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Pieri M, Dormio S, Morosato M, Belletti A, Silvestri D, Montorfano M, Monaco F. Shaping the Anesthetic Approach to TricValve Implantation: Insights From a Case Series. J Cardiothorac Vasc Anesth 2024; 38:911-917. [PMID: 38281824 DOI: 10.1053/j.jvca.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/29/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Caval valve implantation (CAVI) represents a minimally invasive strategy for managing severe tricuspid regurgitation in high-risk patients unsuitable for surgical or transcatheter tricuspid valve implantation. This case series aimed to assess the anesthesia management challenges and outcomes associated with this procedure, seeking to generate insights that can inform and refine anesthesia protocols. DESIGN A case series. SETTING At a cardiac catheterization laboratory of a teaching hospital. PARTICIPANTS Eight patients undergoing CAVI with the Tricvalve system INTERVENTIONS: The anesthetic protocol included preprocedural planning, fast-track general anesthesia, and postprocedural debriefing. Intraoperative management involved anesthesia depth monitoring, real-time guidance via transesophageal echocardiography, and hemodynamic stability maintenance. Postoperative analgesia involved preemptive intravenous paracetamol and morphine as needed. MEASUREMENTS AND MAIN RESULTS No anesthesia-related or implantation-related complications were observed, with a mean procedure duration of 112 ± 44 minutes. The median hospital stay was 4 days, and only 1 patient required brief intensive care unit monitoring. Postoperative right shoulder pain was reported by half of the patients, and was managed with morphine bolus administration (average dose 4.75 ± 3.6 mg). All patients had the device correctly positioned, as confirmed by postoperative transthoracic echocardiograms. None of the patients required outpatient analgesic therapy upon discharge. CONCLUSIONS The authors' study demonstrated the potential of TricValve implantation in effectively managing severe tricuspid regurgitation with no procedure-related complications and a 100% survival rate. A collaborative, interdisciplinary approach and targeted anesthesia management proved crucial for this success. Postoperative shoulder pain emerged as a frequent complication, whose pathogenesis is still not clear, and successfully was managed using targeted analgesic therapy.
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Affiliation(s)
- Marina Pieri
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Dormio
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Morosato
- Cardiothoracic Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Belletti
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Silvestri
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Vita-Salute San Raffaele University, Milan, Italy; Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [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: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Jiang W, Long XM, Wei KQ, Li SC, Zhang Z, He BF, Li H. Application effect of thoracoscopic tricuspid valvuloplasty in geriatric patients with tricuspid valve disease. World J Clin Cases 2022; 10:4810-4817. [PMID: 35801058 PMCID: PMC9198848 DOI: 10.12998/wjcc.v10.i15.4810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/28/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thoracoscopic-assisted technology can ensure that doctors can implement minimally invasive treatment through the right intercostal incision or small incision of the lower sternum. This approach not only can achieve a cardiac correction effect equivalent to that of a thoracotomy but also has the benefit of a clear surgical field ensuring the safety of surgical treatment.
AIM To investigate the effect of thoracoscopic tricuspid valvuloplasty in patients with tricuspid valve disease.
METHODS A total of 41 patients with tricuspid valve disease underwent traditional thoracotomy treatment between January 2018 and June 2020. Forty-one patients with tricuspid valve disease who underwent thoracoscopic tricuspid valvuloplasty treatment between July 2020 and June 2021 in our hospital were selected as controls for our retrospective analysis. The study group underwent thoracoscopic tricuspid valvuloplasty, while traditional thoracotomy was performed in the control group. The operation conditions (the duration of extracorporeal circulation, aorta blocking, endotracheal intubation, and surgery), inflammatory response-related indices (C-reactive protein and white blood cell count) before and after surgery, parameters related to myocardial injury (myocardial troponin T, creatine kinase isoenzyme, creatine kinase, and lactate dehydrogenase), and the incidence of adverse events in the two groups was counted.
RESULTS The duration of extracorporeal circulation (109.35 ± 50.31 min), aortic occlusion (94.26 ± 59.61 min), endotracheal intubation (12.59 ± 3.54 h), and hospital stay (5.29 ± 2.34 d) in the study group were shorter than those in the control group (114.91 ± 46.98 min, 101.37 ± 61.44 min, 13.11 ± 4.01 h, 7.09 ± 3.11 d, respectively). The difference in hospital stay between the two groups was statistically significant (P < 0.05). Serum C-reactive protein level (4.69 ± 1.35 mg/L) and white blood cell count (6.21 ± 1.97 × 109/L) in the study group were found to be not significantly different than those in the control group (5.01 ± 1.18 mg/L, 5.98 ± 2.01 × 109/L, respectively; P > 0.05). Myocardial troponin T (0.04 ± 0.02 ng/mL), creatine kinase isoenzyme (4.02 ± 1.11 mg/mL), creatine kinase (91.35 ± 10.44 U/L), and lactate dehydrogenase (179.81 ± 60.04 U/L) in the study group were also not statistically significant different than those in the control group (0.05 ± 0.03 ng/mL, 3.97 ± 1.05 mg/mL, 89.69 ± 13.05 U/L, 186.35 ± 56.96 U/L; P > 0.05). After the operation, serum C-reactive protein level (7.89 ± 1.73 mg/L) and white blood cell count (10.76 ± 2.35 × 109/L) in the study group were significantly lower than those in the control group (9.96 ± 2.04 mg/L, 14.84 ± 3.07 × 109/L, respectively) (P < 0.05). In addition, myocardial troponin T (0.89 ± 0.32 ng/mL), creatine kinase isoenzyme (26.96 ± 4.95 mg/mL), creatine kinase (608.32 ± 202.33 U/L), and lactate dehydrogenase (282.56 ± 101.34 U/L) in the study group were lower than those in the control group (2.61 ± 0.69 ng/mL, 34.37 ± 6.87 mg/mL, 689.94 ± 214.64 U/L, 369.15 ± 114.46 U/L) (P < 0.05). The incidence of adverse events in the study group (4.88%) was lower than that in the control group (19.51%) (P < 0.05).
