Transesophageal Echocardiography in Patients With Magnetic Gastroesophageal Reflux Devices: A Report of 2 Cases.

Magnetic gastroesophageal reflux devices are becoming a common treatment option for reflux refractory to medical therapy. These devices are inserted laparoscopically with successful outcomes; however, patients may still complain of dysphagia after implantation. Echocardiographers may be hesitant to perform transesophageal echocardiography (TEE) in these patients as esophageal surgery and dysphagia represent relative contraindications to performing TEE. However, we present 2 cases where intraoperative TEE was performed in patients with reflux devices without complication or image degradation. The described cases, in addition to a review of the perioperative management of these devices, support the use of TEE in this patient population.

Pulmonary artery sheath hematoma.

Dissection of the ascending aorta (AA) represents a life-threatening condition typically treated by emergent surgical repair. A rare, potential complication of AA dissection is pulmonary artery (PA) sheath hematoma. Due to the presence of a common adventitial layer between the proximal AA and the PA, dissection can propagate between both vessels, potentially compromising the PA lumen. The resultant acute narrowing of the PA lumen may abruptly increase right ventricular (RV) afterload. Recognition of PA sheath hematoma is important; when seen on echocardiography it is suggestive of AA dissection and has the potential to result in RV hypertension and dysfunction if significant PA compression occurs.

Safety and feasibility of transesophageal echocardiography in patients with prior esophageal surgery.

BACKGROUND: Transesophageal echocardiography (TEE) is a specialized form of cardiac ultrasound and has been associated with rare but serious complications. In patients with prior esophageal surgery, the risk of esophageal damage or the inability to perform a comprehensive and successful TEE warrants further evaluation. METHODS: Retrospective study of patients with prior esophageal surgery who underwent TEE between June 21, 2002 and October 15, 2019. Medical and echocardiographic records were reviewed for image quality and procedural complications. Post-procedure complications and 30-day all-cause mortality were collected. Evaluation by gastroenterology (GI), otolaryngology/ear, nose, throat (ENT), or thoracic surgery (TS) within 30 days of TEE was reviewed in detail. RESULTS: Ninety-five patients with prior esophageal surgery underwent 145 TEEs. The most commonly performed esophageal procedures were anti-reflux operations (89%). TEE image quality was degraded in 16% while transgastric imaging was not completed in 37% of cases. A comprehensive TEE was completed in 57% of patients with diagnostic study goals achieved in 96% of cases. Comments describing procedural difficulty were reported in 6% while comments on procedural complications occurred in 1% of cases. Post-procedure complications occurred in 1% of patients including hypotension and unplanned hospital/ICU admission. CONCLUSIONS: Concern for esophageal damage and the inability to perform a comprehensive and diagnostic TEE may limit the usefulness of TEE in patients with prior esophageal surgery. While TEE-associated complications were rare in this series, a conservative approach with a thorough pre-procedure assessment, including multi-disciplinary evaluation when appropriate, is prudent in this complex cohort of patients.

The Venoarterial Extracorporeal Membrane Oxygenation Weaning Checklist.

Venoarterial extracorporeal membrane oxygenation (vaECMO) is a well-established treatment option for severe cardiogenic shock of various etiologies. Although trials have explored weaning strategies, a brief and conclusive overview is lacking. We present the different aspects of weaning and provide an evidence- and experienced-based guide for clinicians managing patients under vaECMO in the preweaning, weaning, and postweaning phases.

Adult Intraoperative Echocardiography: A Comprehensive Review of Current Practice.

Intraoperative transesophageal echocardiography is a mature imaging modality and critical component of contemporary heart surgery, in which it plays a key role in surgical planning, determination of cardiac chamber filling and function early after cardiopulmonary bypass, and timely assessment of surgical interventions. Intraoperative transesophageal echocardiography affords the unique opportunity to correct suboptimal surgical results before leaving the operating room. Herein, the authors provide a comprehensive review of their institution's experience with intraoperative transesophageal echocardiography, emphasizing a practical assessment of commonly encountered noncongenital surgical heart lesions in adults, anticipation of potential surgical complications, and imaging approaches to facilitate timely surgical correction of unsatisfactory results.

Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report.

Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.

The Safety and Feasibility of Transesophageal Echocardiography in Patients With Esophageal Stricture.

OBJECTIVES: Expert guidelines consistently list esophageal stricture (ES) as a contraindication to the performance of transesophageal echocardiography (TEE), although anecdotally the authors are aware of patients with ES undergoing TEE without apparent complication. Therefore the authors sought to determine the outcomes of patients with ES who had undergone TEE at their institution. DESIGN: Single-center, retrospective review. SETTING: Academic medical center (clinic and affiliated hospital). PARTICIPANTS: Patients with documented ES who also underwent TEE. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In a 10-year period, 1,083 TEE reports were generated for 823 patients who had a diagnosis of ES. One case of esophageal perforation occurred (1/1,083 examination reports [0.09%]) in an 85-year-old male with gastroesophageal reflux disease-related ES who had undergone esophageal dilation the same day as the TEE. In 17.2% of the TEE reports reviewed, changes to the conduct of the examination occurred, such as use of a pediatric probe or avoidance of transgastric imaging. In 8% of reviewed examinations, procedural difficulty was recorded. CONCLUSIONS: Patients with nonmalignant ES commonly present for TEE (>100 per year, on average, at the authors' institution). Severe TEE-related esophageal injury rarely occurred in patients with ES. However, changes to the conduct of the TEE examination and procedural difficulty were not infrequent in this group. Clinicians contemplating TEE in patients with ES should prepare for the possibility of altered examination conduct and possible procedural difficulty.

