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Landa AB, Hoyos J, D'Mello J. Mitral valve repair complicated by left circumflex coronary artery occlusion: The vital role of the anesthesiologist. Ann Card Anaesth 2021; 24:405-407. [PMID: 34269282 PMCID: PMC8404581 DOI: 10.4103/aca.aca_190_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The anatomical relationship between the mitral valve and the left circumflex coronary artery places this vessel at risk for occlusion during mitral valve repair or replacement. In view of the potential high morbidity and mortality of this complication, the anesthesiologist has a vital role in its prompt diagnosis. We present the case of a 47-year-old man who underwent a minimally invasive mitral valve repair, which was complicated by left circumflex coronary artery occlusion.
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Affiliation(s)
- Andres Bacigalupo Landa
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, Florida, United States
| | - Jason Hoyos
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, Florida, United States
| | - Jayanand D'Mello
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, Florida, United States
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Nasrala MLS, Bolzan DW, Lage YG, Prado FS, Arena R, Lima PRL, Feguri G, Silva AMC, Marcondi NO, Hossne N, Guizilini S, Gomes WJ. Extended-time of Noninvasive Positive Pressure Ventilation Improves Tissue Perfusion after Coronary Artery Bypass Surgery: a Randomized Clinical Trial. Braz J Cardiovasc Surg 2018; 33:250-257. [PMID: 30043917 PMCID: PMC6089129 DOI: 10.21470/1678-9741-2017-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/20/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare the effects of extended- versus short-time noninvasive positive pressure ventilation on pulmonary function, tissue perfusion, and clinical outcomes in the early postoperative period following coronary artery bypass surgery in patients with preserved left ventricular function. METHODS Patients were randomized into two groups according to noninvasive positive pressure ventilation intensity: short-time noninvasive positive pressure ventilation n=20 (S-NPPV) and extended-time noninvasive positive pressure ventilation n=21 (E-NPPV). S-NPPV was applied for 60 minutes during immediate postoperative period and 10 minutes, twice daily, from postoperative days 1-5. E-NPPV was performed for at least six hours during immediate postoperative period and 60 minutes, twice daily, from postoperative days 1-5. As a primary outcome, tissue perfusion was determined by central venous oxygen saturation and blood lactate level measured after anesthetic induction, immediately after extubation and following noninvasive positive pressure ventilation protocols. As a secondary outcome, pulmonary function tests were performed preoperatively and in the postoperative days 1, 3, and 5; clinical outcomes were recorded. RESULTS Significant drop in blood lactate levels and an improvement in central venous oxygen saturation values in the E-NPPV group were observed when compared with S-NPPV group after study protocol (P<0.01). The E-NPPV group presented higher preservation of postoperative pulmonary function as well as lower incidence of respiratory events and shorter postoperative hospital stay (P<0.05). CONCLUSION Prophylactic E-NPPV administered in the early postoperative period of coronary artery bypass surgery resulted in greater improvements in tissue perfusion, pulmonary function and clinical outcomes than S-NPPV, in patients with preserved left ventricular function. TRIAL REGISTRATION Brazilian Registry of Clinical trial - RBR7sqj78 - http://www.ensaiosclinicos.gov.br.
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Affiliation(s)
- Mara L S Nasrala
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil
| | - Douglas W Bolzan
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Yumi G Lage
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Fabiana S Prado
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Paulo R L Lima
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Gibran Feguri
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Ageo M C Silva
- Public Health Department, Universidade Federal do Mato Grosso (UFMT), Cuiabá, MT, Brazil
| | - Natasha O Marcondi
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Nelson Hossne
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Solange Guizilini
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Department of the Human Movement Sciences, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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Bolzan DW, Gomes WJ, Rocco IS, Viceconte M, Nasrala MLS, Pauletti HO, Moreira RSL, Hossne NA, Arena R, Guizilini S. Early Open-Lung Ventilation Improves Clinical Outcomes in Patients with Left Cardiac Dysfunction Undergoing Off-Pump Coronary Artery Bypass: a Randomized Controlled Trial. Braz J Cardiovasc Surg 2017; 31:358-364. [PMID: 27982344 PMCID: PMC5144569 DOI: 10.5935/1678-9741.20160057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/24/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To compare pulmonary function, functional capacity and clinical outcomes
amongst three groups of patients with left ventricular dysfunction following
off-pump coronary artery bypass, namely: 1) conventional mechanical
ventilation (CMV); 2) late open lung strategy (L-OLS); and 3) early open
lung strategy (E-OLS). Methods Sixty-one patients were randomized into 3 groups: 1) CMV (n=21); 2) L-OLS
(n=20) initiated after intensive care unit arrival; and 3) E-OLS (n=20)
initiated after intubation. Spirometry was performed at bedside on
preoperative and postoperative days (PODs) 1, 3, and 5. Partial pressure of
arterial oxygen (PaO2) and pulmonary shunt fraction were
evaluated preoperatively and on POD1. The 6-minute walk test was applied on
the day before the operation and on POD5. Results Both the open lung groups demonstrated higher forced vital capacity and
forced expiratory volume in 1 second on PODs 1, 3 and 5 when compared to the
CMV group (P<0.05). The 6-minute walk test distance was
more preserved, shunt fraction was lower, and PaO2 was higher in
both open-lung groups (P<0.05). Open-lung groups had
shorter intubation time and hospital stay and also fewer respiratory events
(P<0.05). Key measures were significantly more
favorable in the E-OLS group compared to the L-OLS group. Conclusion Both OLSs (L-OLS and E-OLS) were able to promote higher preservation of
pulmonary function, greater recovery of functional capacity and better
clinical outcomes following off-pump coronary artery bypass when compared to
conventional mechanical ventilation. However, in this group of patients with
reduced left ventricular function, initiation of the OLS intra-operatively
was found to be more beneficial and optimal when compared to OLS initiation
after intensive care unit arrival.
