experience with a female patient, who had a right sided atrial tumor mimicking a myxoma. Port access surgery was performed through a small right sided "key-hole" working port in the fourth intercostal space. Extracorporeal circulation was conducted by femoro-femoral bypass and a kinetic assisted venous drainage system. Although, the safety and efficacy of port access approach have been well documented for resection of left atrial tumors in some series, use of this technique for right atrial tumor resection can be detrimental.

Tight perioperative glucose control is associated with a reduction in renal impairment and renal failure in non-diabetic cardiac surgical patients.

INTRODUCTION: Acute renal failure after cardiac surgery increases in-hospital mortality. We evaluated the effect of intra- and postoperative tight control of blood glucose levels on renal function after cardiac surgery based on the Risk, Injury, Failure, Loss, and End-stage kidney failure (RIFLE) criteria, and on the need for acute postoperative dialysis. METHODS: We retrospectively analyzed two groups of consecutive patients undergoing cardiac surgery with cardiopulmonary bypass between August 2004 and June 2006. In the first group, no tight glycemic control was implemented (Control, n = 305). Insulin therapy was initiated at blood glucose levels > 150 mg/dL. In the group with tight glycemic control (Insulin, n = 745), intra- and postoperative blood glucose levels were targeted between 80 to 110 mg/dL, using the Aalst Glycemia Insulin Protocol. Postoperative renal impairment or failure was evaluated with the RIFLE score, based on serum creatinine, glomerular filtration rate and/or urinary output. We used the Cleveland Clinic Severity Score to compare the predicted vs observed incidence of acute postoperative dialysis between groups. RESULTS: Mean blood glucose levels in the Insulin group were lower compared to the Control group from rewarming on cardiopulmonary bypass onwards until ICU discharge (p < 0.0001). Median ICU stay was 2 days in both groups. In non-diabetics, strict perioperative blood glucose control was associated with a reduced incidence of renal impairment (p = 0.01) and failure (p = 0.02) scoring according to RIFLE criteria, as well as a reduced incidence of acute postoperative dialysis (from 3.9% in Control to 0.7% in Insulin; p < 0.01). The 30-day mortality was lower in the Insulin than in the Control group (1.2% vs 3.6%; p = 0.02), representing a 70% decrease in non-diabetics (p < 0.05) and 56.1% in diabetics (not significant). The observed overall incidence of acute postoperative dialysis was adequately predicted by the Cleveland Clinic Severity Score in the Control group (p = 0.6), but was lower than predicted in the Insulin group (1.2% vs 3%, p = 0.03). CONCLUSIONS: In non-diabetic patients, tight perioperative blood glucose control is associated with a significant reduction in postoperative renal impairment and failure after cardiac surgery according to the RIFLE criteria. In non-diabetics, tight blood glucose control was associated with a decreased need for postoperative dialysis, as well as 30-day mortality, despite of a relatively short ICU stay.

Dynamic tight glycemic control during and after cardiac surgery is effective, feasible, and safe.

BACKGROUND: Tight blood glucose control reduces mortality and morbidity in critically ill patients, but intraoperative glucose control during cardiac surgery is often difficult, and risks hypoglycemia. In this study, we evaluated the safety and efficacy of a nurse-driven insulin protocol (the Aalst Glycemia Insulin Protocol) for achieving a target glucose level of 80-110 mg/dL during cardiac surgery and in the intensive care unit (ICU). METHODS: We included 483 nondiabetics and 168 diabetics scheduled for cardiac surgery with cardiopulmonary bypass. To anticipate rapid perioperative changes in insulin requirement and/or sensitivity during surgery, we developed a dynamic algorithm presented in tabular form, with rows representing blood glucose ranges and columns representing insulin dosages based on the patients' insulin sensitivity. The algorithm adjusts insulin dosage based on blood glucose level and the projected insulin sensitivity (e.g., reduced sensitivity during cardiopulmonary bypass and normalizing sensitivity after surgery). RESULTS: A total of 18,893 blood glucose measurements were made during and after surgery. During surgery, the mean glucose level in nondiabetic patients was within targeted levels except during (112 +/- 17 mg/dL) and after rewarming (113 +/- 19 mg/dL) on cardiopulmonary bypass. In diabetics, blood glucose was decreased from 121 +/- 40 mg/dL at anesthesia induction to 112 +/- 26 mg/dL at the end of surgery (P < 0.05), with 52.9% of patients achieving the target. In the ICU, the mean glucose level was within targeted range at all time points, except for diabetics upon ICU arrival (113 +/- 24 mg/dL). Of all blood glucose measurements (operating room and ICU), 68.0% were within the target, with 0.12% of measurements in nondiabetics and 0.18% in diabetics below 60 mg/dL. Hypoglycemia < 50 mg/dL was avoided in all but four (0.6%) patients (40 mg/dL was the lowest observed value). CONCLUSIONS: The Aalst Glycemia Insulin Protocol is effective for maintaining tight perioperative blood glucose control during cardiac surgery with minimal risk of hypoglycemia.

Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery.

