Assuntos
Aorta/cirurgia , Valva Aórtica/cirurgia , Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Parada Cardíaca Induzida/métodos , Testemunhas de Jeová , Esternotomia/métodos , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Aorta/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Perda Sanguínea Cirúrgica/prevenção & controle , Parada Cardíaca Induzida/efeitos adversos , Humanos , Masculino , Reoperação/efeitos adversos , Reoperação/métodos , Esternotomia/efeitos adversos , Resultado do TratamentoRESUMO
Left ventricular assist device (LVAD) insertion is an increasingly common treatment of advanced heart failure. Insertion guidelines suggest regurgitant lesions of the mitral valve should not be addressed. However, recent evidence suggests that mitral regurgitation may not necessarily improve with LVAD insertion, and such patients may have worse outcomes. Thus, practice variability is high given the discrepancy between traditional thinking and new evidence that unrepaired mitral regurgitation may increase perioperative mortality. Additionally, the challenges of LVADs can make transesophageal echocardiography evaluation and assessment of mitral valve pathology difficult.
Assuntos
Coração Auxiliar , Insuficiência da Valva Mitral/terapia , Ecocardiografia Transesofagiana/métodos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Insuficiência da Valva Mitral/patologiaRESUMO
BACKGROUND: Acute kidney injury (AKI) is a common serious complication after cardiac surgery. Doppler-determined renal resistive index (RRI) is a promising early AKI biomarker in this population. However, the relationship between aortic valve pathology (insufficiency and/or stenosis) and RRI is unknown. This study aimed to investigate RRI variability related to aortic valve pathology. METHODS: In a retrospective review of cardiac surgery patients, RRI and aortic valve pathology were assessed prior to cardiopulmonary bypass using transesophageal echocardiography. Aortic valve status was categorized into four subgroups: normal (insufficiency and stenosis, none/trace/mild), insufficiency (insufficiency, moderate/severe; stenosis, none/trace/mild), combined insufficiency/stenosis (insufficiency and stenosis, moderate/severe), or stenosis (insufficiency, none/trace/mild; stenosis, moderate/severe). RRI and time-matched hemodynamic and Doppler measurements were compared among subgroups. RESULTS: Of 175 patients, 60 had aortic valve pathology (16 insufficiency, 18 insufficiency/stenosis, 26 stenosis). Compared with the normal subgroup, patients with aortic insufficiency had lower diastolic blood pressure and trough renal Doppler velocities, and higher RRI (0.77 versus 0.69; p < 0.001); patients with combined insufficiency/stenosis also had higher RRI (0.72 versus 0.69, p = 0.042). CONCLUSIONS: Patients with aortic insufficiency and combined insufficiency/stenosis had higher median RRI values compared with normal patients. For these individuals, diastolic flow differences related to aortic insufficiency may explain why their presurgery RRI values often exceeded postoperative thresholds typically associated with AKI. Strategies to account for the potentially confounding effects of aortic insufficiency on renal flow patterns, independent of renal injury, may add to the value of RRI as an early AKI biomarker.
Assuntos
Injúria Renal Aguda/etiologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Resistência Vascular/fisiologia , Injúria Renal Aguda/diagnóstico por imagem , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/fisiopatologia , Fatores Etários , Idoso , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Biomarcadores/análise , Velocidade do Fluxo Sanguíneo/fisiologia , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Análise de Sobrevida , Ultrassonografia Doppler/métodosRESUMO
We present a case series of seven patients with suspected cold agglutinin antibodies, discovered after initiation of bypass. Laboratory analysis of blood samples intraoperatively determined the cause of the aggregation to be rouleaux formation in three of the patients and cold agglutinins in the other four.