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Affiliation(s)
- Douglas W Bolzan
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Walter José Gomes
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Isadora S Rocco
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Departamento de Ciência do Movimento Humana, Escola de Fisioterapia da Universidade Federal de São Paulo (UNIFESP), Santos, SP, Brazil
| | - Marcela Viceconte
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Mara L S Nasrala
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Hayanne O Pauletti
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Rita Simone L Moreira
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Nelson A Hossne
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, USA
| | - Solange Guizilini
- Disciplina de Cirurgia Cardiovascular e Cardiologia da Escola Paulista de Medicina da Universidade de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Departamento de Ciência do Movimento Humana, Escola de Fisioterapia da Universidade Federal de São Paulo (UNIFESP), Santos, SP, Brazil
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Abstract
Thoracic epidural analgesia (TEA) offers a unique oppor tunity for the anesthesiologist to enhance postopera tive recovery for the thoracic surgery patient. By deliver ing analgesics to a limited dermatomal distribution, TEA can provide profound segmental analgesia and also serves to modulate neural outflow to improve cardiac and pulmonary parameters. The notable side-effects of hypotension and respiratory depression can be mini mized by using synergistic combinations of local anes thetic and opioids, and by adopting a continuous infu sion strategy. With thoughtful patient selection, careful technique, and a proactive approach to the recognition of the known hemodynamic and respiratory effects of epidural drugs, TEA can be administered safely. The significant benefits of TEA include better pain relief, increased FEV1, earlier extubation, and, perhaps, de creased morbidity and mortality.
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Fox J, Glas K, Swaminathan M, Shernan S. The Impact of Intraoperative Echocardiography on Clinical Outcomes Following Adult Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016; 9:25-40. [PMID: 15735842 DOI: 10.1177/108925320500900104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past 30 years, intraoperative echocardiography has become an invaluable diagnostic tool and monitor of cardiac performance for the management of cardiac surgical patients. The essential information provided by intraoperative echocardiography regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. Numerous investigations have been conducted in an attempt to specifically demonstrate a beneficial impact of intraoperative echocardiography in cardiac surgery. However, there is a relative paucity of data derived from prospective trials in which the use of intraoperative echocardiography has been randomized among various cardiac surgical patient populations to formally ascertain, rather than simply infer, its putative impact on perioperative decision-making and clinical outcomes. Ironically, the popularity of intraoperative echocardiography has imposed ethical limitations on performing randomized trials in patient populations for whom significant benefit has been previously inferred. Nonetheless, significant evidence has been published to support its almost universal acceptance as an important perioperative diagnostic tool and monitor for cardiac surgical patients. This review focuses on the impact of intraoperative echocardiography on clinical outcomes in the more common adult cardiac surgical scenarios, including coronary artery bypass graft surgery, mitral and aortic valve surgery, and in evaluating the intrathoracic aorta.
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Affiliation(s)
- John Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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London MJ. Ventricular Function and Myocardial Ischemia: Is Transesophageal Echocardiography a Good Monitor? Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925329700100108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Martin J. London
- University of Colorado Health Sciences Center and the Anesthesia Section, Denver Veterans Affairs Medical Center, Denver, CO
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Shanewise JS. How to Reliably Detect Ischemia in the Intensive Care Unit and Operating Room. Semin Cardiothorac Vasc Anesth 2016; 10:101-9. [PMID: 16703242 DOI: 10.1177/108925320601000117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Detection of myocardial ischemia in the perioperative period is important because it allows for intervention that may prevent progression of ischemia to myocardial infarction. Perioperative ischemia is also an important predictor of adverse cardiovascular outcomes. Patients should first be stratified according to their risk of having cardiovascular disease by identifying major, intermediate, and minor predictors of adverse cardiovascular outcome. Electrocardiographic (ECG) monitoring for ischemia is inexpensive and noninvasive, but may not be applicable to all patients and is not perfectly sensitive or specific. Modern operating room monitors can automate ST segment monitoring and be set to alarm if changes occur. Increases in central venous pressure and pulmonary artery pressure can be caused by myocardial ischemia, but have been shown to be very insensitive compared to ECG. Also, detection of these hemodynamic changes requires insertion of invasive monitoring devices. Transesophageal echocardiography can be used to detect myocardial ischemia by identifying changes in regional wall motion. These transesophageal echocardiography changes occur sooner and more frequently than ECG changes, but require greater knowledge and skill to properly interpret.
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Affiliation(s)
- Jack S Shanewise
- Division of Cardiothoracic Anesthesiology, Columbia University College of Physicians & Surgeons, New York, NY, USA.
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Grieshaber P, Görlach G, Niemann B, Böning A, Trummer G. Postoperativ persistierende Myokardischämie nach herzchirurgischen Eingriffen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Herzig J, Bickel A, Eitan A, Intrator N. Monitoring Cardiac Stress Using Features Extracted From S1 Heart Sounds. IEEE Trans Biomed Eng 2015; 62:1169-78. [PMID: 25494499 DOI: 10.1109/tbme.2014.2377695] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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11
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Does high thoracic epidural analgesia with levobupivacaine preserve myocardium? A prospective randomized study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:658678. [PMID: 25918718 PMCID: PMC4395980 DOI: 10.1155/2015/658678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/03/2015] [Accepted: 03/10/2015] [Indexed: 01/14/2023]
Abstract
Background. Our study aimed to compare HTEA and intravenous patient-controlled analgesia (PCA) in patients undergoing coronary bypass graft surgery (CABG), based on haemodynamic parameters and myocardial functions. Materials and Methods. The study included 34 patients that were scheduled for elective CABG, who were randomly divided into 2 groups. Anesthesia was induced and maintained with total intravenous anesthesia in both groups while intravenous PCA with morphine was administered in Group 1 and infusion of levobupivacaine was administered from the beginning of the anesthesia in Group 2 by thoracic epidural catheter. Blood samples were obtained presurgically, at 6 and 24 hours after surgery for troponin I, creatinine kinase-MB (CK-MB), total antioxidant capacity, and malondialdehyde. Postoperative pain was evaluated every 4 hours until 24 hours via VAS. Results. There were significant differences in troponin I or CK-MB values between the groups at postsurgery 6 h and 24 h. Heart rate and mean arterial pressure in Group 1 were significantly higher than in Group 2 at all measurements. Cardiac index in Group 2 was significantly higher than in Group 1 at all measurements. Conclusion. Patients that underwent CABG and received HTEA had better myocardial function and perioperative haemodynamic parameters than those who did not receive HTEA.
