A Clinical Comparison of 2 Bronchial Blockers Versus Double-Lumen Tubes for One-Lung Ventilation.

OBJECTIVES: To compare the quality of lung collapse, time, and number of attempts required to achieve lung isolation, and incidence of intraoperative malpositioning between the EZ blocker (EZB), Fuji Uniblocker (UB), and the left-sided double lumen tube (DLT). DESIGN: Prospective, randomized clinical trial. SETTING: Single tertiary-level, university-affiliated hospital. PARTICIPANTS: Eighty-nine patients undergoing elective open thoracotomies or video-assisted thoracoscopic surgery. INTERVENTIONS: The 89 patients were randomized to receive a DLT, UB, or EZB for one-lung ventilation. MEASUREMENTS AND MAIN RESULTS: The quality of lung collapse at the time of pleural opening and 10 and 20 minutes thereafter were assessed by the surgeon using the Lung Collapse Score (LCS; 0 = no lung collapse to 10 = best lung collapse). The time and number of attempts required to achieve lung isolation and the number of repositions required during surgery were measured. Tracheobronchial tree measurements were performed by radiologists from preoperative computed tomography imaging. The surgeon remained blinded to the type of device used. Twenty-nine patients were randomized to the DLT group and 30 patients to each of the EZB and UB groups. The LCSs among the groups at pleural opening and 10 minutes after pleural opening were not significantly different (p = 0.34 and p = 0.08, respectively). However, at 20 minutes after the pleural opening, the LCSs were significantly different among groups (p = 0.02), with median scores being significantly lower for DLT (9 [IQR 8-9]) than for EZB (9 [IQR 9-10]; p = 0.04) and UB (9.5 [IQR 9-10]; p = 0.02). Lung isolation was achieved fastest in the DLT group (p < 0.01). The frequency of difficult placement did not significantly differ among groups, although it occurred most frequently in UB (n = 7; 23.3%). Intraoperative repositioning also occurred most often with the UB (n = 15; 50.0%). The EZB had the greatest number of cases requiring >2 repositions (n = 4, 13.3%). There were no differences between preoperative airway measurements and time to isolation or incidence of intraoperative repositioning among the groups. CONCLUSIONS: The LCS was comparable among the 3 devices until 20 minutes after pleural opening, when better scores were obtained in the bronchial blocker groups. Lung isolation was achieved fastest with the DLT. The EZB had the highest incidence of cases requiring >2 intraoperative repositions, mostly occurring in R-sided surgery. For L-sided surgery, the EZB performed equally to the UB. This suggests that using the EZB for R-sided video-assisted thoracoscopic surgery may be suboptimal. Preoperative airway dimensions did not correlate with time to achieve isolation or incidence of intraoperative malpositioning.

Multimodality Quantitative Assessment of Aortic Regurgitation: A Systematic Review.

We performed a systematic review on the agreement and reproducibility of 3 advanced imaging methods, 3-dimensional echocardiography (3DE), cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR), for quantifying aortic regurgitation (AR) severity. Medline, Embase, and Cochrane databases were systematically searched using the PICO model from inception to February 4, 2022, for publications that quantified AR severity with 3DE, CCT, or CMR. Measurement agreement and intraobserver and interobserver reproducibility results were extracted from each study. Study quality was assessed using the QUADAS-2 tool. Forty-two publications with 2176 patients with AR were identified. For 3DE, vena contracta (VC) width, VC area, and effective regurgitant orifice area had higher correlations with AR volume than the 2-dimensional echocardiography (2DE)-derived VC width. CCT-derived regurgitant volume had moderate-to-good correlations with 2DE. CMR regurgitant volume measurements had lower intraobserver and interobserver variabilities because of improved endocardial definition, fewer geometric assumptions, and less angle dependence for flow measurements when compared with 2DE. 3DE color flow convergence methods used to quantify AR severity were superior to 2DE methods and could be used in patients with adequate echocardiographic windows. CCT methods also demonstrated improvements over 2DE methods. Although this method is limited due to the radiation exposure, it could play a role in patients with poor echocardiographic windows unable to tolerate CMR. CMR demonstrated the smallest intraobserver and interobserver variability in evaluating AR severity and is a reasonable option for those where the echocardiographic results are mixed and for clinical trials.

