Perioperative Assessment of the Hemodynamic Ventriculoarterial Junction of the Aortic Root by Three-Dimensional Echocardiography.

Improved strategies in aortic valve-preserving operations appreciate the dynamic, three-dimensional complexity of the aortic root and its valve. This depends not only on detailed four-dimensional imaging of the planar dimensions of the aortic root but also on quantitative assessment of the valvar leaflets and their competency. The zones of apposition and resulting hemodynamic ventriculoarterial junction formed in diastole determine valvar competency. Current understanding and assessment of this junction is limited, often relying on intraoperative direct surgical inspection. However, this direct inspection itself is limited by evaluation in a nonhemodynamic state with limited field of view. In this review, we discuss the anatomy of the aortic root, including its hemodynamic junction. We review current echocardiographic approaches toward interrogating the incompetent aortic valve for presurgical planning. Furthermore, we introduce and standardize a complementary approach to assessing this hemodynamic ventriculoarterial junction by three-dimensional echocardiography to further personalize presurgical planning for aortic valve surgery.

Post-cardiopulmonary bypass longitudinal strain provides higher prognostic ability than baseline strain or change in strain.

Context: Global longitudinal strain (GLS) measured by speckle-tracking echocardiography demonstrates excellent prognostic ability in predicting major adverse cardiac events after cardiac surgery. However, the optimal timing of intraoperative GLS measurement that provides the best prognostic value is unclear. Aim: Our goal was to evaluate whether GLS measured prior to cardiopulmonary bypass (pre-CPB GLS), following CPB (post-CPB GLS), or change in GLS provides the strongest association with postoperative complications. Setting and Design: Post hoc analysis of prospectively collected data from a clinical trial (NCT01187329). 72 patients with aortic stenosis undergoing elective AVR ± coronary artery bypass grafting between January 2011 and August 2013. Material and Methods: Myocardial deformation analysis from standardized transesophageal echocardiographic examinations were performed after anesthetic induction and chest closure. We evaluated the association between pre-CPB GLS, post-CPB GLS, and change in GLS (percent change from pre-CPB baseline) with postoperative atrial fibrillation and hospitalization >7 days. The association of post-CPB GLS with duration of mechanical ventilation, N-terminal pro-BNP (NT-proBNP) and troponin T were also assessed. Statistical Analysis: Multivariable logistic regression. Results: Risk-adjusted odds (OR[97.5%CI] of prolonged hospitalization increased an estimated 27% (1.27[1.01 to 1.59];Padj =0.035) per 1% decrease in absolute post-CPB GLS. Mean[98.3%CI] NT-proBNP increased 98.4[20 to 177]pg/mL; Padj =0.008), per 1% decrease in post-CPB GLS. Pre-CPB GLS or change in GLS were not associated with any outcomes. Conclusions: Post-CPB GLS provides the best prognostic value in predicting postoperative outcomes. Measuring post-CPB GLS may improve risk stratification and assist in future study design and patient outcome research.

Pulmonary Venous Flow After Lung Transplantation: Turbulence and High Velocities.

Lung transplantation is the definitive treatment for end-stage lung disease. The pulmonary venous anastomosis has the potential for significant obstructive complications that can lead to considerable morbidity and mortality. The use of intraoperative transesophageal echocardiography, including color-flow and spectral Doppler, is instrumental in evaluating the pulmonary veins after lung transplantation. In this E-challenge, a case of intraoperative pulmonary venous obstruction after bilateral lung transplantation is described, the echocardiographic principles required to evaluate the pulmonary veins and screen for complications are reviewed, and when intervention may be required is discussed.

Mild Acute Kidney Injury after Noncardiac Surgery Is Associated with Long-term Renal Dysfunction: A Retrospective Cohort Study.

BACKGROUND: Perioperative acute kidney injury is common. However, it is unclear whether this merely represents a transient increase in creatinine or has prognostic value. Therefore, the long-term clinical importance of mild postoperative acute kidney injury remains unclear. This study assessed whether adults who do and do not experience mild kidney injury after noncardiac surgery are at similar risk for long-term renal injury. METHODS: This study is a retrospective cohort analysis of adults having noncardiac surgery at the Cleveland Clinic who had preoperative, postoperative, and long-term (1 to 2 yr after surgery) plasma creatinine measurements. The exposure (postoperative kidney injury) and outcome (long-term renal injury) were defined and staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) initiative criteria. The primary analysis was for lack of association between postoperative kidney injury (stage I vs. no injury) and long-term renal injury. RESULTS: Among 15,621 patients analyzed, 3% had postoperative stage I kidney injury. Long-term renal outcomes were not similar in patients with and without postoperative stage I injury. Specifically, about 26% of patients with stage I postoperative kidney injury still had mild injury 1 to 2 yr later, and 11% had even more severe injury. A full third (37%) of patients with stage I kidney injury therefore had renal injury 1 to 2 yr after surgery. Patients with postoperative stage I injury had an estimated 2.4 times higher odds of having long-term renal dysfunction (KDIGO stage I, II, or III) compared with patients without postoperative kidney injury (odds ratio [95% CI] of 2.4 [2.0 to 3.0]) after adjustment for potential confounding factors. CONCLUSIONS: In adults recovering from noncardiac surgery, even small postoperative increases in plasma creatinine, corresponding to stage I kidney injury, are associated with renal dysfunction 1 to 2 yr after surgery. Even mild postoperative renal injury should therefore be considered a clinically important perioperative outcome.