Assuntos
Agregação Eritrocítica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Crioglobulinas/fisiologia , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Stents/efeitos adversos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Feminino , Humanos , Substituição da Valva Aórtica Transcateter/tendênciasAssuntos
Ponte Cardiopulmonar/métodos , Temperatura Baixa , Seio Coronário/cirurgia , Estenose Coronária/sangue , Complicações Intraoperatórias/sangue , Idoso , Ponte Cardiopulmonar/efeitos adversos , Seio Coronário/patologia , Estenose Coronária/diagnóstico , Crioglobulinas/metabolismo , Humanos , Complicações Intraoperatórias/diagnóstico , MasculinoRESUMO
Surgical patients with pulmonary hypertension present a significant challenge to the anesthesiologist. Continuous perioperative monitoring of pulmonary artery (PA) pressure is recommended and most often accomplished with a PA catheter. Placement of a PA catheter may be difficult or contraindicated, and in these cases, transesophageal echocardiography is a useful alternative to monitor dynamic PA physiology. In this case, we used intraoperative transesophageal echocardiography to detect changes in peak PA pressure and guide clinical treatment in a patient with pulmonary hypertension and an extensive PA aneurysm undergoing partial nephrectomy.
Assuntos
Aneurisma/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Monitorização Intraoperatória/métodos , Nefrectomia/métodos , Artéria Pulmonar/diagnóstico por imagem , Aneurisma/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Artéria Pulmonar/cirurgiaRESUMO
The presence of cold agglutinins (CA) during cardiac surgery with cardiopulmonary bypass usually creates the need for an altered surgical plan. In this case, the CA were discovered after the initiation of bypass, limiting the time, and cardioplegia solutions that could be used in the new approach. The inability to cannulate the coronary sinus with a retrograde cardioplegia catheter excluded the standard approach to myocardial preservation with CA of using continuous warm blood. For this case, we used intermittent cold crystalloid delivered via the antegrade needle for the first half of the procedure and through the saphenous vein graft anastomosis during the aortic valve portion of the cross-clamp period.
Assuntos
Seio Coronário , Autoanticorpos , Soluções Cardioplégicas , Ponte de Artéria Coronária , Parada Cardíaca Induzida , HumanosAssuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Estenose da Valva Mitral/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Feminino , Hemodinâmica , Humanos , Interpretação de Imagem Assistida por Computador , Período Intraoperatório , Pessoa de Meia-Idade , Valva Mitral/fisiopatologia , Valva Mitral/cirurgia , Estenose da Valva Mitral/fisiopatologia , Estenose da Valva Mitral/cirurgia , Valor Preditivo dos Testes , Índice de Gravidade de DoençaRESUMO
Introduced in 1977, transesophageal echocardiography (TEE) offered imaging through a new acoustic window sitting directly behind the heart, allowing improved evaluation of many cardiac conditions. Shortly thereafter, TEE was applied to the intraoperative environment, as investigators quickly recognized that continuous cardiac evaluation and monitoring during surgery, particularly cardiac operations, were now possible. Among the many applications for perioperative TEE, this review will focus on four recent advances: three-dimensional TEE imaging, continuous TEE monitoring in the intensive care unit, strain imaging, and assessment of diastolic ventricular function.
