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This study examined the characteristics, intraoperative, and postoperative course of patients undergoing inferior vena cava tumor thrombectomy for metastatic renal cell carcinoma.A single-center case series that reported demographic data and intraoperative and postoperative outcomes for patients with renal cell carcinoma undergoing inferior vena cava thrombectomy.This investigation was performed at a large quaternary referral center.Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2005, to March 10, 2017, undergoing inferior vena cava thrombectomy for level III and IV renal cell carcinoma.No interventions were performed.Sixty-five patients who met the inclusion criteria were identified, with 31 patients diagnosed with level III and 34 with level IV renal cell carcinoma. Patients with level IV tumors were significantly more likely to have greater intraoperative blood loss, had longer surgical duration and hospital stays, and had more frequently required blood products, pressors, and cardiopulmonary bypass intraoperatively. Intraoperative transesophageal echo was more frequently used in level IV thrombectomy compared to level III (91.2% v 67.7%). Of patients with level IV thrombus, 41.2% developed postoperative atrial fibrillation compared to only 3.2% with level III thrombus. The 30-day mortality was 4.6% for both groups.Patients undergoing inferior vena cava tumor thrombectomy for renal cell carcinoma had more complex intraoperative and postoperative courses with level IV compared to level III tumor thrombus.

Objectives Expert guidelines consistently list esophageal stricture (ES) as a contraindication to the performance of transesophageal echocardiography (TEE), although anecdotally the authors are aware of patients with ES undergoing TEE without apparent complication. Therefore the authors sought to determine the outcomes of patients with ES who had undergone TEE at their institution. Design Single-center, retrospective review. Setting Academic medical center (clinic and affiliated hospital). Participants Patients with documented ES who also underwent TEE. Interventions None. Measurements and Main Results In a 10-year period, 1,083 TEE reports were generated for 823 patients who had a diagnosis of ES. One case of esophageal perforation occurred (1/1,083 examination reports [0.09%]) in an 85-year-old male with gastroesophageal reflux disease–related ES who had undergone esophageal dilation the same day as the TEE. In 17.2% of the TEE reports reviewed, changes to the conduct of the examination occurred, such as use of a pediatric probe or avoidance of transgastric imaging. In 8% of reviewed examinations, procedural difficulty was recorded. Conclusions Patients with nonmalignant ES commonly present for TEE (>100 per year, on average, at the authors’ institution). Severe TEE-related esophageal injury rarely occurred in patients with ES. However, changes to the conduct of the TEE examination and procedural difficulty were not infrequent in this group. Clinicians contemplating TEE in patients with ES should prepare for the possibility of altered examination conduct and possible procedural difficulty.

XTRACORPOREAL CIRCULATORY support among patients with genetic disorders producing erythrocyte fragility requires specific considerations involving decreasing shear stresses on red blood cells (RBCs) and vigilant intraoperative and postoperative monitoring for catastrophic hemolytic anemia. Hereditary spherocytosis (HS) is an autosomal dominant hemolytic anemia characterized by spheroid-shaped erythrocytes with increased osmolality and rigidity. Clinical presentation of HS varies depending on genetic penetrance. Decreased flexibility within the RBC membrane limits deformation and increases the possibility of hemolysis. Specifically, the mechanical stress of cardiopulmonary bypass (CPB) on HS erythrocytes presents a challenge during cardiac surgery. Although previous case reports of successful use of CPB during cardiac surgery in HS patients have been published, 1-13 significant perioperative hemolysis also has been reported. 6 The authors report the successful use of CPB in an adult HS patient undergoing multiple complex cardiac congenital repairs and review perioperative concerns and management.

ACQUIRED HEMOPHILIA A occurs as a result of development of inhibitory autoantibodies to factor VIII in the coagulation cascade. These antibodies result in impaired hemostasis and bleeding disorders of variable severities through varied mechanisms including impairment of binding of factor VIII to membrane phospholipids, factor IX, and/or von Willebrand factor. Common presentation includes mucocutaneous and soft tissue hemorrhage, although hemarthroses typically seen in severe congenital hemophilia A are rare. Most patients are diagnosed during the course of evaluation of bleeding symptoms, and for such patients requiring cardiac surgery, management has been described previously. The successful postoperative management of a case of acquired hemophilia A diagnosed perioperatively after cardiac surgery is reported here.