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Hyler S, Pischke SE, Halvorsen PS, Espinoza A, Bergsland J, Tønnessen TI, Fosse E, Skulstad H. Continuous monitoring of regional function by a miniaturized ultrasound transducer allows early quantification of low-grade myocardial ischemia. J Am Soc Echocardiogr 2015; 28:486-94. [PMID: 25636368 DOI: 10.1016/j.echo.2014.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sensitive methods for the early detection of myocardial dysfunction are still needed, as ischemia is a leading cause of decreased ventricular function during and after heart surgery. The aim of this study was to test the hypothesis that low-grade ischemia could be detected quantitatively by a miniaturized epicardial ultrasound transducer (Ø = 3 mm), allowing continuous monitoring. METHODS In 10 pigs, transducers were positioned in the left anterior descending and circumflex coronary artery areas. Left ventricular pressure was obtained by a micromanometer. The left internal mammary artery was grafted to the left anterior descending coronary artery, which was occluded proximal to the anastomosis. Left internal mammary artery flow was stepwise reduced by 25%, 50%, and 75% for 18 min each. From the transducers, M-mode traces were obtained, allowing continuous tissue velocity traces and displacement measurements. Regional work was assessed as left ventricular pressure-displacement loop area. Tissue lactate measured from intramyocardial microdialysis was used as reference method to detect ischemia. RESULTS All steps of coronary flow reduction demonstrated reduced peak systolic velocity (P < .05) and regional work (P < .01).The decreases in peak systolic velocity and regional work were closely related to the degree of ischemia, demonstrated by their correlations with lactate (R = -0.74, P < .01, and R = -0.64, P < .01, respectively). The circumflex coronary artery area was not affected by any of the interventions. CONCLUSIONS The epicardially attached miniaturized ultrasound transducer allowed the precise detection of different levels of coronary flow reduction. The results also showed a quantitative and linear relationship among coronary flow, ischemia, and myocardial function. Thus, the ultrasound transducer has the potential to improve the monitoring of myocardial ischemia and to detect graft failure during and after heart surgery.
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Affiliation(s)
- Stefan Hyler
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Søren E Pischke
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | | | - Andreas Espinoza
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Jacob Bergsland
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tor Inge Tønnessen
- Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, Oslo University, Oslo, Norway
| | - Erik Fosse
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, Oslo University, Oslo, Norway
| | - Helge Skulstad
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
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Couture P, Bolduc L, Demey N, Deschamps A, Pellerin M, Denault A, Tardif JC. Real-Time Compared to Off-Line Evaluation of Segmental Wall Motion Abnormalities with Transesophageal Echocardiography Using Dobutamine Stress Testing. J Cardiothorac Vasc Anesth 2012; 26:191-6. [DOI: 10.1053/j.jvca.2011.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Indexed: 11/11/2022]
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De Mey N, Couture P, Laflamme M, Denault AY, Perrault LP, Deschamps A, Rochon AG. Intraoperative changes in regional wall motion: can postoperative coronary artery bypass graft failure be predicted? J Cardiothorac Vasc Anesth 2012; 26:371-5. [PMID: 22459932 DOI: 10.1053/j.jvca.2012.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the accuracy of new intraoperative regional wall motions abnormalities (RWMAs) detected by transesophageal echocardiography (TEE) to predict early postoperative coronary artery graft failure. DESIGN A retrospective study. SETTING A tertiary care university hospital. PATIENTS Five thousand nine hundred ninety-eight patients who underwent coronary artery bypass graft (CABG) surgery. INTERVENTIONS An evaluation of RWMAs recorded with intraoperative TEE before and after cardiopulmonary bypass (CPB) in patients who had coronary angiography for suspected postoperative myocardial ischemia based on electrocardiogram (ECG), CK-MB, troponin T, hemodynamic compromise, low cardiac output, and malignant ventricular arrhythmia. Sensitivity, specificity, positive and negative predictive values, odds ratio, 95% confidence interval, and chi-square analysis were used. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients (0.7%) underwent early coronary angiography for the suspicion of early graft dysfunction. Of the 32 patients with diagnosed early graft dysfunction, 5 patients (15.6%) had shown new intraoperative RWMAs as detected by TEE, 21 patients (65.6%) had no new RWMAs, no report was available in 5 patients (15.6%), and 1 examination (3.1%) was excluded because of poor imaging quality. The sensitivity of TEE to predict graft failure was 15.6%, the specificity was 57.1%, and the positive predictive and negative values were 62.5% and 12.9%, respectively. The odds ratio and 95% confidence interval was 0.1190 (0.0099-1.4257) when TEE was positive compared with coronary angiography. No association was found between new RWMAs detected with TEE and graft failure as documented with coronary angiography (p = 0.106). CONCLUSIONS In this retrospective study, RWMAs detected with TEE were of limited value to predict early postoperative CABG failure.
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Affiliation(s)
- Nathalie De Mey
- Department of Anesthesiology, Montreal Heart Institute, University of Montréal, Montreal, Quebec, Canada
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Laflamme M, DeMey N, Bouchard D, Carrier M, Demers P, Pellerin M, Couture P, Perrault LP. Management of early postoperative coronary artery bypass graft failure. Interact Cardiovasc Thorac Surg 2012; 14:452-6. [PMID: 22223760 DOI: 10.1093/icvts/ivr127] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P = 0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P = 0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.
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Affiliation(s)
- Maxime Laflamme
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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Carrillo López A, Sala MF, Salgado AR. El papel del catéter de Swan-Ganz en la actualidad. Med Intensiva 2010; 34:203-14. [DOI: 10.1016/j.medin.2009.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 05/21/2009] [Accepted: 05/26/2009] [Indexed: 02/02/2023]
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Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur J Anaesthesiol 2010; 27:92-137. [DOI: 10.1097/eja.0b013e328334c017] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Guía de práctica clínica para la valoración del riesgo cardiaco preoperatorio y el manejo cardiaco perioperatorio en la cirugía no cardiaca. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73133-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Sound travels through objects that block light. Only very recently has technology advanced enough to decipher ultrasound for medical use. Machines have become smaller, cheaper, more versatile and more advanced than ever before. The medical use of ultrasound spreads across many fields so that traditional areas no longer have a monopoly. With this comes the question of training doctors. This has been done by various colleges and societies worldwide. Some have been quicker to act than others. There also needs to be an understanding of when broad experience and advanced technical skills are required or when limited skills will do. In addition, some procedures can be performed more safely with ultrasound where the knowledge of ultrasound is not paramount. This article covers current provision of training in echocardiography and ultrasound in areas relevant to anaesthetists who are working in critical care (including accident and emergency) and complex surgery (mainly cardiac).
