Recovery and safety with prolonged high-frequency jet ventilation for catheter ablation of atrial fibrillation: A hospital registry study from a New England healthcare network.

STUDY OBJECTIVE: To investigate post-procedural recovery as well as peri-procedural respiratory and hemodynamic safety parameters with prolonged use of high-frequency jet ventilation (HFJV) versus conventional ventilation in patients undergoing catheter ablation for atrial fibrillation. DESIGN: Hospital registry study. SETTING: Tertiary academic teaching hospital in New England. PATIENTS: 1822 patients aged 18 years and older undergoing catheter ablation between January 2013 and June 2020. INTERVENTIONS: HFJV versus conventional mechanical ventilation. MEASUREMENTS: The primary outcome was post-anesthesia care unit (PACU) length of stay. In secondary analyses we assessed the effect of HFJV on intra-procedural hypoxemia, defined as the occurrence of peripheral hemoglobin oxygen saturation (SpO2) <90%, post-procedural respiratory complications (PRC) as well as intra-procedural hypocarbia and hypotension. Multivariable negative binomial and logistic regression analyses, adjusted for patient and procedural characteristics, were applied. MAIN RESULTS: 1157 patients (63%) received HFJV for a median (interquartile range [IQR]) duration of 307 (253-360) minutes. The median (IQR) length of stay in the PACU was 244 (172-370) minutes in patients who underwent ablation with conventional mechanical ventilation and 226 (163-361) minutes in patients receiving HFJV. In adjusted analyses, patients undergoing HFJV had a longer PACU length of stay (adjusted absolute difference: 37.7 min; 95% confidence interval [CI] 9.7-65.8; p = 0.008). There was a higher risk of intra-procedural hypocarbia (adjusted odds ratio [ORadj] 5.90; 95%CI 2.63-13.23; p < 0.001) and hypotension (ORadj 1.88; 95%CI 1.31-2.72; p = 0.001) in patients undergoing HFJV. No association was found between the use of HFJV and intra-procedural hypoxemia or PRC (p = 0.51, and p = 0.97, respectively). CONCLUSION: After confounder adjustment, HFJV for catheter ablation procedures for treatment of atrial fibrillation was associated with a longer length of stay in the PACU. It was further associated with an increased risk of intra-procedural abnormalities including abnormal carbon dioxide homeostasis, as well as intra-procedural arterial hypotension.

Transcatheter mitral valve implantation: Implications of interventional technique and 3D echocardiography for complex valve-in-valve paravalvular leak.

Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to surgical reoperation in failed bioprostheses and rings. Residual mitral regurgitation following TMVR can present as a valve-in-valve paravalvular leak (PVL) and is associated with increased morbidity and mortality. Current therapies for valve-in-valve PVL are limited. We present a case of a symptomatic patient with severe valve-in-valve PVL after TMVR for a previous surgical bioprosthesis leak, who then underwent a second TMVR as a valve-in-valve-in-valve implantation with a 29 mm Edwards® SAPIEN 3 valve via transseptal approach using three-dimensional (3D) echocardiography. This unique case highlights the complexity of this clinical entity and recognizes 3D transesophageal echocardiography as a valuable tool to guide valve-in-valve PVL closures.

Curriculum for Subspecialty Anesthesia Training in Adult Structural Heart Disease Imaging: A Single-Center Experience.

Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging.

The Many Faces of the Interatrial Septum: A Diagnostic Dilemma and Considerations for Defect Closure Device Selection.

PATENT FORAMEN ovales (PFOs) and atrial septal defects (ASDs) are 2 examples of interatrial septal pathology.1 The presence of a PFO is a well-known risk factor for cryptogenic stroke.1,2 Newer evidence over the course of the last decade suggests percutaneous device closure of PFOs significantly reduces the subsequent risk of recurrent stroke.2 Among ASDs, the ostium secundum type is the most common pathology and, due to its anatomy, is most amenable to transcatheter closure.1 The tools that are available to percutaneously close these different pathologies vary, and choosing the correct device for the procedure can have significant impact on the clinical outcome. The authors here present a case that highlights how the differentiation of an ASD from a PFO using 2-dimensional (2D) and 3-dimensional (3D) echocardiography can affect the clinical decision-making and outcome in a challenging structural heart disease case.

Hemodynamic intolerance and pericardial effusion associated with high-frequency jet ventilation during pulmonary vein isolation.

