Texas Heart Institute journal
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Case Reports
Pharmacologic resolution of functional outflow tract obstruction after mitral valve repair.
A 74-year-old woman with mitral regurgitation secondary to ruptured chordae tendineae, complicated by a cleft in the posterior mitral leaflet and a severely calcified mitral annulus, underwent mitral valve repair by implantation of polytetrafluoroethylene chords and closure of the cleft, without the use of an annuloplasty ring. Immediately after the repair severe left ventricular outflow tract obstruction developed secondary to the systolic anterior motion of the mitral valve. ⋯ The obstruction was severe enough to render impossible the weaning of the patient from cardiopulmonary bypass. This problem was reversed by the infusion of beta-blocking agents into the extracorporeal circuit.
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Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings. All mitral and tricuspid valve repairs were performed by the same surgeon. ⋯ Two patients required late (> 3 month) mitral valve replacement for recurrent regurgitation. We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount.
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Cardiac anesthesiologists have the responsibility to detect myocardial ischemia in a timely manner, which can be a challenging task in the perioperative environment. Transesophageal echocardiography pulmonary artery catheterization, and electrocardiography are the 3 major methods available for monitoring perioperative ischemia. Echocardiography, the newest and most sophisticated method, has been shown to be highly sensitive for detecting ischemia associated with systolic dysfunction. ⋯ Pulmonary artery catheterization can provide information about systolic dysfunction, diastolic dysfunction, and mitral regurgitation, but the sensitivity and safety of catheterization have been questioned. Electrocardiography can be a superb monitoring device as long as clinicians pay adequate attention to lead selection and placement, filter selection, and gain adjustment. The optimal monitoring approach should integrate all 3 available monitoring systems in order to increase the likelihood of detecting both supply- and demand-mediated ischemia.
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The major therapeutic approach to systemic and pulmonary hypertension and vasospasm in cardiac surgery patients involves the use of parenteral agents that reverse systemic vasoconstriction and produce vasodilation. Potential pharmacologic approaches include 1) alpha1-adrenergic receptor blockers, ganglionic blockers, and calcium channel blockers; 2) central alpha2-adrenergic receptor agonists, dopamine1-adrenergic receptor agonists, potassium channel modulators, and vascular cyclic nucleotide stimulators; 3) phosphodiesterase enzyme inhibitors, and 4) angiotensin-converting enzyme inhibitors. Of the currently available intravenous vasoactive therapies, the mainstay agents are the nitrovasodilators and the dihydropyridine-type calcium channel blockers. ⋯ Intravenous dihydropyridine-type calcium channel blockers inhibit mechanical responses of cardiac muscle and vascular smooth muscle by blocking inward calcium currents. Nicardipine is an arterial specific vasodilator. Treatment for vasospasm is usually empiric; pharmacologic options include nitroglycerin, but dihydropyridine calcium channel blockers and phosphodiesterase inhibitors should also be considered.