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Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OFM, Sicari R, Van den Berghe G, Vermassen F, Vanhorebeek I, Vahanian A, Auricchio A, Bax JJ, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, McGregor K, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas P, Widimsky P, De Caterina R, Agewall S, Al Attar N, Andreotti F, Anker SD, Baron-Esquivias G, Berkenboom G, Chapoutot L, Cifkova R, Faggiano P, Gibbs S, Hansen HS, Iserin L, Israel CW, Kornowski R, Eizagaechevarria NM, Pepi M, Piepoli M, Priebe HJ, Scherer M, Stepinska J, Taggart D, Tubaro M. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009; 30:2769-812. [PMID: 19713421 DOI: 10.1093/eurheartj/ehp337] [Citation(s) in RCA: 431] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raffaele De Caterina
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Stefan Agewall
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Nawwar Al Attar
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Felicita Andreotti
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Stefan D. Anker
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Gonzalo Baron-Esquivias
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Guy Berkenboom
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Laurent Chapoutot
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Renata Cifkova
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Pompilio Faggiano
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Simon Gibbs
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Henrik Steen Hansen
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Laurence Iserin
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Carsten W. Israel
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Ran Kornowski
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | | | - Mauro Pepi
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Massimo Piepoli
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Hans Joachim Priebe
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Martin Scherer
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Janina Stepinska
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - David Taggart
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Marco Tubaro
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Skarvan K, Filipovic M. Transösophageale Echokardiographie für Herzchirurgen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past--they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The post-operative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre- and intraoperative aspects of peri-CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short- and long-term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.
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Affiliation(s)
- W S Hirsch
- Division of Cardiovascular Disease, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141, USA
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Abstract
The monitoring of cardiovascular function is an indispensable element in anaesthesia. A thorough understanding of pathophysiology in various disease states allows optimal balancing of the invasiveness and completeness of haemodynamic monitoring. The prevention of both intraoperative and postoperative complications is therefore a primary goal.
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Affiliation(s)
- J I Poelaert
- Cardiac Anaesthesia and Postoperative Cardiac Surgical Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, B9000 Gent, Belgium.
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Gurbuz AT, Hecht ML, Arslan AH. Intraoperative Transesophagial Echocardiography Modifies Strategy in Off-Pump Coronary Artery Bypass Grafting. Ann Thorac Surg 2007; 83:1035-40. [PMID: 17307455 DOI: 10.1016/j.athoracsur.2006.10.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 08/17/2006] [Accepted: 10/06/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND Off-pump coronary artery bypass graft surgery (OPCAB) can improve operative morbidity and mortality in high risk patients. Intraoperative transesophageal echocardiography (ITEE) is being employed increasingly during cardiac surgery. METHODS Routine ITEE was performed in 744 OPCAB patients performed over a five year period. Mean patient age was 69.1 +/- 8.0 years. There were a high percentage of patients over 70 years (39%), diabetics (26%), poor left ventricular function (< or = 35%) (31%), recent myocardial infarction (24%), unstable angina (15%), and preoperative intraaortic balloon pump (5.6%); mean graft number was 3.4. RESULTS There was a major modification in intraoperative strategy in 117 patients (16%) and minor modification in 77 patients (10%) due to information available through the ITEE (total 26%). Graft revision was performed in 39 patients, graft construction was modified due to severe ascending aortic atherosclerosis in 31, and an intraoperative intraaortic balloon pump was placed due to previously underappreciated left ventricular dysfunction and new intraoperative left ventricular dysfunction in 37 patients. Ten patients were placed on cardiopulmonary bypass due to previously unknown intracardiac pathology (three atrial septal defect repairs and five valvular procedures, two others). Intracoronary shunts were placed due to new wall motion changes during anastomosis in 77 patients. There were two emergent conversions to cardiopulmonary bypass. There were no complications due to ITEE probe placement. CONCLUSIONS Intraoperative transesophageal echocardiography is a valuable adjunct and can result in a major change of surgical strategy in a significant number of patients when used routinely for OPCAB. It may also improve surgical outcome and add to the OPCAB benefits.
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Affiliation(s)
- Ahmet Tayfun Gurbuz
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Tucson Heart Hospital, Tucson, Arizona, USA.
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27
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Odell DH, Cahalan MK. Assessment of Left Ventricular Global and Segmental Systolic Function with Transesophageal Echocardiography. ACTA ACUST UNITED AC 2006; 24:755-62. [PMID: 17342962 DOI: 10.1016/j.atc.2006.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The evaluation of LV global and segmental systolic function is a primary application for perioperative TEE. Although the practical techniques customarily used for these applications have limitations, they afford direct measures of function not otherwise available to the clinician in the operating room or intensive care setting.
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Affiliation(s)
- David H Odell
- Department of Anesthesiology, Room 3C-444, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132-2304, USA.
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28
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Rouine-Rapp K, Rouillard KP, Miller-Hance W, Silverman NH, Collins KK, Cahalan MK, Bostrom A, Russell IA. Segmental Wall-Motion Abnormalities After an Arterial Switch Operation Indicate Ischemia. Anesth Analg 2006; 103:1139-46. [PMID: 17056946 DOI: 10.1213/01.ane.0000240874.26646.d0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We prospectively studied 29 consecutive neonates undergoing an arterial switch operation to determine if segmental wall motion abnormalities (SWMA) represented myocardial ischemia. Intraoperative transesophageal echocardiogram was recorded at baseline and twice after cardiopulmonary bypass. Cardiac troponin I (cTnI) levels were measured before sternal incision and 3, 6, 12, 24, 48, and 72 h after removal of the aortic cross-clamp. Immediate postoperative Holter and 15-lead electrocardiograms (ECG) were evaluated for ischemia. Transthoracic echocardiograms were obtained before hospital discharge. At bypass termination, immediately after protamine administration, segmental wall motion was normal in nine neonates and abnormal in 20. SWMA were transient in five and present at the time of chest closure in 15 neonates. Neonates in whom SWMA were present at chest closure had more segments involved than those in whom SWMA were transient (P > 0.001). Neonates with SWMA at chest closure had higher cTnI levels postoperatively versus neonates with normal wall motion (P = 0.02). Postoperative ECG data were available in 26 neonates. There was ECG evidence of myocardial ischemia in two of eight neonates with normal wall motion, one of five with transient SWMA, and nine of 13 with SWMA at chest closure. CTnI levels at 12, 24, and 48 h and intraoperative SWMA were predictive of postoperative SWMA. We believe these data indicate that SWMA, which persist at the completion of an arterial switch operation, and which are present in multiple myocardial segments, correlate with myocardial ischemia. Further follow-up of these patients is needed to determine if increased intraoperative myocardial ischemia correlates with long-term outcomes.