Preintervention imaging and intraoperative management care of the hypertrophic obstructive cardiomyopathy patient.

With an estimated overall mortality of less than 1 percent per year, hypertrophic cardiomyopathy, is the most common genetic cardiomyopathy. Intraoperative transesophageal echocardiography is the standard of care for assessing patients with hypertrophic obstructive cardiomyopathy undergoing surgical septal myectomy, allowing surgical planning, intraoperative hemodynamic monitoring, and postprocedural assessment of the repair, including detection of immediate complications. At various phases during surgical septal myectomy, the changing hemodynamic conditions may lead to worsening or improvement in left ventricle outflow tract obstruction by change in preload or afterload, systolic anterior motion of the mitral valve, or sympathetic stimulation. These characteristics represent unique challenges in the management of these patients, requiring a comprehensive understanding of the management of all the conditions required to decrease the left ventricle outflow tract gradient avoiding obstruction, which include the maintenance of sinus rhythm, adequate rate avoiding tachycardia and bradycardia, and avoidance of systemic hypotension preserving preload and afterload, with adequate vasoactive agents. The aim of this review is to summarize the perioperative assessment and management of patients undergoing hypertrophic obstructive myopathy surgery.

Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications.

The gold standard treatment for end-stage heart failure, with 50% mortality within 5 years of diagnosis, is considered heart transplantation. Despite the improvements in immunosuppression, the period of highest mortality risk in the heart transplantation population is during the first year post-transplantation, with primary graft dysfunction being the leading cause of mortality. After adequate preoperative assessment of the recipient, including patients on mechanical support, the intraoperative care of heart transplantation patients requires extensive monitoring followed by proficient management of anesthesia induction and maintenance, ventilation, and fluid therapy. The focus on weaning from cardiopulmonary bypass should be on preventing right ventricular failure and high pulmonary vascular resistances, with protocolized blood conservation strategies and transfusion protocols. The early postoperative care of a heart transplantation patient is focused on the post-cardiopulmonary bypass and transplantation status, with particular attention to the presence of primary graft dysfunction, right ventricular performance, pulmonary pressures, and vasoplegia. The aim is early extubation, inotropic and chronotropic support weaning, and chest tube removal to facilitate discharge of the patient from the intensive care unit. The increased complexity of heart transplantation recipients, including the incremental use of pre- transplantation mechanical circulatory support and extended criteria donor hearts, requires extensive and sophisticated preparation of the cardiac anesthesiologist. This article aims to provide an overview of the intraoperative and early postoperative anesthesia management of heart transplantation patients.

Ex-vivo lung perfusion.

PURPOSE OF REVIEW: Ex-vivo lung perfusion (EVLP) has been developed to expand the donor pool for lung transplantation recipients. The role of EVLP in organ preservation, evaluation and potential reconditioning is reviewed. RECENT FINDINGS: EVLP has been shown to significantly increase the utilization of donor lungs for transplantation. Evidence suggests that patient outcomes from EVLP lungs are comparable to standard procurement technique. Novel strategies are being developed to treat and recondition injured donor lungs. EVLP may also prove to be a tool for translational research of lung diseases. SUMMARY: EVLP has been shown to be an effective system to expand donor pool for lung transplantation without detriment to recipients. Future potential ex-vivo developments may further improve patient outcomes as well as increasing availability of donor organs.

The Evolving Role of Extracorporeal Membrane Oxygenation in Lung Transplantation: Implications for Anesthetic Management.

Lung transplantation has become an accepted therapy for most causes of end-stage lung disease. Between 30 to 50% of lung transplants require extracorporeal life support (ECLS). In many lung transplantation centers, extracorporeal membrane oxygenation (ECMO) is replacing cardiopulmonary bypass (CPB) as the primary choice for intraoperative ECLS. This review will discuss the evolving role of ECMO in lung transplantation and its implications for anesthetic management.