Objective The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. Design A retrospective review. Setting A single tertiary referral academic hospital. Participants Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. Interventions None. Measurements and Main Results After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. Conclusions Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

Objective The purpose of this study was to examine the effect of perioperative statin administration on renal outcomes after cardiac surgery. Design A retrospective chart review. Setting A university hospital. Participants Patients presenting for cardiac surgery. Interventions The records of 2,760 patients admitted for coronary artery bypass graft (CABG) surgery from 1997 to 2006 were reviewed. In-hospital mortality, the need for renal replacement therapy (RRT), and acute renal failure (ARF) were considered the primary outcomes. Univariate and multiple logistic regression analyses were performed to assess the relationship between each outcome and statin therapy while adjusting for other patient characteristics. Main Results Of the 2,760 patients, 1,557 were taking preoperative statins. On univariate analysis, the mortality rate for patients receiving statins was 2.4% versus 4.2% for those not receiving statins (p = 0.008). The requirement for RRT was 1.9% for patients receiving statins versus 3.6% for those not receiving statins (p = 0.011). The incidence of ARF was not statistically significant between groups (28% v 27.5%). On multivariate analysis, statin therapy was associated with a 43% decrease in the risk of death and a 46% decrease in the risk of RRT, but statins were not associated with a decreased risk of ARF. Also, the beneficial effects of statins were age-dependent, with younger patients experiencing a greater advantage. Conclusions The preoperative use of statins is associated with decreased in-hospital mortality and a reduction in the need for RRT.

o o S d e c T t VER THE LAST 2 DECADES, utilization of percutaneous coronary interventions (PCIs) for the treatment of oronary artery disease has increased by more than 320%.1 In ontemporary practice, most nonsurgical interventions for cornary artery disease involve placement of stents in the diseased oronary circulation2 because coronary artery stent placement mproves the shortand long-term patency rate of coronary essels compared with simple balloon angioplasty.3,4 In 2003 lone, 84% of the 660,000 coronary procedures performed in he United States involved placement of at least 1 coronary tent.1 The initial trials of coronary artery stents were compliated by unacceptably high rates of stent thrombosis (up to .6% incidence if PCI was performed during myocardial inarction).5-9 Stent thrombosis is a potentially lethal event charcterized by the formation of platelet-rich thrombus on the etal stent struts before the development of a protective endohelial barrier. Mortality rates between 30% and 50% have been eported when stent thrombosis occurs and myocardial infarcion always follows. This rate of thrombosis has subsequently ecreased to less than 1% due, in large part, to a better undertanding of the pathophysiology of thrombosis, implementation f effective antiplatelet agents, and advances in stent deployent and design.10 Given the increasing role of PCI in the management of oronary artery disease and the aging of the population, there ill be many more patients presenting in the perioperative eriod with a history of coronary stent placement, either recent r remote. Perioperative physicians need to be aware of the ssues surrounding antiplatelet therapy, stent thrombosis, and leeding risks as they pertain to this patient population. The roblem is further confounded by the fact that this is one of the

Objectives This study’s purpose was to review non-cardiac surgery (NCS) in patients with hypertrophic obstructive cardiomyopathy (HOCM) to examine perioperative management and quantify postoperative mortality and worsening heart failure. Design Retrospective review. Setting A single tertiary care center. Participants The study included 57 adult patients with HOCM who underwent NCS from January 1, 1996, through January 31, 2014. Interventions Noncardiac surgery. Measurements and Main Results The authors identified 57 HOCM patients who underwent 96 NCS procedures. Vasoactive medications were administered to the majority of NCS patients. Three patients (3%) died within 30 days of NCS, but causes of death did not appear to be cardiac in nature. Death after NCS was not significantly associated with preoperative left ventricular ejection fraction (p = 0.2727) or peak instantaneous systolic resting gradient (0.8828), but was associated with emergency surgery (p = 0.0002). Three patients experienced worsening heart failure postoperatively, and this was significantly associated with preoperative New York Heart Association Class III-IV symptoms compared with I-II symptoms (p = 0.0008). Conclusions HOCM patients safely can undergo NCS at multidisciplinary centers experienced in caring for these patients. The mortality rate in this study was less than that reported in the majority of other studies. Postoperative complications, including increasing heart failure, may occur, especially in patients with more severe preoperative cardiac symptoms.

Objective To compare cerebral near-infrared regional spectroscopy (NIRS) with the 12-lead electroencephalogram for the detection of ischemia during carotid artery clamping for carotid endarterectomy (CEA). Design Prospective, observational. Setting Single, tertiary care center. Participants Ninety patients older than 18 undergoing elective, unilateral CEA. Interventions In addition to EEG monitoring, all patients underwent continuous blinded NIRS monitoring with sensors placed bilaterally above the supraorbital ridge. Measurements and Main Results Seventeen patients were excluded, leaving 73 patients available for evaluation. Four patients (5.5%) required shunting based on EEG findings. Changes in cerebral oxygen saturation (rSO2) were assessed on the operative side using the average value for the 1 minute prior to cross-clamp and the lowest rSO2 value the first 5 minutes postclamp. Each 1% absolute decrease and each 1% relative decrease from baseline conferred a 50% increase in the need for shunt placement (OR 1.5; 95% CI (1.03–2.26); p = 0.03 and OR 1.4; 95% CI (1.02–1.81); p = 0.04 respectively). Sensitivity, specificity, and positive and negative predictive values were determined using significant cutoffs of≥5% absolute change or≥10% relative change. Positive predictive value was low (

Fig 1. Intraoperative transgastric LV short-axis view obtained apical to the papillary muscles showing a dilated apex. The anterior and lateral walls display changes consistent with left ventricular hypertrabeculation/noncompaction, including characteristic thickening with a 2-layer appearance and deep recesses between prominent trabeculations.