Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Oct 2022
ReviewThe Intraoperative Assessment of Right Ventricular Function During Cardiac Surgery.
The importance of right ventricular (RV) dysfunction in patients undergoing cardiac surgery is well recognized. There is extensive literature regarding the accurate assessment of RV dysfunction with both echocardiography and hemodynamic data, but the majority of these studies are with transthoracic echocardiography (TTE) and in awake patients. Many of the tools used to assess the RV with TTE are angle-dependent and, therefore, may be inaccurate with transesophageal echocardiography (TEE). ⋯ The purpose of this review is to discuss the intraoperative tools available to the cardiac anesthesiologist for the assessment of RV function. The authors review the available literature surrounding intraoperative RV assessment, from subjective assessment to traditional objective tools that were developed for TTE and newer technology that can be adapted to both TTE and TEE. Future work should focus on whether or not these intraoperative RV assessment tools predict outcome after cardiac surgery.
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J. Cardiothorac. Vasc. Anesth. · Oct 2022
ReviewTranscatheter Mitral Valve Interventions for Mitral Regurgitation: A Review of Mitral Annuloplasty, Valve Replacement, and Chordal Repair Devices.
Significant mitral regurgitation (MR) is the most common valvular disease in the United States in patients older than 75. However, many patients with severe MR are at a high risk for surgical repair due to other significant comorbidities. Over the past decade, many transcatheter mitral valve devices have been studied that address the different mechanisms of MR, but only a few have received a Conformité Européene (CE) mark or United States Food and Drug Administration (FDA) approval. ⋯ Finally, the NeoChord DS 1000 received a CE mark for transcatheter chordal repair. Each of these devices is reviewed in detail, including device indications, performance in clinical trials, anesthetic management, intraprocedural imaging guidance, and postprocedural complications. Although percutaneous devices will appear and disappear from use, understanding the procedural considerations remains highly relevant, as these key principles will apply to the next generation of transcatheter valve interventions.
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J. Cardiothorac. Vasc. Anesth. · Oct 2022
ReviewEuglycemic Diabetic Ketoacidosis Associated With Sodium-Glucose Cotransporter-2 Inhibitors After Cardiac Surgery: A Review of Current Literature.
There is growing evidence to support the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for type 2 diabetes mellitus (T2DM) and the management of heart failure. As such, more patients undergoing cardiac surgery are on SGLT2-inhibitor therapy. Despite the numerous benefits of SGLT2 inhibitors on cardiac health, they can be associated with an increased risk of diabetic ketoacidosis, often with normal glucose levels (euglycemic diabetic ketoacidosis or EDKA), which potentially can be detrimental in this vulnerable patient population. ⋯ SGLT2 inhibitor-induced EDKA is a medical emergency that can be difficult to identify in the postcardiac surgical patient due to the overlap of signs and symptoms with other frequent scenarios in these patients. A reduction in SGLT2 inhibitor-associated EDKA can be mitigated by the appropriate perioperative discontinuation of the medication, clinical awareness, and early investigation to diagnose the condition, with emphasis on serum β-hydroxybutyrate. Future quality improvement initiatives are needed to assist in reducing EDKA in patients taking SGLT2 inhibitors in the perioperative surgical setting.
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J. Cardiothorac. Vasc. Anesth. · Oct 2022
ReviewSepsis-induced cardiomyopathy reviewed: The case for early consideration of mechanical support.
Sepsis-induced cardiomyopathy (SCM) is an increasingly recognized problem encountered in critical care medicine. It generally is characterized as a decrease in left, right, or biventricular ejection fraction followed by a recovery of function over a period of days to weeks. Venoarterial extracorporeal membrane oxygenation (ECMO) has been used for the treatment of adults with various etiologies of shock, including cardiogenic and septic shock. This review summarizes current pathophysiologic mechanisms leading to SCM and provides a detection and treatment algorithm for SCM, as well as a discussion about the rationale and recent clinical data surrounding the use of ECMO and other forms of mechanical circulatory support for SCM.
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J. Cardiothorac. Vasc. Anesth. · Oct 2022
ReviewBiventricular repair as an alternative to single-ventricle palliation in a child with hypoplastic left heart structures: What the anesthesiologist should know.
Enhanced techniques for single-ventricle palliation (SVP), in which the Fontan procedure is the final phase, have improved the survival and quality of life in patients not eligible for biventricular repair (BiVR). However, Fontan physiology also is associated with predictable long-term consequences that ultimately affect quality of life and freedom from adverse events. Given this harsh reality, the advances in ventricular rehabilitation strategies and the conversion from SVP increasingly are being used to achieve biventricular circulation in patients with left-heart hypoplasia who previously were considered to be marginal or unacceptable candidates for BiVR. ⋯ In addition, reverse double-switch surgery has been used as an option for patients with a left ventricle of insufficient size and function to support the systemic circulation, who would otherwise require a Fontan surgery. Despite improved management and surgical technique, the outcomes after biventricular staging repair and conversion remain variable, and the complications ultimately may exclude patients from future single-ventricle palliation or transplant. The anesthesiologist should have a basic understanding of the anatomy and physiology of this growing patient population in order to develop adequate perioperative management options.