BACKGROUND: High-frequency jet ventilation (HFJV) is used during pulmonary vein isolation (PVI) to increase catheter stability and improve outcomes. In prior studies, hemodynamic intolerance to HFJV was rare. OBJECTIVES: To evaluate the incidence of hemodynamic or respiratory intolerance of HFJV during PVI. METHODS: Retrospective observational analysis of consecutive patients undergoing PVI performed by 2 operators (PT, JW) at our institution between February 2019 and June 2020 who developed persistent hypotension or abnormal ventilatory parameters in association with HFJV. RESULTS: Among 194 PVIs, there were 8 cases (4%) of conversion from HFJV to conventional ventilation, 6 for refractory hypotension and 2 for persistently abnormal gas exchange. In 6 patients, including 5 of the 6 patients with refractory hypotension, a new, small pericardial effusion without tamponade was noted just after HFJV was initiated. In patients with persistent hypotension, a decrease in left ventricular filling and systolic function was frequently noted. Both the hemodynamic changes and effusion resolved almost immediately after discontinuation of HFJV. In 4 patients rechallenged with HFJV, the hypotension and/or effusion recurred quickly and again resolved immediately after return to conventional ventilation. CONCLUSION: HFJV-associated hypotension and systolic dysfunction, often accompanied by a transient pericardial effusion, is present in a small proportion of patients undergoing PVI, and resolves with cessation of HFJV. The mechanism of these changes is unclear and warrants further study.

Development of an Instrument for Preoperative Prediction of Adverse Discharge in Patients Scheduled for Cardiac Surgery.

OBJECTIVE: Inability of home discharge occurs in nearly a third of patients undergoing cardiac surgery and is associated with increased mortality. The authors aimed to evaluate the incidence and risk factors for adverse discharge disposition (ADD) after cardiac surgery and develop a prediction tool for preoperative risk assessment. DESIGN: This retrospective cohort study included adult patients undergoing cardiac surgery between 2010 and 2018. The primary outcome was ADD, defined as in-hospital mortality, discharge to a skilled nursing facility, or transfer to a long-term care hospital. The authors created a prediction tool using stepwise backward logistic regression and used 5-fold and leave-one-out cross-validation. SETTING: University hospital network. PARTICIPANTS: Adult patients living at home prior to surgery, who underwent coronary artery bypass grafting and/or valve procedures at the authors' institution. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 3,760 patients were included in the final study cohort. The observed rate of ADD was 33.3%. The prediction model showed good discrimination and accuracy, with C-statistic of 0.78 (95% confidence interval [CI] 0.76-0.79) and unmodified Brier score of 0.177 (reliability 0.001). The final model comprised 14 predictors. Patients who experienced ADD were more likely to be older, of female sex, to have had higher length of hospital stay prior to surgery, and to have undergone emergency surgery. CONCLUSIONS: The authors present an instrument for prediction of loss of the ability to live independently in patients undergoing cardiac surgery. The authors' score may be useful in identifying high-risk patients such that earlier coordination of care can be initiated in this vulnerable patient population.

Artificial Intelligence for Dynamic Echocardiographic Tricuspid Valve Analysis: A New Tool in Echocardiography.

There has been a resurgence of interest in the structure and function of the tricuspid valve (TV) with the established prognostic impact of functional tricuspid regurgitation. Current 3-dimensional transesophageal echocardiography prototype software is limited to exploration of the mitral and aortic valves exclusively. Thus, newer analytical software is required for dynamic geometric analysis of the TV morphology for remodeling. This article presents a preliminary experience with novel artificial intelligence-based semiautomated software for TV analysis. The software offers high correlation to surgical inspection by its ability to analyze morphology and dynamics of the valve throughout the cardiac cycle. In addition, it allows higher reproducibility of data analysis and reduces interobserver variability with minimal need for manual intervention. Integration of interactivity through preprocedural placement of specific devices of different sizes and shapes in the mitral and aortic positions facilitates prognostic evaluation of surgical and interventional procedures.

Clinical utility of surveillance and clinically prompted right heart catheterization in patients listed for heart transplantation.