Modified Cabrol Shunt for Atrioventricular Groove Rupture After Mitral Valve Replacement.

Rupture of the atrioventricular (AV) groove is the Achilles' heel of mitral valve replacement, and it has been associated with high rates of mortality. Here, we report successful management of a type 1 AV groove disruption using a modified Cabrol shunt to the right atrium in a patient with a severely calcified mitral annulus.

Anesthetic considerations in robotic mitral valve surgery.

The robotic approach to cardiac surgery offers patients numerous potential advantages compared with a traditional sternotomy approach including shorter hospital length of stay, reduced pain, fewer blood transfusions, and a quicker return to normal daily activities. At the same time, robotic cardiac surgery requires that the anesthesiologist employs several subspecialty skillsets in order to provide optimal care for these patients. Multiple different regional anesthesia techniques may be used to improve analgesia, reduce opioid dosages, and facilitate rapid extubation at the conclusion of the case. Several peripheral cannulation strategies for cardiopulmonary bypass (CPB) exist and the anesthesia team may assist with percutaneous cannulation of the superior vena cava (SVC) or positioning of an endo-pulmonary vent. Similarly the anesthesiologist may be asked to percutaneously cannulate the coronary sinus for retrograde cardioplegia delivery. The need for one-lung ventilation (OLV) and heavy reliance on transesophageal echocardiography (TEE) occupy much of the anesthesiologist's attention during these cases. Variations in institutional practice exist. Reviews of current practice and future studies may help refine the anesthetic approach to robot-assisted cardiac surgery.

Iatrogenic Right Coronary Artery Occlusion Following Tricuspid Valve Repair: Case Report of a Rare but Recognized Complication.

Iatrogenic occlusion of the right coronary artery (RCA) is a rare complication after tricuspid valve surgery. We review the case of a 74-year-old female who presented for mitral and tricuspid valve annuloplasty. Unanticipated postcardiopulmonary bypass biventricular hypokinesis was encountered, necessitating extracorporeal support. Emergent coronary angiography demonstrated near-complete RCA occlusion from a taut periarterial suture near the RCA. Deployment of a drug-eluting stent restored normal flow, and the patient made a full recovery. Although an exceedingly rare complication, iatrogenic RCA injury after tricuspid valve operations should be considered in the setting of unexpected ventricular compromise.

Cardiopulmonary Bypass Without Heparin.

Due to familiarity, short half-life, ease of monitoring, and the availability of a reversal agent, heparin remains the anticoagulant of choice for cardiac operations requiring cardiopulmonary bypass (CPB). However, occasionally patients require CPB but should not receive heparin, most often because of acute or subacute heparin-induced thrombocytopenia (HIT). In these cases, if it is not feasible to wait for the disappearance of HIT antibodies, an alternative anticoagulant must be selected. A number of non-heparin anticoagulant options have been explored. However, current recommendations suggest the use of a direct thrombin inhibitor such as bivalirudin. This review describes the use of heparin alternatives for the conduct of CPB with a focus on the direct thrombin inhibitors.

Diastolic Mitral Regurgitation in a Patient With Complex Native Mitral and Aortic Valve Endocarditis: A Rare Phenomenon With Potential Catastrophic Consequences.

Diastolic mitral valve regurgitation is a rare phenomenon described in patients with atrioventricular conduction abnormalities, severe left ventricular systolic or diastolic dysfunction with regional wall motion dyssynchrony, or severe acute aortic valve regurgitation. The presence of diastolic mitral valve regurgitation in acute aortic regurgitation due to endocarditis suggests critical severity requiring urgent surgical valve replacement. We describe a case of diastolic mitral regurgitation in the setting of complex native mitral-aortic valve endocarditis in a patient in normal sinus rhythm and review the etiologic mechanisms of this phenomenon, echocardiographic assessment, and therapeutic implications for hemodynamic management.

Anesthetic pharmacology and perioperative considerations for heart transplantation.

From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.

Diastolic function and new-onset atrial fibrillation following cardiac surgery.

BACKGROUND: Numerous studies have reported predictors of new-onset postoperative atrial fibrillation (POAF) following cardiac surgery, which is associated with increased length of stay, cost of care, morbidity, and mortality. The purpose of this study was to examine the association between preoperative diastolic function and occurrence of new-onset POAF in patients undergoing a variety of cardiac surgeries at a single institution. METHODS: Using data from a prospective study from November 2007 to January 2010, a retrospective review was conducted. The diastolic function of each patient was determined from preoperative transthoracic echocardiograms. Occurrence of new-onset POAF was prospectively noted for each patient in the original study. Demographic and operative characteristics of the study population were analyzed to determine predictors of POAF. RESULTS: Of 223 patients, 91 (40.8%) experienced new-onset POAF. Univariate predictors of POAF included increasing age, male gender, operations involving mitral valve repair/replacement, nonsmoking, hypertension, increased intraoperative pulmonary artery pressure, grade I diastolic dysfunction, abnormal diastolic function of any grade, decreased medial e', elevated medial E/e', and increased left atrial volume. Multivariate predictors of POAF included increasing age, increased left atrial volume, and elevated initial intraoperative pulmonary artery pressure. Even after exclusion of patients with hypertrophic obstructive cardiomyopathy or those undergoing mitral valve operations, diastolic dysfunction was not a multivariate predictor of POAF. CONCLUSIONS: In the patient population studied here, preoperative diastolic dysfunction was not predictive of POAF. In addition to increasing age, initial intraoperative pulmonary artery systolic pressure and left atrial volume were both significant multivariate predictors of POAF.