Annals of cardiac anaesthesia
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A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. ⋯ However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.
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Transesophageal echocardiography (TEE) is a semi-invasive, monitoring and diagnostic tool, which is used in the perioperative management of cardiac surgical and hemodynamically unstable patients. The low degree of invasiveness and the capacity to visualize and assimilate dynamic information that can change the course of the patient management is an important advantage of TEE. Although TEE is reliable, comprehensive, credible, and cost-effective, it must be performed by a trained echocardiographer who understands the indications and the potential complications of the procedure, and has the ability to achieve proper acquisition and interpretation of the echocardiographic data. ⋯ Two-dimensional (2D) and Motion (M) mode imaging are used for obtaining anatomical information, while Doppler and Color Flow imaging are used for information on blood flow. 3D technology enables us to view the cardiac structures from different perspectives. Despite the recent advances of 3D TEE, a sharp, optimized 2D image is pivotal for the reconstruction. This article describes the relevant underlying physical principles of ultrasound and focuses on a systematic approach to instrumentation and use of controls in the practical use of transesophageal echocardiography.
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Transcatheter aortic valve implantation (TAVI) is an emergent technique for high-risk patients with aortic stenosis. TAVI poses significant challenges about its management because of the procedure itself and the population who undergo the implantation. Two devices are currently available and marketed in Europe and several other technologies are being developed. ⋯ However, after the initial experiences, many groups began to employ, routinely, sedation plus local anaesthesia for TAVI, and their procedural and periprocedural success demonstrates that it is feasible. TAVI is burdened with potential important complications: vascular injuries, arrhythmias, renal impairment, neurological complications, cardiac tamponade, prosthesis malpositioning and embolization and left main coronary artery occlusion. The aim of this work is to review the anaesthetic management of TAVI based on the available literature.
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Extracorporeal membrane oxygenation (ECMO) is an adaptation of conventional cardiopulmonary bypass techniques to provide cardiopulmonary support. ECMO provides physiologic cardiopulmonary support to aid reversible aspects of the disease process and to allow recovery. ECMO does not provide treatment of the underlying disease. ⋯ Vascular access for ECMO support is either percutaneous through a single-site, dual-lumen bicaval cannula or transthoracic via separate cannulas. The modes of support are either veno-venous or veno-arterial ECMO. In this article, the physiologic aspects of ECMO support are outlined.
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The preoperative cardiac assessment of patients undergoing noncardiac surgery is common in the daily practice of medical consultants, anesthesiologists, and surgeons. The number of patients undergoing noncardiac surgery worldwide is increasing. Currently, there are several noninvasive diagnostic tests available for preoperative evaluation. ⋯ The preferred stress test is the exercise electrocardiogram (ECG). Stress imaging with exercise or pharmacologic stress agents is to be considered in patients with abnormal rest ECG or patients who are unable to exercise. After reviewing this article, the reader should develop an understanding of the following: (1) the magnitude of the cardiac preoperative morbidity and mortality, (2) how to select a patient for further preoperative testing, (3) currently available noninvasive cardiac testing for the detection of coronary artery disease and assessment of left ventricular function, and (4) an approach to select the most appropriate noninvasive cardiac test, if needed.