CONCLUSION Thoracoscopic tricuspid valvuloplasty can achieve good results in treating patients with tricuspid valve disease, reduce the risk of adverse events, and promote the rapid recovery of patients.
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Affiliation(s)
- Wei Jiang
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Mao Long
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ke-Quan Wei
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Si-Cong Li
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ze Zhang
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Bang-Fu He
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Hui Li
- Department of Cardiothoracic and Vascular Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Monaco F, Di Prima AL, Kim JH, Plamondon MJ, Yavorovskiy A, Likhvantsev V, Lomivorotov V, Hajjar LA, Landoni G, Riha H, Farag A, Gazivoda G, Silva F, Lei C, Bradic N, El-Tahan M, Bukamal N, Sun L, Wang C. Management of Challenging Cardiopulmonary Bypass Separation. J Cardiothorac Vasc Anesth 2020; 34:1622-1635. [DOI: 10.1053/j.jvca.2020.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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Song YY, Zhang B, Gu JW, Zhang YJ, Wang Y. The predictive value of procalcitonin in ventilator-associated pneumonia after cardiac valve replacement. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:423-426. [PMID: 32425062 DOI: 10.1080/00365513.2020.1762242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study aimed to evaluate the predictive value of procalcitonin (PCT) in ventilator-associated pneumonia (VAP) after cardiac valve replacement. A total of 80 patients who underwent cardiac valve replacement in our department were enrolled in this study. Of these patients,40 were diagnosed with VAP and assigned to the observation group, while the other 40 patients not diagnosed with VAP were assigned to the control group. The changes in serum PCT, white blood cell count and C-reactive protein (CRP) were observed before each operation (T0), on the first day after the operation (T1), the second day after the operation (T2) and the third day after the operation (T3). After the operation, the serum PCT in the observation group was significantly higher than those at different time points after the operation, and also significantly higher than those in the control group (p < .05). In the control group, PCT was significantly higher after the operation than before the operation (p < .05), but the differences among the different postoperative time points were not statistically significant (p > .05). In the two groups, the white blood cell count and CRP were significantly higher after the operation than before the operation (p < .05), but the differences between the two groups were not statistically significant (p > .05). Serum PCT is an early, sensitive and highly specific high-risk monitoring index and has an early prediction value for VAP after cardiac valve replacement.
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Affiliation(s)
- Yan-Yan Song
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Bin Zhang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ji-Wei Gu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yu-Jing Zhang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yun Wang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
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Kim JH, Lerose CC, Landoni G, Di Prima AL, Licheri M, Oriani A, Alaidroos M, Zangrillo A, Monaco F. Differences in Biomarkers Pattern Between Severe Isolated Right and Left Ventricular Dysfunction After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:650-658. [PMID: 31473115 DOI: 10.1053/j.jvca.2019.07.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/10/2019] [Accepted: 07/14/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To find out if there are any differences in biomarkers between severe isolated right ventricular (RV) dysfunction and severe isolated left ventricular (LV) dysfunction after cardiac surgery using cardiopulmonary bypass. DESIGN Observational study. SETTING Teaching hospital. PARTICIPANTS A total of 46 patients who had severe isolated RV or LV dysfunction after cardiac surgery. INTERVENTION The authors collected perioperative clinical and biomarker data. MEASUREMENTS AND MAIN RESULTS Severe isolated RV dysfunction patients (n = 20) had higher postoperative direct bilirubin (p = 0.030), total bilirubin (p = 0.044), glucose (p = 0.011), and international normalized ratio (INR) (p = 0.050) by repeated measure analysis of variance when compared with patients with severe isolated LV dysfunction (n = 26). The RV group also showed lower preoperative alanine transferase (19.3 ± 1.5 v 32.7 ± 4.2, p = 0.001), higher 4-hour INR (1.5 ± 0.3 v 1.4 ± 0.2, p = 0.008), and higher 48-hour INR (1.8 ± 0.4 v 1.4 ± 0.1, p < 0.001). None in the LV group died, whereas 4 patients in the RV group died (all of them had preoperative atrial fibrillation and underwent double valve replacement surgery). CONCLUSION The authors observed biomarkers differences between severe isolated RV dysfunction and severe isolated RV dysfunction.
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Affiliation(s)
- Jun Hyun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Caterina Cecilia Lerose
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moad Alaidroos
- Clinical Research Unit Cardiovascular Department, IRCCS - Policlinico San Donato, Milan, Italy; Vascular Surgery Unit Policlinico San Marco, Zingonia, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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