The Swan-Ganz catheter as a teaching tool for the anesthesiologist learning minimally invasive cardiac surgery.

OBJECTIVE: To perform minimally invasive cardiac surgery through the smallest possible wound and with the least number of incisions in the heart or aorta, the necessary cannulations to undergo cardiopulmonary bypass must be done through peripheral vessels. A difficult skill to learn for the cardiac anesthesiologist is how to safely and efficiently position the coronary sinus catheter (Endoplege; Edwards Lifesciences LLC, Irvine, CA USA) required for retrograde cardioplegia administration. METHODS: In patients in whom a Swan-Ganz catheter was inserted as part of the operative management strategy for non-minimally invasive heart surgery, we have been using it as a training tool to learn how to visualize and manipulate right-sided catheters under transesophageal echocardiography. We developed this teaching technique to help hone some of the necessary skills needed to place the Endoplege catheter for minimally invasive cardiac surgery. Manipulation was done with the goal of visualizing the catheter and guiding it into the coronary sinus. For a 4-month period, anesthesia records were retrospectively reviewed. RESULTS: Fifteen patients, for a total of 19 catheter manipulations, were found in whom we had documented the use of the Swan-Ganz catheter and details about the insertion as a training tool. The coronary sinus and the catheter were visualized 100% of the time. The Swan-Ganz catheter was successfully inserted into the coronary sinus in 17 of 19 catheter manipulations. CONCLUSIONS: The Swan-Ganz catheter can be used as a training tool to develop some of the necessary skills to place catheters into the coronary sinus with transesophageal echocardiography guidance.

Cannulation of the middle cardiac vein during MICS.

Coronary sinus cannulation for retrograde cardioplegia administration during cardiac surgery is common practice. Several of the cannulas that are placed by the cardiac surgeon on open procedures are now placed by the cardiac anesthesiologist during minimally invasive cardiac surgery, including the coronary sinus catheter. The understanding of the cardiac venous anatomy is very important during coronary sinus catheter placement. We present a case where a percutaneously placed coronary sinus catheter was inadvertently placed into the middle cardiac vein but detected with the use of fluoroscopy.

Edwards EndoVent as a pacing catheter for minimally invasive aortic valve surgery: a novel approach.

OBJECTIVE: The placement of epicardial pacing wires before weaning from bypass during port-access heart surgery can be difficult or impossible. Sometimes, it is necessary to pacing the patient to wean from bypass, and it is problematic to exchange the Edwards pulmonary vent (EndoVent) for a pace catheter under the drapes. Our objective was to devise an effective means of pacing the patient using the pulmonary vent catheter. METHODS: All patients having aortic valve minimally invasive port-access surgery have a pacing wire deployed through the Edwards EndoVent catheter. We did a retrospective chart analysis of these cases. RESULTS: After reviewing the anesthesia records, we determined that we were able to reliably convert the pulmonary vent catheter, which is beneficial for the surgery, into a pacing catheter before weaning from bypass 100% of the time. The mean pacing threshold current was 1.60 mA with the wire in the right ventricular apex. CONCLUSIONS: We found that in all 25 patients we were able to rapidly convert the vent catheter into a reliable pacing catheter without any complications.

Response to nitric oxide during adult cardiac surgery.

Pulmonary hypertension is associated with significant morbidity and mortality in adult cardiac surgery patients. Inhaled nitric oxide is known to be a selective pulmonary vasodilator in this setting. However, it is not known which cardiac surgery patients benefit most from nitric oxide therapy. This study sought to prospectively determine whether a patient's baseline pulmonary vascular resistance could be used to predict responsiveness to inhaled nitric oxide therapy. Subjects were 30 consecutive cardiac surgery patients with pulmonary hypertension immediately prior to induction of anesthesia. There were 2 study groups: Group 1 (n = 15) had an initial pulmonary vascular resistance between 125 and 300 dyn-s/cm5, while group 2 (n = 15) had an initial pulmonary vascular resistance of greater than 300 dyn-s/cm5. Both groups were empirically treated with inhaled nitric oxide (30 ppm) upon separation from bypass. The conduct of anesthesia, surgery, and cardiopulmonary bypass were controlled. A therapeutic algorithm dictated the use of vasoactive substances for all patients. Heart rate, mean arterial pressure, pulmonary vascular resistance, peripheral vascular resistance, cardiac index, and right ventricular ejection fraction were monitored throughout the operative experience. Patients with a higher initial pulmonary vascular resistance had a significantly greater percent reduction in pulmonary vascular resistance after the initiation of nitric oxide therapy. This study suggests that pulmonary vascular resistance is more dramatically affected by inhaled nitric oxide in cardiac surgery patients with a greater degree of pulmonary hypertension.