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Affiliation(s)
- Kathryn Rouine-Rapp
- Department of Anesthesia, University of California-San Francisco, 94143-0648, USA.
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29
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Roediger L, Larbuisson R, Lamy M. New approaches and old controversies to postoperative pain control following cardiac surgery. Eur J Anaesthesiol 2006; 23:539-50. [PMID: 16677435 DOI: 10.1017/s0265021506000548] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2006] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the effect of postoperative pain control in cardiac surgical patients on morbidity, mortality and other outcome measures. BACKGROUND New approaches in pain control have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated in cardiac surgical patients. METHODS We searched Medline for the period of 1980 to the present using the key terms analgesics, opioid, non-steroidal anti-inflammatory drugs, cardiac surgery, regional analgesia, spinal, epidural, fast-track cardiac anaesthesia, fast-track cardiac surgery, myocardial ischaemia, myocardial infarction, postoperative care, accelerated care programmes, postoperative complications, and we examined and discussed the articles that were identified to be included in this review. RESULTS Pain management in cardiac surgery is becoming more important with the establishment of minimally invasive direct coronary artery bypass surgery and fast-track management of conventional cardiac surgery patients. Advances have been made in this area and encompass specific techniques, such as central neuraxial blockade or selective nerve blocks, and drugs (opioids, sedative-hypnotics and non-steroidal anti-inflammatory drugs). Ideally, these therapies provide not only patient comfort but also mitigate untoward cardiovascular responses, pulmonary responses, and other inflammatory and secondary sympathetic responses. The introduction of these newer approaches to perioperative care has reduced morbidity, but not mortality, in cardiac surgical patients. CONCLUSIONS Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of cardiac surgery, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Reorganization of the perioperative team (anaesthesiologists, surgeons, nurses and physical therapists) will be essential to achieve successful fast-track cardiac surgical programmes. Developments and improvements of multimodal interventions within the context of 'fast-track' cardiac surgery programmes represents the major challenge for the medical professionals working to achieve a 'pain and risk free' perioperative course.
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Affiliation(s)
- L Roediger
- University Hospital of Liége, Department of Anaesthesia and Intensive Care Medicine, Belgium.
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Abstract
Adequate postoperative analgesia prevents unnecessary patient discomfort. It may also decrease morbidity, postoperative hospital length of stay and, thus, cost. Achieving optimal pain relief after cardiac surgery is often difficult. Many techniques are available, and all have specific advantages and disadvantages. Intrathecal and epidural techniques clearly produce reliable analgesia in patients undergoing cardiac surgery. Additional potential benefits include stress response attenuation and thoracic cardiac sympathectomy. The quality of analgesia obtained with thoracic epidural anesthetic techniques is sufficient to allow cardiac surgery to be performed in awake patients without general endotracheal anesthesia. However, applying regional anesthetic techniques to patients undergoing cardiac surgery is not without risk. Side effects of local anesthetics (hypotension) and opioids (pruritus, nausea/vomiting, urinary retention, and respiratory depression), when used in this manner, may complicate perioperative management. Increased risk of hematoma formation in this scenario has generated much of lively debate regarding the acceptable risk-benefit ratio of applying regional anesthetic techniques to patients undergoing cardiac surgery.
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Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois 60637, USA.
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31
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Entok E, Cavusoglu Y, Kaya E, Vardareli E, Timuralp B. Detection of hibernate myocardium by 99mTc sestamibi gated SPECT during low-dose dobutamine infusion plus nitrate in patients with first acute myocardial infarction. Nucl Med Commun 2005; 26:765-72. [PMID: 16096579 DOI: 10.1097/01.mnm.0000172739.90746.f3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To investigate the role of Tc-MIBI gated SPECT imaging following the administration of low-dose dobutamine plus nitrate (LDD+nitrate) in the assessment of left ventricular function and the perfusion of hibernate myocardial tissue. METHODS The study group comprised 29 patients diagnosed as having acute myocardial infarction. In the first month post-infarction, Tc-MIBI gated SPECT imaging was performed in all patients at rest-dobutamine stress and LDD+nitrate. Ejection fraction, end diastolic volume (EDV), end systolic volume (ESV), stroke volume, volume, extent score, and reversibility score values were calculated. RESULTS The findings of Tc-MIBI gated SPECT imaging following the administration of LDD+nitrate and the rest Tc-MIBI gated SPECT findings revealed that while the levels of ejection fraction (P=0.004) and reversibility score (P=0.000) increased significantly, there was a significant decrease in EDV (P=0.001), ESV (P=0.001), volume (P=0.017), stroke volume (P=0.257) and extent score (P=0.039) values. CONCLUSION The use of Tc-MIBI gated SPECT concomitantly with the administration of LDD+nitrate is useful in the determination of myocardial hibernation in patients with left ventricular failure following acute myocardial infarction.
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Affiliation(s)
- Emre Entok
- Department of Nuclear Medicine, Osmangazi University Medical Faculty, 26480 Eskişehir, Turkey.
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Hunsaker RP. Intraoperative transesophageal echocardiography: standard monitor and diagnostic instrument for difficult situations? J Clin Anesth 2005; 17:155-7. [PMID: 15896578 DOI: 10.1016/j.jclinane.2005.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2005] [Accepted: 02/23/2005] [Indexed: 11/20/2022]
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Mierdl S, Byhahn C, Lischke V, Aybek T, Wimmer-Greinecker G, Dogan S, Viehmeyer S, Kessler P, Westphal K. Segmental myocardial wall motion during minimally invasive coronary artery bypass grafting using open and endoscopic surgical techniques. Anesth Analg 2005; 100:306-314. [PMID: 15673848 DOI: 10.1213/01.ane.0000143565.18784.54] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Current options for minimally invasive surgical treatment of single-vessel coronary artery disease include beating heart procedures without cardiopulmonary bypass (CPB) via mini-thoracotomy (MIDCAB) and totally endoscopic robot-assisted techniques (TECAB) with CPB. Both procedures are associated with potential myocardial stress before revascularization, such as single-lung ventilation (SLV), temporary coronary artery occlusion, cardiac luxation, intrathoracic carbon dioxide insufflation, and extended CPB and operating time. In this echocardiographic study we sought to evaluate the extent of intraoperative segmental wall motion abnormalities (SWMA) during MIDCAB and TECAB surgery and to identify factors affecting SWMA. Forty-six patients with single-vessel coronary artery disease were studied. Sixteen patients were operated using the MIDCAB technique and 30 patients with TECAB. In both groups sequential transesophageal echocardiograms were recorded during the entire procedure. Hemodynamic data and oxygenation variables were acquired simultaneously. In both groups, mild but obvious perioperative SWMA were identified and noted to increase during the course of the operation. These SWMA were more pronounced in the TECAB group. Independent of operating time, these changes disappeared completely after revascularization. No significant hemodynamic compromise was observed. We conclude that MIDCAB and TECAB techniques are associated with significant perioperative SWMA. The appearance of more profound SWMA in the TECAB group compared with the MIDCAB patients might have been the result of intrathoracic CO(2) insufflation, as SLV was used in both groups. No persistent SWMA or post-CPB SWMA were apparent in either group. More extensive intraoperative ventricular SWMA was detected in the TECAB group, suggesting that a more frequent risk for right ventricular dysfunction may exist during TECAB procedures.