BACKGROUND AND OBJECTIVES: The 2016 ISHLT guidelines recommend that patients listed for orthotopic heart transplantation (OHT) undergo periodic surveillance right heart catheterization (RHC) to re-assess hemodynamics (Class I, level of evidence C). However, the impact of RHC on management remains unclear. The aim of this study was to determine the utility of both surveillance and clinically prompted RHCs in patients listed for OHT. METHODS: A retrospective study was conducted in adult patients listed for OHT at our hospital from 2006 through 2014. Each patient included had at least one RHC after being listed for OHT. The primary outcome was management change: hospitalization, surgery (OHT or mechanical circulatory support [MCS]), change in United Network for Organ Sharing (UNOS) status, or initiation/modification of vasoactive drugs, diuretics or neurohormonal blockade. RESULTS: Of the 194 patients included, 85 (43%) patients had more than one RHC. The median time between listing and transplantation was 115 days. Of the 376 RHCs performed, 187 (50%) were prompted by a clinical change; 189 (50%) were performed for surveillance. In 90.4% of clinically prompted RHCs and 42.9% of surveillance RHCs, a clinically important management change was implemented. Initiation/modification of vasoactive drugs, placement of MCS and/or change in UNOS transplant status occurred in 61 (33%) of the clinically prompted RHCs and 26 (14%) of the surveillance RHCs. Patients who underwent management change were more likely to receive a heart transplant (HR 1.58; CI 1.15-2.18) without an increased rate of death over the study period compared to those who did not have a management change. Multivariable analysis revealed that a hemoglobin level <12.2 g/dL (OR 2.96; CI 1.36-6.42) and a total bilirubin level >0.9 mg/dL (OR 5.07; CI 2.09-12.3) were predictors of management change. CONCLUSIONS: In patients awaiting OHT, RHCs prompted by clinical instability or routine surveillance resulted in frequent management changes, including earlier heart transplant and MCS implant. Our study supports the Class I recommendation to perform surveillance RHC in patients listed for OHT and suggests that centers should consider maintaining a low threshold for repeat RHC during the formal waiting time.

Klippel-Feil syndrome: A very unusual cause of severe aortic regurgitation visualized by multimodality imaging.

A 51-year-old man with Klippel-Feil syndrome (KFS) and immunodeficiency syndrome, status postintravenous immunoglobulin therapy, presented with shortness of breath. He was found to have severe aortic regurgitation in the setting of a trileaflet aortic valve with thickened leaflets and mild prolapse of the right coronary cusp with left ventricular dilation and borderline left ventricular ejection fraction. Although various cardiac anomalies have been described in KPS, otherwise unexplained severe aortic regurgitation has not been previously reported to the best of our knowledge. The patient underwent an uncomplicated surgical aortic valve replacement with a 25-mm Medtronic Avalus pericardial tissue valve resulting in symptomatic improvement. Intra-operative management and transesophageal echocardiography can be particularly challenging in KFS patients. We describe the first reported case of severe aortic regurgitation in KPS, review the cardiac anomalies associated with the syndrome, and highlight the clinical challenges in intra-operative management of these patients.

A Comparison of Inflammatory Responses Between Robotically Enhanced Coronary Artery Bypass Grafting and Conventional Coronary Artery Bypass Grafting: Implications for Hybrid Revascularization.

OBJECTIVE: The inflammatory response elicited by robotically enhanced coronary artery bypass grafting (r-CABG) has not been well described. When r-CABG is performed as part of hybrid coronary revascularization, the inflammatory milieu and the timing of percutaneous coronary intervention may affect the stent patency negatively in the short and long term. The goal of this study was to describe the extent and time course of cytokine release after r-CABG compared with conventional CABG (c-CABG) and to elucidate the optimal timing for r-CABG in the setting of hybrid coronary revascularization for a future study. DESIGN: Prospective, observational study. SETTING: Tertiary-care center in a university hospital. PARTICIPANTS: The study comprised patients scheduled to undergo r-CABG or c-CABG from October 2012 to November 2014. INTERVENTIONS: Cytokine levels of interleukin (IL)-6, IL-8, IL-10; tumor necrosis factor-α; and C-reactive protein (CRP) were measured at the following time points: preprocedure; at the end of the procedure; and at 4, 8, 12, 24, and 48 hours after the procedure. MEASUREMENTS AND MAIN RESULTS: Twenty-eight patients undergoing r-CABG and 10 patients undergoing c-CABG were enrolled. The levels of cytokines after r-CABG and c-CABG were compared using the mixed-effect linear regression model for longitudinal data. Cytokine release in the r-CABG group was comparatively less for IL-6, IL-10, tumor necrosis factor, and CRP levels. They all trended toward the baseline by the 48th hour in both groups, except CRP levels, which reached their peak at 48 hours in both groups. CONCLUSIONS: The inflammatory response to r-CABG was blunted compared with that of c-CABG. The high CRP levels on the second postoperative day after r-CABG were a cause for concern in regard to percutaneous coronary intervention performed at that time period, but additional studies are necessary.