Assuntos
Ponte Cardiopulmonar/métodos , Soluções para Diálise/metabolismo , Hemofiltração/métodos , Falência Renal Crônica/sangue , Peptídeos/sangue , Diálise Renal/métodos , Soluções para Diálise/administração & dosagem , Eptifibatida , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Soluções Farmacêuticas/administração & dosagem , UltrafiltraçãoAssuntos
Cateterismo Cardíaco/métodos , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Implante de Prótese de Valva Cardíaca/métodos , Estenose da Valva Mitral/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Sistemas Computacionais , Humanos , Masculino , Estenose da Valva Mitral/cirurgia , Índice de Gravidade de DoençaRESUMO
Avoiding or managing hyperkalemia during cardiac surgery, especially in a patient with chronic renal insufficiency, can be challenging. Hyperkalemic cardioplegia solution is usually administered to achieve and maintain an electrical arrest of the heart. This solution eventually mixes in with the systemic circulation, contributing to elevated systemic potassium levels. Administration of packed red blood cells, hemolysis, tissue damage, and acidosis are also common causes of hyperkalemia. Current strategies to avoid or manage hyperkalemia include minimizing the volume of cardioplegia administered, shifting potassium from the extracellular into the intracellular space (by the administration of sodium bicarbonate when the pH is low and/or dextrose-insulin when effects relatively independent of serum pH are desired), using zero-balanced ultrafiltration (Z-BUF) with normal saline as the replacement fluid (to remove potassium from the body rather than simply shift the electrolyte across cellular membranes), and, occasionally, hemodialysis (1). We report the application of Z-BUF using an electrolyte-balanced, low potassium dialysate solution rather than isotonic saline to avoid a high chloride load and the potential for hyperchloremic acidosis to successfully treat hyperkalemia while on cardiopulmonary bypass.
Assuntos
Ponte Cardiopulmonar/métodos , Hemofiltração/métodos , Hiperpotassemia/terapia , Parada Cardíaca Induzida/métodos , Humanos , Hiperpotassemia/sangue , Hiperpotassemia/fisiopatologia , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/fisiopatologiaRESUMO
PURPOSE OF REVIEW: This review examines recent advances and findings in the field of pain management in patients undergoing thoracic surgery. RECENT FINDINGS: Acute and chronic postoperative pain continues to remain a major problem and a primary concern for patients. Although thoracic epidural analgesia is still considered a 'gold standard', more evidence exists that paravertebral blockade has similar efficacy with a better side-effect and safety profile. The cornerstone of pain management remains a multimodal therapeutic strategy that provides both a central and a peripheral block by combining regional techniques with opioid and nonopioid analgesics. SUMMARY: Pain after thoracic surgery has a profound impact on perioperative outcome. Beyond the immediate perioperative period, acute pain contributes to the development of the debilitating chronic pain syndrome. Going forward, both procedural and pharmacologic interventions for acute and chronic pain should be studied in definitive multicenter, well designed randomized clinical trials.
Assuntos
Dor Aguda/terapia , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Anestesia por Condução , Humanos , Bloqueio Nervoso , Medição da Dor , Procedimentos Cirúrgicos Torácicos/métodosRESUMO
BACKGROUND: Cardiac resynchronization therapy using a left ventricular (LV) lead inserted via the coronary sinus (CS) improves symptoms of congestive heart failure, decreases hospitalizations, and improves survival. An epicardial LV lead is often placed surgically after a failed percutaneous attempt, but whether it offers the same benefits is unknown. OBJECTIVE: The purpose of this study was to determine if patients who receive a surgical LV lead after failed CS lead placement for cardiac resynchronization therapy derive the same benefit as do patients with a successfully placed CS lead. METHODS: A total of 452 patients underwent attempted CS lead insertion. Forty-five patients who had failed CS lead placement and then had surgical LV lead placement were matched with 135 patients who had successful CS lead placement. RESULTS: No major differences in preoperative variables were seen between groups. Postprocedural complications of acute renal injury (26.2% vs 4.9%, P <.001) and infection (11.9% vs 2.4%, P = .03) were more common in the surgical group. Mean long-term follow-up was 32.4 +/- 17.5 months for surgical patients and 39.4 +/- 14.8 months for percutaneous patients. At follow-up, all-cause mortality (30.6% vs 23.8%, P = .22) and readmission for congestive heart failure (26.2% vs 31.5%, P = .53) were similar between surgical and percutaneous groups. Improvement in New York Heart Association functional class (60.1% vs 49.6%, P = .17) was similar between surgical and percutaneous groups. CONCLUSION: Surgical LV lead placement offers functional benefits similar to those of percutaneous placement but with greater risk of perioperative complications, including acute renal failure and infection.