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Affiliation(s)
- S Mierdl
- *Department of Anesthesiology, Intensive Care Medicine and Pain Control, †Department of Thoracic and Cardiovascular Surgery, J.W. Goethe-University Hospital, Frankfurt, Germany
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Kamming D, Davies W. Thoracic epidural analgesia for coronary artery surgery. A bridge too far? Eur J Anaesthesiol 2005; 22:85-8. [PMID: 15816584 DOI: 10.1017/s0265021505000165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Leung JM, Bellows WH, Pastor D. Does intraoperative evaluation of left ventricular contractile reserve predict myocardial viability? A clinical study using dobutamine stress echocardiography in patients undergoing coronary artery bypass graft surgery. Anesth Analg 2004; 99:647-654. [PMID: 15333387 DOI: 10.1213/01.ane.0000133137.78510.8b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To determine the contractile reserve of the left ventricle during reperfusion as a predictor of myocardial viability in patients undergoing coronary artery bypass graft surgery, we measured the response of left ventricular regional wall motion and thickening by using dobutamine stress echocardiography (DSE) after myocardial revascularization. All patients were monitored with radial and pulmonary arterial catheters, transesophageal echocardiography, standard five-lead clinical electrocardiography, and three-channel Holter electrocardiography. Immediately after separation from cardiopulmonary bypass, dobutamine was administered IV starting at 5 microg. kg(-1). min(-1), with increases in rate every 3 min to 10, 20, 30, and 40 microg. kg(-1). min(-1). Within 1 wk after surgery, resting and redistribution thallium-201 myocardial perfusion imaging (thallium studies) was performed to assess the relationship between the intraoperative contractile response and myocardial viability. One-hundred patients completed DSE up to 10 microg. kg(-1). min(-1), and 85 patients received the larger escalating doses of the DSE. Seventy-two patients had postoperative thallium studies. At the completion of the small-dose dobutamine infusion, 689 (97.7%) of 705 segments had a normal response (improvement), and 16 segments (2.3%) had a positive response (deterioration). During large-dose dobutamine infusion, 577 (95.8%) of 602 segments had a normal response, and 25 segments (4.2%) had a positive response. Myocardial segments that had a positive response during large-dose DSE (48%) were more likely to be considered as nonviable on postoperative thallium studies compared with segments that had a normal response (14.7%) (P < 0.00001). By using thallium studies as the reference standard, the sensitivity of DSE was low (31% and 48% for small- and large-dose DSE, respectively) in predicting nonviable myocardium. However, the specificity was higher (86% and 85% for small- and large-dose DSE, respectively). In a separate analysis of patients who developed new regional wall motion abnormalities (RWMA) in the early intraoperative reperfusion period, 15 (75%) of 20 abnormally contracting myocardial segments had normal postoperative thallium studies. Our results demonstrate that a normal response to DSE is highly specific for viable myocardium; however, a positive response to DSE has low sensitivity in predicting nonviable myocardium. The majority of new postbypass regional wall motion abnormalities appear to be related to stunned myocardium.
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Affiliation(s)
- Jancqueline M Leung
- *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; and †Department of Cardiovascular Anesthesiology, Kaiser Permanente Medical Center, San Francisco, California
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Bruch C, Comber M, Schmermund A, Eggebrecht H, Bartel T, Erbel R. Diagnostic usefulness and impact on management of transesophageal echocardiography in surgical intensive care units. Am J Cardiol 2003; 91:510-3. [PMID: 12586283 DOI: 10.1016/s0002-9149(02)03264-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Maslow A, Bert A, Schwartz C, Mackinnon S. Transesophageal Echocardiography in the noncardiac surgical patient. Int Anesthesiol Clin 2002; 40:73-132. [PMID: 11910251 DOI: 10.1097/00004311-200201000-00007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew Maslow
- Rhode Island Hospital, Brown University Medical Center, Providence 02903, USA
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Laitio TT, Mäkikallio TH, Huikuri HV, Kentala ESH, Uotila P, Jalonen JR, Helenius H, Hartiala J, Yli-Mäyry S, Scheinin H. Relation of heart rate dynamics to the occurrence of myocardial ischemia after coronary artery bypass grafting. Am J Cardiol 2002; 89:1176-81. [PMID: 12008171 DOI: 10.1016/s0002-9149(02)02300-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Postoperative myocardial ischemia is a common finding after coronary artery bypass grafting (CABG) and is associated with an adverse short-term clinical outcome. The reasons and pathophysiologic background for the occurrence of ischemia after CABG are not well established. We tested the hypothesis that altered heart rate (HR) behavior precedes the onset of myocardial ischemic episodes in patients after CABG. Time-domain HR variability measurements, along with analysis of Poincaré plots and fractal scaling analysis were assessed in 40 CABG patients from 48-hour postoperative Holter recordings. Twenty patients experienced 195 ischemic episodes during the postoperative course. In the univariate analysis of HR variability measurements of the first postoperative day (POD), the increased ratio between the short-term (SD1) and long-term (SD2) HR variability analyzed from the Poincaré plot and the decreased short- and intermediate-term fractal scaling exponents alpha(1) and alpha(2) were significantly associated with ischemia during the study period (p <0.01, p <0.05, and p <0.05, respectively). In the multivariate model, the increased SD1/SD2 ratio of the first POD was the most powerful independent predictor of all possible confounding variables for the occurrence of postoperative ischemia (corresponding to a change of 0.15 U; odds ratio 2.2 and 95% confidence interval 1.2 to 5.7; p <0.01). Altered HR dynamics have been associated with myocardial ischemic episodes in patients after CABG, suggesting that the autonomic nervous system has an important role in the pathogenesis of myocardial ischemia in the postoperative phase of CABG.