Successful MitraClip Transcatheter Mitral Valve Repair in the Setting of an Interatrial Mass.

MitraClip procedure is an emerging minimally invasive technique for patients with severe mitral regurgitation (MR) who are at high risk for surgery. Transseptal puncture is a key step in MitraClip procedure that is usually performed superiorly and posteriorly in the interatrial septum for optimal MitraClip placement. The presence of interatrial masses such as patent foramen ovale closure device or thrombus makes transeptal puncture more challenging. Safety and efficacy of MitraClip transcatheter mitral valve repair in the presence of intracardiac masses have not been described in the literature. This case describes a 65-year-old woman deemed high-risk for surgery, with symptomatic, severe primary MR and an unusual interatrial mass who underwent a successful MitraClip procedure with the use of three-dimensional (3-D) transesophageal echocardiography (TEE).

Medication errors in anesthesia: unacceptable or unavoidable? / Erros de medicação em anestesia: inaceitável ou inevitável?

Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Resumo Os erros de medicação são as causas mais comuns de morbidade e mortalidade dos pacientes. Além disso, esses erros aumentam os encargos financeiros da instituição. Embora o impacto varie de nenhum dano a efeitos adversos graves, inclusive o óbito, é preciso estar atento à ordem de prioridades porque os erros de medicação são evitáveis. Na atualidade, com as pessoas cientes e os processos médicos em evidência, frear esse problema é de extrema prioridade. O esforço individual para diminuir os erros de medicação pode não obter sucesso até que uma mudança nos protocolos e sistemas existentes seja incorporada. Muitas vezes, os erros de medicação ocorridos não podem ser revertidos. A melhor maneira de "tratar" esses erros é impedi-los. Os erros de medicação (devido à troca de seringa), de overdose (devido a mal-entendido ou preconcepção da dose, mal uso de bomba e erro de diluição), de via de administração incorreta, de subdosagem e de omissão são causas comuns de erro de medicação que ocorrem no período perioperatório. A omissão e erros no cálculo de medicamentos ocorrem comumente em UTI. Os erros de medicação podem ocorrer no período perioperatório, tanto durante a preparação e administração quanto na manutenção de registros. Um grande número de erros humanos e do sistema pode ser responsabilizado pela ocorrência de erros de medicação. A necessidade do momento é parar o jogo da culpa, aceitar os erros e desenvolver uma cultura segura e "justa" para evitar os erros de medicação. Os sistemas recém-criados, como o Veinrom, um sistema de administração de líquidos, é uma nova abordagem na prevenção de erros de medicação devido aos medicamentos mais comumente usados em anestesia. Desenvolvimentos semelhantes, juntamente com médicos vigilantes, uma cultura de local de trabalho seguro e apoio organizacional, todos em conjunto podem ajudar a evitar esses erros.

Medication errors in anesthesia: unacceptable or unavoidable?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

[Medication errors in anesthesia: unacceptable or unavoidable?] / Erros de medicação em anestesia: inaceitável ou inevitável?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Near-Infrared Spectroscopy: The New Must Have Tool in the Intensive Care Unit?

Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit. Currently, NIRS in the critical care setting is predominantly being used for infants and neonates. A number of studies in the past decade have shown promising results for the use of NIRS in surgical/trauma intensive care units during shock management as a prognostic tool and in guiding resuscitation. It is evident that over the past 2 decades, NIRS has gone from being a laboratory fascination to an actively employed clinical tool. Even though the benefit of routine use of this technology to achieve better outcomes is still questionable, the fact that NIRS is a low-cost, noninvasive monitoring modality improves the attractiveness of the technology. However, more research may be warranted before recommending its routine use in the critical care setting.

Anomalous Coronary Artery: Run of a Lifetime.

The anatomy of the coronary circulation is well described with incidence of congenital anomalies of approximately 0.3% to 1.0%. Although often incidental, 20% are life-threatening. A 25-year-old woman with syncopal episodes collapsed following a 10-km run. Coronary anatomy evaluation showed an anomalous left main coronary artery originating from the right sinus of valsalva and following a course between the aorta and the pulmonary outflow tract. Percutaneous coronary intervention was followed by eventual surgical revascularization. Abnormal course of coronary arteries plays a role in the pathogenesis of sudden death on exertion. Origin of the left main coronary from the right sinus of valsalva is a rare congenital anomaly. The expansion of the roots of the aorta and pulmonary trunk with exertion lead to compression of the coronary artery and syncope. Our patient raises awareness of a potentially fatal coronary artery path. Intraoperative identification of anomalous coronaries by utilizing intraoperative transesophageal echocardiography was critical.