Angiotensin II in Vasodilatory Shock.

The Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial demonstrated the vasopressor effects and catecholamine-sparing properties of angiotensin II. As a result, the Food and Drug Administration has approved angiotensin II for the treatment of vasodilatory shock. This review details the goals of treatment of vasodilatory shock in addition to the history, current use, and recent research regarding the use of angiotensin II. An illustrative case of the use of angiotensin II is also incorporated for understanding the clinical utility of the drug.

Vasodilatory shock in the ICU and the role of angiotensin II.

PURPOSE OF REVIEW: There are limited vasoactive options to utilize for patients presenting with vasodilatory shock. This review discusses vasoactive agents in vasodilatory, specifically, septic shock and focuses on angiotensin II as a novel, noncatecholamine agent and describes its efficacy, safety, and role in the armamentarium of vasoactive agents utilized in this patient population. RECENT FINDINGS: The Angiotensin II for the Treatment of High-Output Shock 3 study evaluated angiotensin II use in patients with high-output, vasodilatory shock and demonstrated reduced background catecholamine doses and improved ability to achieve blood pressure goals associated with the use of angiotensin II. A subsequent analysis showed that patients with a higher severity of illness and relative deficiency of intrinsic angiotensin II and who received angiotensin II had improved mortality rates. In addition, a systematic review showed infrequent adverse reactions with angiotensin II demonstrating its safety for use in patients with vasodilatory shock. SUMMARY: With the approval and release of angiotensin II, a new vasoactive agent is now available to utilize in these patients. Overall, the treatment for vasodilatory shock should not be a one-size fits all approach and should be individualized to each patient. A multimodal approach, integrating angiotensin II as a noncatecholamine option should be considered for patients presenting with this disease state.

Everolimus induced pneumonitis in a lung transplant recipient.

Everolimus is a mechanistic target of rapamycin inhibitor used for the treatment of various cancers and prevention of allograft rejection in solid organ transplantation. We present a case of a lung transplant recipient on everolimus who was admitted with generalized weakness, hypoxia and new onset bilateral pulmonary infiltrates on imaging. Extensive workup revealed no infectious etiology and high levels of serum everolimus levels. Her condition deteriorated over the hospital course with symptoms and signs of systemic everolimus toxicity. She was treated with high-dose steroids with significant improvement. Follow-up imaging showed resolution of infiltrates. Everolimus induced pneumonitis is seldom reported in the lung transplant literature. It is important to recognize early signs of toxicity to intervene and preserve the lung allograft.

Transvenous Lead Extraction: A Clinical Commentary for Anesthesiologists.

With increasing use of cardiovascular implantable electronic devices, the need for lead extractions has increased to an annual volume of more than 10,000 extractions worldwide. This article provides a focused clinical commentary on the perioperative management, identification, and treatment of life-threatening complications associated with lead extractions. In addition, a summary of indications, techniques, and lead extraction complications is provided. Although uncommon, lead extractions are associated with a consistent rate of major procedure-related complications and mortality. Major life-threatening complications include vascular laceration, cardiac avulsion, hemothorax, pericardial effusion, and cardiac arrest. Comprehensive preoperative risk assessment and adequate planning and preparedness are crucial to decreasing all procedure-related adverse events. The location of the procedure (electrophysiology suite v hybrid operating room) and the nature of cardiac surgical backup are determined after meticulous risk stratification. In addition to decisions on vascular access, invasive monitoring, and modality of rhythm support, transesophageal echocardiography plays a crucial role in early diagnosis, timely management, and potential prevention of these complications.

Left Ventricular Apex Venting in High-Risk Redo Sternotomy With Severe Aortic Insufficiency: A Case Report.

Redo cardiac surgery in patients with severe aortic insufficiency can present unique challenges to the anesthesiologist. We report a case highlighting the challenge and importance of interdisciplinary planning between cardiothoracic surgeons and anesthesiologists prior to high-risk surgery. Failure to place an endoaortic balloon and percutaneous coronary sinus catheter due to anatomical abnormalities prompted the adoption of an alternate technique involving apical ventricular venting to assist sternal reentry. Apical left ventricular venting was successfully used to prevent ventricular dilation and dysfunction during institution of cardiopulmonary bypass with significant aortic regurgitation and hypothermia-induced ventricular fibrillation.

Brachial Arterial Pressure Monitoring during Cardiac Surgery Rarely Causes Complications.

BACKGROUND: Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications. METHODS: The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization. RESULTS: Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality. CONCLUSIONS: Brachial artery cannulation for hemodynamic monitoring during cardiac surgery rarely causes complications.