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Affiliation(s)
- Timo T Laitio
- Department of Anesthesiology, Turku University Hospital, Turku, Finland
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39
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Mierdl S, Byhahn C, Dogan S, Aybek T, Wimmer-Greinecker G, Kessler P, Meininger D, Westphal K. Segmental wall motion abnormalities during telerobotic totally endoscopic coronary artery bypass grafting. Anesth Analg 2002; 94:774-80, table of contents. [PMID: 11916772 DOI: 10.1097/00000539-200204000-00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED In addition to single-lung ventilation (SLV), intrathoracic CO2 insufflation is mandatory for adequate exposure during totally endoscopic coronary artery bypass grafting. With transesophageal echocardiography, we investigated biventricular myocardial wall motion in 25 patients with isolated disease of the left anterior descending coronary artery who underwent totally endoscopic coronary artery bypass grafting with the "Da Vinci" robotic surgical system. At distinct time points during the operation, a cine loop of both ventricles was registered from a transgastric mid-short-axis view. Myocardial wall motion analysis was performed according to an established segmentation model of the left ventricle and to an established five-point scale for wall motion (1, normal; 5, dyskinesia). Significant alterations from preoperative baseline wall motion were visible in the septal, inferior, and anterior segments of the left ventricle at some time during the prebypass period, combined with a markedly decreased PaO2 under SLV and increased intrathoracic pressure. The same findings applied to the right ventricle; however, wall motion abnormalities were more pronounced here. After myocardial revascularization, weaning from cardiopulmonary bypass, CO2 deflation, and return to double-lung ventilation, myocardial wall motion recovered to baseline values. Clinically significant hemodynamic instability did not occur. The data suggest that robot-assisted coronary artery bypass grafting leads to significant prebypass alterations of biventricular segmental wall motion. On the basis of our data, it cannot be definitively stated whether the observed results were due to reduced oxygenation during SLV and thus "real" myocardial ischemia, intrathoracic CO2 insufflation with positive pressure leading to mechanical compromise of the heart, absolute or relative hypovolemia, or a combination of these factors. However, in this cohort, which consisted of patients with single-vessel disease and good ventricular function, these changes were of limited clinical relevance. IMPLICATIONS Segmental myocardial wall motion was evaluated with transesophageal echocardiography during robot-assisted totally endoscopic coronary artery bypass grafting. Significant biventricular segmental wall motion abnormalities occurred before cardiopulmonary bypass under single-lung ventilation and carbon dioxide insufflation. The changes in myocardial wall motion were of limited clinical relevance.
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Affiliation(s)
- Stephan Mierdl
- Department of Anesthesiology, J. W. Goethe-University Hospital Center, Frankfurt, Germany
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Al-Tabbaa A, Gonzalez RM, Lee D. The role of state-of-the-art echocardiography in the assessment of myocardial injury during and following cardiac surgery. Ann Thorac Surg 2001; 72:S2214-8; discussion S2218-9, S2267-70. [PMID: 11789844 DOI: 10.1016/s0003-4975(01)03300-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Use of intraoperative echocardiography during open heart surgery, transesophageal probes, high-frequency transducers, and color Doppler imaging provide important diagnostic information to surgeons and anesthesiologists. Early detection of myocardial ischemia, assessment of valvular disorders, and the ability to monitor for intracardiac air are among the most important roles of intraoperative transesophageal echocardiography. Large prospective studies are necessary to evaluate whether these changes affect the outcome of patients undergoing coronary artery bypass grafting in terms of morbidity, mortality, hospital length of stay, and functional recovery. The application of new techniques such as contrast-enhanced transesophageal echocardiography helps to assess the adequacy of cardioplegia distribution and, thus, myocardial protection during cardiopulmonary bypass, which has a significant influence on outcomes as well.
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Affiliation(s)
- A Al-Tabbaa
- VA Boston Healthcare System, Harvard Medical School, Massachusetts, USA.
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41
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Williams EF. Monitoring Perioperative Ischemia. Semin Cardiothorac Vasc Anesth 2001. [DOI: 10.1053/seva.2001.23715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This report addresses monitoring for ischemia during surgery and whether perioperative ischemia leads to increased morbidity and mortality in patients with cor onary artery disease (CAD) who are undergoing sur gery. Based on previous studies, it is generally accepted that perioperative ischemia is common in patients with CAD undergoing noncardiac surgery. The incidence of ischemia during the operative period varies greatly with cardiac risk factors, type of surgery, duration of surgery, and the monitor used to detect ischemia. Be cause perioperative cardiac morbidity is the leading cause of death after anesthesia and surgery, it is pru dent for the anesthesia clinician to have an understand ing of the tools available for monitoring as well as their clinical utility. These tools are summarized, and recom mendations are made regarding their use.
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Affiliation(s)
- Elliott F. Williams
- Address reprint requests to Elliott F. Williams, MD, 167 Abbotts Grove Court, High Point, NC 27265
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Balaguru D, Auslender M, Colvin SB, Rutkowski M, Artman M, Phoon CK. Intraoperative myocardial ischemia recognized by transesophageal echocardiography monitoring in the pediatric population: a report of 3 cases. J Am Soc Echocardiogr 2000; 13:615-8. [PMID: 10849516 DOI: 10.1067/mje.2000.105175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We used continuous intraoperative transesophageal echocardiography (TEE) monitoring to detect intraoperative myocardial ischemia in children after they had been weaned from cardiopulmonary bypass for cardiac surgery. Three pediatric patients are described here to illustrate the usefulness of such TEE monitoring in surgical procedures involving coronary arteries. The indications for intraoperative TEE monitoring and a simplified scheme for immediate qualitative interpretation are discussed.