Comparison of Index Hospitalization Costs Between Robotic CABG and Conventional CABG: Implications for Hybrid Coronary Revascularization.

OBJECTIVES: To compare the direct costs of the index hospitalization and 30-day morbidity and mortality incurred during robotic and conventional coronary artery bypass grafting at a single institution based on hospital clinical and financial records. DESIGN: Retrospective study, propensity-matched groups with one-to-one nearest neighbor matching. SETTING: University hospital, a tertiary care center. PARTICIPANTS: Two thousand eighty-eight consecutive patients who underwent primary coronary artery bypass grafting (CABG) from January 2007 to March 2012. INTERVENTIONS: One hundred forty-one matched pairs were created and analyzed. MEASUREMENTS AND MAIN RESULTS: Robotic CABG was associated with a decrease in operative time (5.61±1.1 v 6.6±1.15 hours, p<0.001), a lower need for blood transfusion (12.8% v 22.6%, p = 0.04), a shorter length of stay (6 [4-9]) v 7 [5-11] days, p = 0.001), a shorter ICU stay (31 [24-49] hours v 52 [32-96.5] hours, p<0.001) and lower NY state complications composite rate (4.26% v 13.48%, p = 0.01). In spite of that, the cost of robotic procedures was not significantly different from matched conventional cases ($18,717.35 [11,316.1-34,550.6] versus $18,601 [13,137-50,194.75], p = 0.13), except 26 hybrid coronary revascularizations in which angioplasty was performed on the same admission (hybrid 25,311.1 [18,537.1-41,167.85] versus conventional 18,966.13 [13,337.75-56,021.75], p = 0.02). CONCLUSION: Robotically assisted CABG does not increase the cost of the index hospitalization when compared to conventional CABG unless hybrid revascularization is performed on the same admission.

HeartWare Ventricular Assist Device Placement in a Patient With Corrected Dextro-Transposition of Great Arteries: A Case Report and Its Clinical Challenges.

Given the improved survival in patients with corrected dextro-transposition of great arteries (D-TGA), it has evolved into an adult congenital heart defect. It is important to understand the management and complications observed in this population that eventually progresses to systemic ventricular failure requiring cardiac transplantation. Our case focuses on the rapid right ventricle (RV) deterioration of a patient with corrected D-TGA following a surgical procedure requiring systemic support. With such patients awaiting heart transplantation, there are limited assist devices available for RV support and no right ventricular assist device is approved for destination therapy yet. Current indications for implantation of the HeartWare ventricular assist device (HVAD) are limited by the Food and Drug Administration (FDA) to the left ventricle support as a bridge to transplantation. However, its use in the United States for right-sided support has rarely been described for adult congenital defects. In this case, a HeartWare assist device was used to provide systemic support as a bridge to cardiac transplant. The size and implantation design of the HVAD makes it a promising option for patients with this challenging patient population and RV failure as a late complication.

Intraoperative management of carotid endarterectomy.

First reports on surgical treatment of cerebrovascular atherosclerosis date to the early 1950s. With advancements in surgical technique, carotid endarterectomy (CEA) has become the treatment of choice for patients with both symptomatic and asymptomatic severe carotid stenosis. Given the benefits that surgery offers beyond medical management, the number of CEA procedures continues to increase. The intraoperative management of patients undergoing CEA is challenging because of the combination of patient and surgical factors. This article explores and reviews the literature on anesthetic management and considerations of patients undergoing CEA.

Thoracic anesthesia and cross field ventilation for tracheobronchial injuries: a challenge for anesthesiologists.

Tracheobronchial injuries are rare but life threatening sequel of blunt chest trauma. Due to the difficult nature of these injuries and the demanding attributes of the involved surgery, the anesthesiologist faces tough challenges while securing the airway, controlling oxygenation, undertaking one-lung ventilation, maintaining anesthesia during tracheal reconstruction, and gaining adequate postoperative pain control. Amongst the few techniques that can be used with tracheobronchial injuries, cross field ventilation is a remotely described and rarely used technique, especially in injuries around the carina. We effectively applied cross field ventilation in both our cases and the outcome was excellent.