Positive Bubble Study But No Evidence of Interatrial Defect in a Patient with Recurrent Cryptogenic Stroke.

Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.

Supraglottic airway versus endotracheal tube for transesophageal echocardiography guided watchman procedures.

Context: Atrial fibrillation (AF) is the most common arrhythmia in adults. For over 90% of non-valvular AF patients, the left atrial appendage is the primary site of thrombus formation. Left atrial appendage occlusion using the FDA-approved Watchman™ device has been shown to have better clinical outcomes with minimal post-procedural complications when compared to warfarin therapy for patients with contraindications to anticoagulation. Traditionally, this procedure requires an endotracheal tube (ETT) to facilitate transesophageal echocardiography (TEE) guidance. However, recently supraglottic airway (SGA) has emerged as a feasible, non-inferior alternative to ETT for procedures requiring TEE. Aims: Compare outcomes between TEE guided Watchman™ procedures performed with a SGA versus ETT. Settings and Design: A single tertiary care academic medical center. Methods and Materials: Retrospective Observational Study comparing SGA and ETT patients. Statistical Analysis Used: 1:4 propensity score matching of SGA and ETT patients. Results: 42 SGA patients were matched with 155 ETT patients. All patients underwent procedure with TEE. SGA patients had shorter operating room time (11 min difference, P = 0.00001) and considerably shorter PACU length of stays (45 min difference, P = 0.024). Statistically significant, but clinically trivial differences were seen in procedure times (P = 0.015) and fluoroscopy times (P = 0.017). Patients in the SGA group received lower fentanyl (P < 0.00001) dosages. No significant differences were observed in postoperative complications, organ-specific morbidity or 30-day mortality. Conclusions: General anesthesia with SGA is likely a safe, feasible alternative to ETT in Watchman™ procedures requiring TEE guidance. Use of SGA was associated with significant reductions in operating room time and PACU length of stay, potentially offering advantages in terms of resource utilization.

Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation.

OBJECTIVE: Surgical aortic valve replacement requires a comprehensive transoesophageal echocardiography (TEE) assessment before and after the intervention by cardiac anaesthesiologists. For patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI), TEE is not routinely used. We started using transthoracic echocardiography (TTE) as a diagnostic and monitoring modality during TF-TAVI procedures. The aim of this study is to examine the usefulness of TTE before and after TF-TAVI. We hypothesised that TTE can serve as a screening tool in TF-TAVI patients and help rule out significant paravalvular leaks (PVLs), and serve as a monitoring tool. METHODS: A retrospective, observational study of 24 patients who underwent TF-TAVI with perioperative TTE over a 3-month period was conducted. Intraoperatively, two TTE examinations were performed. The first was a baseline pre-procedural TTE examination after anaesthetic induction, and the second was performed after TAVI valve implantation. Both pre- and post-procedural examinations included five focused TTE views. PVLs were graded as none, non-significant (trace or mild) or significant (moderate or severe). RESULTS: The average age and median body mass index of the patients were 82 years and 28.5 kg m-2, respectively. The average time recorded for the pre- and post-TAVI TTE examinations were approximately 4 and 5.5 min, respectively. Non-significant PVL was detected in 6 (25%) patients, and no leak was detected in 18 (75%) patients. CONCLUSION: A focused TTE examination was found to be a useful adjunct during TF-TAVI for a cardiac anaesthesiologist in the absence of TEE, and useful in ruling out significant PVLs.

Acute Right Ventricular Failure Postintubation in a Mitral Stenosis Patient.

Mitral stenosis (MS) is prevalent in 0.02-0.2% of the population in developed countries. The pathophysiology of MS results in elevated left atrial pressures and over-time results in pulmonary hypertension (HTN) which ultimately affects the right ventricle. In addition, MS restricts the diastolic filling of the left ventricle. Therefore, during induction patients with MS are limited by their ability to increase cardiac output by increasing stroke volume. Anesthesia goals in severe MS are to avoid sudden changes in heart rate, as well as systemic and pulmonary artery pressures. We report a patient who sustained severe hypotension upon induction and intubation which was resistant to conventional medications. Intraoperative transesophageal echocardiography displayed unique right atrial and right ventricular dilatation. In addition, the leftward inter-ventricular, inter-atrial septal shift and septal bounce were noted as the characteristic findings. Intravenous epinephrine bolus was administered to achieve normo-tension and normal chamber dimensions and interventricular septal position.

Patient Selection and Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed with Monitored Anesthesia Care Versus General Anesthesia.

OBJECTIVE: The aim of this study was to compare outcomes of monitored anesthesia care (MAC) versus general anesthesia (GA) for transfemoral transcatheter aortic valve replacement (TF-TAVR) and to describe a selection process for the administration of MAC. DESIGN: Retrospective analysis of patients who underwent TF-TAVR under MAC or GA. SETTING: Department of Cardiac Anesthesia, Albany Medical Center, a tertiary university hospital. PARTICIPANTS: Patients selected for TF-TAVR. INTERVENTIONS: Patients were divided into those who underwent MAC and those who underwent GA. MEASUREMENTS AND MAIN RESULTS: The study comprised 104 consecutive patients (55% male, mean age 83 years) who underwent TF-TAVR under MAC (n = 60) or GA (n = 37) from 2014 to 2015. Seven patients were converted from MAC to GA and were omitted from analysis. There was no statistically significant difference between 30-day mortality and complications between the 2 groups. The MAC group had a significantly shorter median intensive care unit length of stay (48 h v 74 h, p = 0.0002). The MAC group also demonstrated reduced procedural time (45.5 min v 62 min, p = 0.003); operating room time (111 min v 153 min, p = <0.001); and fluoroscopy time (650 s v 690 s, p = 0.03). CONCLUSIONS: Patient selection for TF-TAVR with MAC can be formalized and implemented successfully. MAC allows for the minimizing of patient exposure to unnecessary interventions and improving resource utilization in suitable TAVR patients. Selection requires a multidisciplinary clinical decision-making process. MAC demonstrates good outcomes compared with GA, yet it is important to have a cardiac anesthesiologist present in the event of emergency conversion to GA.