Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Dec 2014
ReviewPulmonary endarterectomy: part I. Pathophysiology, clinical manifestations, and diagnostic evaluation of chronic thromboembolic pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary hypertension (PH) remains underdiagnosed. ⋯ This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.
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The structural defects associated with the various forms of congenital heart disease lead to pathological and functional changes that place patients at risk for adverse events, and in fact the perioperative incidence of morbidity and mortality has been documented to be increased in children with congenital heart disease. Patients with congenital heart disease can present to the anesthesiologist in a relatively precarious state of balance of several hemodynamic factors, including preload, ventricular contractility, systemic vascular resistance, pulmonary vascular resistance, heart rate, and cardiac rhythm. Anesthetic drugs can affect each of these, and an ideal anesthetic drug for such patients does not exist. The purpose of this article is to review the hemodynamic effects of anesthetic drugs and how they may contribute to the occurrence of adverse events in children with congenital heart disease.
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Semin Cardiothorac Vasc Anesth · Sep 2014
Efficacy of Evolving Early-Extubation Strategy on Early Postoperative Functional Recovery in Pediatric Open-Heart Surgery: A Matched Case-Control Study.
There has been a paradigm shift toward "fast-track" management with early extubation (EE) in cardiac surgery. Our retrospective, matched case-control study wishes to define the benefits of EE in pediatric congenital heart surgery. We examined 50 consecutive pediatric cardiac surgery patients extubated in the operating room (February 2009 to July 2009) against a control group of delayed-extubation patients. ⋯ The reintubation rate was not significant. EE patients have equivalent hemodynamic profiles shown by a decreased necessity for inotropic support. We conclude that EE is feasible in low-/medium-risk pediatric congenital heart surgery patients.
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Semin Cardiothorac Vasc Anesth · Jun 2014
ReviewA 2014 Update on Coagulation Management for Cardiopulmonary Bypass.
Coagulopathy after cardiac surgery with cardiopulmonary bypass is a serious complication that may result in massive bleeding requiring transfusion of significant amounts of blood products, plasma, and platelets. In addition to increased patient morbidity and mortality it is associated with longer hospital stay and increased resource utilization. The current review discusses aspects in cardiopulmonary bypass-induced coagulopathy with emphasis on point-of-care testing and individualized "goal-directed" therapy in patients who develop excessive bleeding after cardiac surgery.
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Semin Cardiothorac Vasc Anesth · Jun 2014
ReviewPerioperative Diastolic Dysfunction: A Comprehensive Approach to Assessment by Transesophageal Echocardiography.
Left ventricular diastolic dysfunction (LVDD) has only recently been recognized as an important determinant of perioperative morbidity. Intraoperative echocardiographers have been slow to adopt assessment of LVDD into clinical practice. This has been partly attributable to the complex measurements required to characterize LVDD, which are in turn related to how our understanding of diastole has evolved. ⋯ However, given the limitations of flow velocity, direct measurement of tissue velocity can significantly improve the characterization of diastolic dysfunction. The evolution of Doppler and speckle-based methods of assessing tissue motion have vastly improved our understanding of diastolic function. With the development of simpler algorithms for categorization, and their gradual adoption by perioperative echocardiographers, LVDD should be better diagnosed and treated to improve postoperative outcomes.