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Affiliation(s)
- D Balaguru
- Pediatric Cardiology Program and the Division of Cardiovascular Surgery, New York University Medical Center, New York, NY 10016, USA
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43
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ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999. [DOI: 10.1213/00000539-199910000-00010] [Citation(s) in RCA: 436] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mangano DT. Peri-operative cardiovascular morbidity: new developments. Best Pract Res Clin Anaesthesiol 1999. [DOI: 10.1053/bean.1999.0032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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45
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Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999; 89:870-84. [PMID: 10512257 DOI: 10.1097/00000539-199910000-00010] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J S Shanewise
- Division of Cardiac Anesthesia and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
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46
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Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884-900. [PMID: 10511663 DOI: 10.1016/s0894-7317(99)70199-9] [Citation(s) in RCA: 233] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- J S Shanewise
- American Society of Echocardiography, Raleigh, NC 27607, USA
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Couture P, Denault AY, Carignan S, Boudreault D, Babin D, Ruel M. Intraoperative detection of segmental wall motion abnormalities with transesophageal echocardiography. Can J Anaesth 1999; 46:827-31. [PMID: 10490149 DOI: 10.1007/bf03012970] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To compare two methods of analysis of regional wall-motion (RWM) using transesophageal echocardiography (TEE). METHODS Thirty patients undergoing coronary artery bypass surgery were studied. The transgastric short axis view at the mid-papillary level was recorded before and after cardiopulmonary bypass. All images were reviewed by an anesthesiologist trained in TEE and an echocardiographer. Regional wall motion was graded: 1 normal, 2 hypokinetic, 3 akinetic, and 4 dyskinetic. The left ventricle was evaluated according to the guidelines of the American Society of Echocardiography using 6-segment, and 4-segment models. Agreement between observers (interobservers), and for one observer at two different moments (intraobservers), for grading each segment was defined as RWM abnormality scores within 1 grade. A wall-motion score index (WMSI), which is the sum of individual scores divided by the number of segments visualized, was calculated. A Bland Altman analysis was used to assess interobserver variability. RESULTS Agreement between observers occurred in 96% and 94% of the examined segments, using 4- and 6-segment models respectively. Intraobserver agreement was 99% and 97% for the 4- and 6-segment models. The mean differences (bias) of the interobserver variability in grading the segments were 0.04 +/- 0.79 and 0 +/- 0.72 using a 4- or 6-segment model. The mean difference of the interobserver variability in WMSI were -0.05 +/- 0.42 and 0.05 +/- 0.37 using a 4- or a 6-segment model. CONCLUSION Both methods, using either a 4- or a 6-segment model, result in a high intraobserver and interobserver agreement, and a low interobserver variability.
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Affiliation(s)
- P Couture
- Department of Anesthesia, Montreal Heart Institute, Quebec, Canada.
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Bilotta F, Fiorani L, Lendaro E, Picardo S, La Rosa I, Rosa G, Fedele F. Pulmonary Transit of Sonicated Albumin Microbubbles During Controlled Mechanical Ventilation. Anesth Analg 1999. [DOI: 10.1213/00000539-199908000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bilotta F, Fiorani L, Lendaro E, Picardo S, La Rosa I, Rosa G, Fedele F. Pulmonary transit of sonicated albumin microbubbles during controlled mechanical ventilation: a transthoracic echocardiographic study. Anesth Analg 1999; 89:273-7. [PMID: 10439729 DOI: 10.1097/00000539-199908000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Air-filled human serum albumin microspheres are ultrasonic contrast tracers that pass through the right ventricle, traverse the lungs, and effectively opacify the left heart chambers in spontaneously breathing patients. In this clinical study, we assessed whether they also do so in anesthetized patients during and after mechanical ventilation. In 20 anesthetized patients undergoing intermittent positive pressure ventilation (IPPV) for elective peripheral neurosurgical procedures, a sonicated ultrasound contrast drug (0.06 mL/kg) was injected i.v. before inducing anesthesia in spontaneously breathing patients (baseline), during IPPV, and 5 and 30 min after tracheal extubation. Transthoracic echocardiograms were obtained in the four-chamber apical view and were recorded for off-line analysis. Time to contrast appearance in the right ventricle and pulmonary transit time were measured in cardiac cycles. The peak intensity of right and left ventricular chamber opacification were scored on a scale ranging from 1 (no contrast or traces only) to 5 (attenuation). After each injection, the time for contrast appearance in the right ventricle was similar in all patients. Pulmonary transit time increased significantly during IPPV and was normal 5 min and 30 min after extubation. Right ventricular chamber opacification achieved high-grade intensity and remained constant before, during, and after IPPV. Conversely, although the baseline contrast injection resulted in high-grade left ventricular chamber opacification, the intensity decreased significantly during IPPV, remained low 5 min after extubation, and was normalized 30 min after extubation. IMPLICATIONS During intermittent positive pressure ventilation, i.v. sonicated albumin microbubbles pass through the lungs poorly and inefficiently opacify the left ventricle compared with the effects observed during spontaneous ventilation.
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Affiliation(s)
- F Bilotta
- Department of Anesthesia, University of Rome La Sapienza, Italy
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50
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Kitahata H, Tanaka K, Kimura H, Kawahito S, Oshita S. The feasibility of gastrothoracic ventricular pacing during transesophageal echocardiography. Anesth Analg 1999; 89:21-5. [PMID: 10389772 DOI: 10.1097/00000539-199907000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED We evaluated whether ventricular pacing is possible using pacing electrodes attached to a transesophageal echocardiography (TEE) probe in 20 patients undergoing elective cardiovascular surgery. A bipolar pacing lead was fixed with silicone adhesive anteriorly to the TEE probe with the distal electrode 25 mm from the TEE probe tip. The TEE probe was positioned to obtain a transgastric short-axis view of the left ventricle. The distal or proximal electrode on the TEE probe was the cathode; the chest electrode placed at the V5 lead position was the anode. Gastrothoracic ventricular pacing (GVP) was performed at 100 bpm at 30- or 50-ms pulse duration. Transgastric ventricular pacing (TVP) was also attempted using both TEE probe electrodes alternately as cathode/anode. Maximal generator output was 32 mA. GVP with the distal electrode as cathode was successful in 75% and 80% of patients at 30- and 50-ms pulse durations and 23.3+/-5.8 mA and 22.6+/-5.8 mA threshold currents, respectively. However, success rates (20% and 25%, respectively) were significantly lower with the proximal electrode as cathode using the same pulse durations and 14.4+/-5.3 mA and 16.7+/-6.8 mA threshold currents. The TVP success rate was significantly lower than that for GVP. With optimization, this system could become an available technique for intraoperative emergency ventricular pacing. IMPLICATIONS Using an endocardial pacing lead attached to a transesophageal echocardiography probe, gastrothoracic ventricular pacing can be performed successfully without complications in 75%-80% of patients undergoing cardiovascular surgery.
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Affiliation(s)
- H Kitahata
- Department of Anesthesiology, Tokushima University School of Medicine, Japan.
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