Anesthetic management for transcatheter aortic valve replacement: A national anesthesia clinical outcomes registry analysis.

Background: General anesthesia has traditionally been used in transcatheter aortic valve replacement; however, there has been increasing interest and momentum in alternative anesthetic techniques. Aims: To perform a descriptive study of anesthetic management options in transcatheter aortic valve replacements in the United States, comparing trends in use of monitored anesthesia care versus general anesthesia. Settings and Design: Data evaluated from the American Society of Anesthesiologists' (ASA) Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. Materials and Methods: Multivariable logistic regression was used to identify predictors associated with use of monitored anesthesia care compared to general anesthesia. Results: The use of monitored anesthesia care has increased from 1.8% of cases in 2013 to 25.2% in 2017 (p = 0.0001). Patients were more likely ages 80+ (66% vs. 61%; p = 0.0001), male (54% vs. 52%; p = 0.0001), ASA physical status > III (86% vs. 80%; p = 0.0001), cared for in the Northeast (38% vs. 22%; p = 0.0001), and residents in zip codes with higher median income ($63,382 vs. $55,311; p = 0.0001). Multivariable analysis revealed each one-year increase in age, every 50 procedures performed annually at a practice, and being male were associated with 3% (p = 0.0001), 33% (p = 0.012), and 16% (p = 0.026) increased odds of monitored anesthesia care, respectively. Centers in the Northeast were more likely to use monitored anesthesia care (all p < 0.005). Patients who underwent approaches other than percutaneous femoral arterial were less likely to receive monitored anesthesia care (adjusted odds ratios all < 0.51; all p = 0.0001). Conclusion: Anesthetic type for transcatheter aortic valve replacements in the United States varies with age, sex, geography, volume of cases performed at a center, and procedural approach.

Coronary Artery Bypass Grafting in a Patient with Dextrocardia with Situs Inversus.

Dextrocardia involves embryologic malformations leading to a right hemithorax heart with rightward apex. Situs inversus encompasses all viscera in mirrored position. A 76-year-old male with dextrocardia with situs inversus presented for coronary artery bypass grafting due to a non-ST elevation myocardial infarction. Management was altered accordingly. Electrocardiography leads and defibrillator pads were reversed. A left internal jugular vein central venous catheter provided direct access to the right atrium. Transesophageal echocardiography confirmation of aortic and venous cannulation required turning the probe right for the right-sided aorta and left for liver visualization, respectively. Proactive surgical and anesthetic management was imperative for the successful and uneventful outcome for this patient.