BACKGROUND: The purpose of this study was to evaluate the feasibility and effectiveness of a right video-assisted approach for atrioventricular valve disease after previous cardiac surgery. METHODS AND RESULTS: Between December 1st 1997 and May 1st 2006, 80 adults (mean age 65+/-12 years; 56% female) underwent reoperative surgery using a video-assisted approach without rib spreading. Previous cardiac operations included mitral valve (39%), CABG (29%), congenital (10%), and other (23%). For 25% of patients, this was at least their third cardiac operation. Mean time to redo surgery was 15+/-12 years. Femoral vessel cannulation and endoaortic clamping were routinely used. Mean preoperative Euroscore was 9.0+/-2.7 (5 to 20) and predicted mortality was 16.0+/-14.2% (4 to 86). Median preoperative NYHA class was II and mean follow-up was 25+/-22 months. Lung adhesions necessitated sternotomy in 4 cases and cannulation problems in another patient. Total operative mortality was 3.8% (n=3), O/E for mortality being 0.24. Procedures were mitral valve repair (45%; n=36), replacement (50%; n=40) and tricuspid valve replacement (5%; n=4). Additional procedures were performed in 44% (n=35). Mean aortic crossclamp and procedure time were 92+/-37 and 267+/-64 minutes. Mean postoperative blood loss was 815+/-1083 mL. Postoperative morbidity included 2 strokes (2.5%). Mean hospital stay was 10.7+/-6.7 days. Survival at 1 and 4 years was 93.6+/-2.8% and 85.6+/-6.4%. There was 1 late reoperation at 5 years. Median NYHA class at follow-up was II. When comparing, all but 1 patient (98.8%) preferred their minimally invasive approach when considering perioperative pain, postoperative rehabilitation, and final esthetic result. CONCLUSIONS: Video-assisted minimal access correction of atrioventricular valve disease after previous cardiac surgery is not only feasible but had lower than predicted mortality and strong patient satisfaction. It should therefore be used more frequently in today's practice.

Endoscopic correction of the adult form of scimitar syndrome and mitral regurgitation: anatomic and technical considerations.

Scimitar syndrome is a congenital cardiac anomaly characterized by anomalous venous drainage of the right lung into the inferior vena cava. We report the combination of scimitar syndrome and mitral regurgitation and describe port-access correction for the adult form by means of an intraatrial baffle combined with mitral valve repair. Related considerations and modifications required in the standard Heartport (Cardiovations, Somerville, NJ) technique are discussed.

Avoiding vascular complications during minimally invasive, totally endoscopic intracardiac surgery.

OBJECTIVE: The introduction of minimally invasive valve surgery has been associated with an increased use of peripheral vessel cannulation in cardiopulmonary bypass. These techniques are associated with potential problems at the aorta or cannulation sites. The goal of this study was to review and describe our current practice to avoid vascular problems during cannulation of peripheral vessels. METHOD: Data collection for this study was done retrospectively by reviewing the files of all patients who underwent a minimally invasive mitral and/or tricuspid surgery in our institution from 1997 to the end of 2005. RESULTS: Our cohort of 978 patients revealed an overall rate of peripheral vascular complication of 1.0% with 44.4% presenting at the time of the surgery and 63.6% at long-term follow-up. Acute peripheral vascular problems were treated by simple graft replacement of the diseased segment in most cases. All aortic complications happened at the time of the surgery (complication rate of 0.9%) with 60% of them associated with cannulation problems. Most patients were treated by replacement of the ascending aorta. CONCLUSIONS: A systematic and careful approach is associated with a low risk of vascular problems. Prevention and planning with precise surgical technique remain the main conditions to safely use peripheral cannulation and perfusion for minimally invasive mitral valve surgery.

Muscle relaxation does not influence venous oxygen saturation during cardiopulmonary bypass.

STUDY OBJECTIVE: To examine whether the omission of neuromuscular blocking drugs during cardiopulmonary bypass (CPB) is associated with increased anesthetic requirements, higher frequency of intraoperative movements, and lower venous oxygen saturation (SvO(2)). DESIGN: Prospective, randomized study. SETTING: Large community hospital. PATIENTS: 30 ASA physical status III and IV patients scheduled for cardiac surgery. INTERVENTIONS: Patients were randomized to one of two groups: group 1 (n = 15) received a 3xED(95) bolus dose of cisatracurium at induction and thereafter no more neuromuscular blocking drug; group 2 (n = 15) received a continuous infusion of cisatracurium during the entire procedure. INTERVENTIONS: Both groups received a standardized anesthetic with bispectral index-guided propofol target-controlled infusion and a remifentanil infusion steered by hemodynamic changes. Venous oxygen saturation was continuously determined during CPB. MEASUREMENTS AND MAIN RESULTS: Propofol consumption was 5.4 +/- 1.7 and 4.4 +/- 1.0 mg/(kg/h) in groups 1 and 2, respectively (P = 0.07). Remifentanil consumption was 0.15 +/- 0.05 and 0.17 +/- 0.05 mug/(kg/min) in groups 1 and 2, respectively (P = 0.19). In groups 1 and 2, no patient recalled any intraoperative phenomena; none moved or had diaphragmatic contractions. During CPB, SvO(2) was 81.3 +/- 3.2% (76%-85%) in group 1 and 80.6 +/- 3.1% (73%-85%) in group 2 (P = 0.53). CONCLUSIONS: Omitting the continuous administration of neuromuscular blocking drugs during CPB did not increase anesthetic requirements. No intraoperative movements occurred, nor was there decreased SvO(2).

