Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Sep 2007
Case ReportsIntracardiac thrombosis and acute right ventricular failure following complex reoperative cardiac surgery with aprotinin and deep hypothermic circulatory arrest.
Although coagulopathy and bleeding are common in the setting of cardiac surgery, a growing number of case reports in the literature suggest that hypercoagulability may also result in significant morbidity and mortality. We present a case of apparent hypercoagulability with formation of thrombus in the cardiac chambers following reoperative cardiac surgery using cardiopulmonary bypass, aprotinin, and deep hypothermic arrest. A review of those hypercoagulable disorders with reported impact on cardiac surgery and a discussion follow the case presentation.
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Semin Cardiothorac Vasc Anesth · Jun 2007
ReviewManagement of pulmonary hypertension in the operating room.
Pulmonary artery hypertension is defined as persistent elevation of mean pulmonary artery pressure > 25 mm Hg with pulmonary capillary wedge pressure < 15 mm Hg or elevation of exercise mean pulmonary artery pressure > 35 mm Hg. Although mild pulmonary hypertension rarely impacts anesthetic management, severe pulmonary hypertension and exacerbation of moderate hypertension can lead to acute right ventricular failure and cardiogenic shock. ⋯ Recent advances in pharmacology provide anesthesiologists with a wide variety of options for selective pulmonary vasodilatation. Pulmonary hypertension is a major determinant of perioperative morbidity and mortality in special situations such as heart and lung transplantation, pneumonectomy, and ventricular assist device placement.
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Semin Cardiothorac Vasc Anesth · Jun 2007
ReviewCurrent therapies for pulmonary arterial hypertension.
Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature, characterized by relentless deterioration and death. Patients with PAH are known to be at increased risk for anesthetic complications and surgical morbidity and mortality. However, outcomes in patients have improved with the recent development of new drug therapies. ⋯ Surgical and interventional treatments of PAH, including atrial septostomy, pulmonary thromboendarterectomy, and transplantation, are briefly reviewed, and the rationale, indications, and selection criteria for each are discussed. Although available medical and surgical therapies for PAH have improved patient outcomes, acute decompensated right heart failure (RHF) remains a common and challenging complication of PAH. The authors review this topic and provide an outline of the general pathophysiology of RHF and an approach to its management.
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Therapeutic hypothermia, introduced more than 5 decades ago, remains an important neuroprotective factor in the surgery for the correction of congenital heart disease, in particular when intraoperative circulatory arrest is required. Hypothermia decreases cerebral metabolism and energy consumption and reduces the extent of degenerative processes such as the excitotoxic cascade, apoptotic and necrotic cell death, microglial activation, oxidative stress, and inflammation. Neurological outcome has become the focus of several studies in the recent years, and deep hypothermic circulatory arrest durations of more than 40 minutes are associated with increased mid- and long-term disability. ⋯ Although evidence from animal studies suggests potential benefit from very low temperatures, postoperative development of choreoathetosis has been found to correlate with the degree of intraoperative hypothermia, recommending the use of central temperatures greater than 15 degrees C in the clinical practice. Cooling times longer than 20 minutes are needed to obtain homogeneous brain cooling and effective neuroprotection. Finally, there is evidence that the sites of temperature monitoring used in the clinical practice may underestimate brain temperature after cardiopulmonary bypass, with the risk of postoperative hyperthermic brain damage.
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Semin Cardiothorac Vasc Anesth · Mar 2007
ReviewBrain monitoring and protection during pediatric cardiac surgery.
With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on long-term functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. ⋯ Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.