Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Jun 2006
ReviewTransesophageal echocardiography in the intensive care unit.
Transesophageal echocardiography provides unique diagnostic capabilities, allowing for a very precise look at the structure and hemodynamics of the human heart. It is minimally invasive and portable, and quickly diagnoses sudden hemodynamic changes in intensive care patients. It provides invaluable and precise information about myocardial dysfunction and intracardiac volume status. ⋯ Finally, in heart transplants or in managing patients with mechanical heart assist devices, transesophageal echocardiography is an invaluable tool in assessing progress of treatment and complications arising from the procedures. With the introduction of multiplane transesophageal echocardiography probes, technology, and experienced personnel, transesophageal echocardiography becomes the extension of the physical examination in the intensive care unit. This example is one of only a few whereby technology brings the physician closer to the patient.
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Semin Cardiothorac Vasc Anesth · Jun 2006
ReviewAortic arch atheroma: stroke reduction in cardiac surgical patients.
Cardiac surgery is increasingly performed on elderly patients with extensive coronary artery abnormalities who have impaired left ventricular function, decreased physiologic reserve, and multiple comorbid conditions. Considerable numbers of these patients develop perioperative neurologic complications ranging from subtle cognitive dysfunction to more evident postoperative confusion, delirium, and, less commonly, clinically apparent stroke. Magnetic resonance imaging studies have elucidated that a considerable number of patients have new ischemic brain infarcts, particularly after conventional coronary artery bypass graft surgery. ⋯ Preoperative magnetic resonance angiography may be of value for screening patients with significant atheroma of the proximal thoracic aorta. It is likely that for patients with no significant atheromatous disease, conventional coronary artery revascularization is the most effective long-term strategy, whereas patients with atheromatous thoracic aorta may be better managed with beating heart surgery, hybrid techniques, or medical therapy alone. Patient stratification based on the aortic atheromatic burden should be addressed in future trials designed to tailor treatment strategies to improve long-term outcomes of coronary heart disease and reduce the risks of perioperative neurologic injury.
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In this article, the incidence of nervous system injuries associated with noncardiac surgery is reviewed briefly. In general, these can be divided into injuries that are clinically apparent (eg, stroke or peripheral nerve damage), which may generally be detectable on clinical examination, and more subtle forms of brain injury (eg, personality changes and postoperative cognitive dysfunction), injuries that are primarily detected by neuropsychological testing.
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Semin Cardiothorac Vasc Anesth · Jun 2006
Beating heart versus conventional cardiopulmonary bypass: the octopus experience: a randomized comparison of 281 patients undergoing coronary artery bypass surgery with or without cardiopulmonary bypass.
In the Octopus Study, 281 coronary artery bypass surgery patients were randomized to surgery with or without cardiopulmonary bypass. The primary objective was to compare cognitive outcome between off-pump and on-pump coronary artery bypass surgery. Before and after surgery, psychologists administered a battery of 10 neuropsychological tests to the patients. ⋯ This suggests that the natural fluctuations in performance during repeated neuropsychological testing should be included in the statistical analysis of cognitive decline. Using an alternative definition of cognitive decline that takes these natural fluctuations in performance into account, the proportions of coronary artery bypass surgery patients displaying cognitive decline were substantially lower. This indicates that the incidence of cognitive decline after coronary artery bypass surgery has been overestimated.