Preinduction glycemia and body mass index are important predictors of perioperative insulin management in patients undergoing cardiac surgery.

STUDY OBJECTIVE: To investigate whether preinduction glucose is an important predictor for perioperative insulin management in patients undergoing cardiac surgery. DESIGN: Prospective cohort study. SETTING: Large community hospital. PATIENTS: 80 consecutive patients scheduled for cardiac surgery. INTERVENTIONS: Patients were subdivided into those with a preinduction blood glucose of 110 mg/dL or lower with or without history of diabetes (group 1) and those with a preinduction blood glucose of above 110 mg/dL with or without history of diabetes (group 2). In group 1, there were no known diabetics. In group 2, 31% (11/35) had diabetes (group 2DM), while 24/35 (69%) did not (group 2NDM). An insulin infusion was started intraoperatively and adjusted according to a strict protocol in order to maintain normoglycemia (80-110 mg/dL) until discharge from intensive care. MEASUREMENTS AND MAIN RESULTS: In patients with preinduction glucose above 110 mg/dL, whether or not previously treated for diabetes, perioperative insulin requirements were higher, and intraoperative insulin management was more difficult than in those with lower preinduction glucose. In patients with a preinduction glucose above 110 mg/dL, hospital stay was longer, and inhospital mortality was significantly higher than in those with lower preinduction glucose. Multivariate analyses showed that preinduction glycemia was a good predictor of intraoperative insulin consumption, as was the body mass index (BMI) for intensive care and total insulin needs. CONCLUSIONS: In cardiac surgical patients with a preinduction glucose above 110 mg/dL, even if diabetes was not previously suspected, perioperative insulin requirements were higher, and intraoperative insulin management is more difficult than in those with a preinduction glucose 110 mg/dL or lower. Preinduction glycemia and BMI are good predictors of perioperative insulin management. Preinduction glycemia above 110 mg/dL predicts difficult perioperative glucose control and, moreover, that a preinduction blood glucose of 110 mg/dL or lower is associated with less insulin need.

Intraoperative severity assessment of coronary artery stenosis in patients at risk: the role of transesophageal echocardiography.

A 71-yr-old male was scheduled for infrarenal abdominal aortic aneurysm repair. Although he had only minor clinical predictors for increased perioperative cardiovascular risk with >4 estimated metabolic equivalents for activities, intraoperative transesophageal echocardiography revealed an abnormal maximal-to-prestenotic blood flow velocity ratio in the left main coronary artery. Postoperatively, a severe distal left main coronary artery stenosis was confirmed with coronary angiography. Understanding the flow velocity patterns in the coronary arteries helps the anesthesiologist to detect coronary lesions with transesophageal echocardiography.

Effect of N2O on sevoflurane vaporizer settings during minimal- and low-flow anesthesia.

BACKGROUND: Uptake of a second gas of a delivered gas mixture decreases the amount of carrier gas and potent inhaled anesthetic leaving the circle system through the pop-off valve. The authors hypothesized that the vaporizer settings required to maintain constant end-expired sevoflurane concentration (Etsevo) during minimal-flow anesthesia (MFA, fresh gas flow of 0.5 l/min) or low-flow anesthesia (LFA, fresh gas flow of 1 l/min) would be lower when sevoflurane is used in oxygen-nitrous oxide than in oxygen. METHODS: Fifty-six patients receiving general anesthesia were randomly assigned to one of four groups (n = 14 each), depending on the carrier gas and fresh gas flow used: group Ox.5 l (oxygen, MFA), group NOx.5 l (oxygen-nitrous oxide, MFA after 10 min high fresh gas flow), group Ox1 l (oxygen, LFA), and group NOx1 l (oxygen-nitrous oxide, LFA after 10 min high fresh gas flow). The vaporizer dial settings required to maintain Etsevo at 1.3% were compared between groups. RESULTS: Vaporizer settings were higher in group Ox.5 l than in groups NOx.5 l, Ox1 l, and NOx1 l; vaporizer settings were higher in group NOx.5 l than in group NOx1 l between 23 and 47 min, and vaporizer settings did not differ between groups Ox1 l and NOx1 l. CONCLUSIONS: When using oxygen-nitrous oxide as the carrier gas, less gas and vapor are wasted through the pop-off valve than when 100% oxygen is used. During MFA with an oxygen-nitrous oxide mixture, when almost all of the delivered oxygen and nitrous oxide is taken up by the patient, the vaporizer dial setting required to maintain a constant Etsevo is lower than when 100% oxygen is used. With higher fresh gas flows (LFA), this effect of nitrous oxide becomes insignificant, presumably because the proportion of excess gas leaving the pop-off valve relative to the amount taken up by the patient increases. However, other unexplored factors affecting gas kinetics in a circle system may contribute to our observations.