Transient Recurrent Laryngeal Nerve Palsy After Failed Placement of a Transesophageal Echocardiographic Probe in an Anesthetized Patient

“Other” Neurologic Complications After Cardiac Surgery

Compared to the neurologic morbidity of stroke and cognitive dysfunction, “other” neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.

Neurologic complications of cardiac tests and procedures

Arterial or central venous vascular access is the cornerstone of invasive cardiac diagnosis, monitoring, and therapeutics. Although procedural safety has significantly improved with protocols perfected over decades of use, their prevalence renders even the uncommon neurologic complication clinically relevant. Serious peripheral nerve complications result from direct or indirect nerve injuries in the setting of a hematoma or compartment syndrome. Functional outcome is dependent upon prompt diagnosis and early treatment, so proceduralists should be aware of the relevant anatomy and early signs of nerve injury. Ischemic stroke is the most common central nervous system complication of diagnostic and therapeutic cardiac catheterization, and is presumed to be due to embolization of atherosclerotic plaque or thrombus dislodged during guiding catheter manipulation, platelet-fibrin thrombus that forms on the catheters, or air that appears during catheter flushing. Acute neurologic deterioration after thrombolysis for acute myocardial infarction should be presumed to be an intracranial hemorrhage until proven otherwise. The ideal angiography suite of the future is patientcentric and multipurpose, coordinating diagnostic and therapeutic strategies for multivascular disease, allowing for multispecialty collaboration, and, in the event of a neurologic complication of a cardiac procedure, facilitating the various treating physicians to converge efficiently upon the patient.

Incidence and Risk Factors of Postoperative Vocal Cord Paralysis in 987 Patients After Cardiovascular Surgery

BACKGROUND

Vocal cord paralysis (VCP) after cardiovascular surgery can affect the postoperative outcome. The aim of the present study was to clarify the incidence of VCP after cardiovascular surgery and the relationship between the surgery characteristics and the risk of VCP.

METHODS

A total of 987 consecutive patients who underwent cardiovascular surgery (cardiac, n = 895; aortic, n = 92) were enrolled. We retrospectively assessed the incidence and the risk of VCP according to the length and types of surgery and the details of each VCP case and compared them between the aortic and the nonaortic group.

RESULTS

Twenty-three patients (2.3%: cardiac, n =15; aortic, n = 8) were expertly diagnosed with VCP (left, n = 19; right, n = 2; bilateral, n = 2). In the multivariate analysis, the risk for VCP increased with the duration of the operation (odds ratio [OR], 4.4, 95% confidence interval [CI] 1.7 to 11.4), and aortic procedures (OR, 5.6, CI 2.3 to 13.5) exhibited higher risk compared with coronary artery bypass grafting. Among the VCP cases, the incidence of poor outcomes (ie, bilateral VCP, repeated airway treatment, death within 6 months) was significantly higher in the aortic group (p = 0.016). All patients that were intubated for longer than 100 hours exhibited poor outcomes.

CONCLUSIONS

Aortic procedures and prolonged operation increase the risk of VCP. Severe VCP tended to be associated with aortic surgery and intubation for more than 100 hours.

A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination

OBJECTIVE

More than a decade before the introduction of intraoperative transesophageal echocardiography (TEE), epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons and anesthesiologists with clinical decision making. Although TEE has since become increasingly more popular, epicardial echocardiography may be the most convenient intraoperative imaging technique when TEE probe placement cannot be performed or is contraindicated. The authors developed a comprehensive examination protocol for the intraoperative interrogation of cardiac structures using an epicardial/epiaortic echocardiographic approach.

DESIGN

Retrospective analysis of patient's medical records.

SETTING

Single-center academic tertiary care hospital.

PARTICIPANTS

Patients undergoing cardiac surgery.

INTERVENTIONS

A total of 10 echocardiographic views were obtained for imaging cardiac structures, the ascending aorta, and proximal aortic arch. The described imaging planes permit the evaluation of ventricular performance, valvular function, cardiac structural abnormalities, and aortic disease.

MEASUREMENTS AND MAIN RESULTS

A comprehensive epicardial/epiaortic echocardiographic examination was performed in 20 patients undergoing cardiac surgery requiring a full sternotomy. The described imaging planes were obtained in all patients in less than 8 minutes (range, 3.5-8 minutes; mean, 5.5 minutes).

CONCLUSION

The present manuscript delineates a protocol for performing a comprehensive, intraoperative epicardial/epiaortic echocardiographic examination. Echocardiographic imaging planes of cardiac and aortic anatomy are described. This protocol may be useful for cardiac surgeons and anesthesiologists seeking to use this technique as a cardiac imaging modality that is complementary to TEE.