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Previous studies on readmissions after left ventricular assist device (LVAD) implantation have focused on hospital readmissions after dismissal from the index hospitalization. Because few data exist, the purpose of this study was to examine intensive care unit (ICU) readmissions in patients during their initial hospitalization for LVAD implantation to determine reasons for, factors associated with, and incidence of mortality after ICU readmission.A retrospective analysis was performed from February 2007 to March 2015 of patients at our institution receiving first-time LVAD implantation. After LVAD implantation, patients dismissed from the ICU who then required ICU readmission before hospital dismissal were compared to those not requiring ICU readmission before hospital dismissal with respect to preoperative, intraoperative, and postoperative factors.Among 287 LVAD patients, 266 survived their initial ICU admission, of which 49 (18.4%) required ICU readmission. The most common reasons for readmission were bleeding and respiratory failure. Factors found to be univariably associated with ICU readmission were preoperative hemoglobin, preoperative aspartate aminotransferase, preoperative atrial fibrillation, preoperative dialysis, longer cardiopulmonary bypass times, and higher intraoperative allogeneic blood transfusion requirements. Multivariable analysis revealed ICU readmission to be independently associated with preoperative dialysis (odds ratio, 12.86; 95% confidence interval, 3.16-52.28; P.001). Overall mortality at 1 year was 22.6%. Survival after hospital dismissal was worse for patients who required ICU readmission during the index hospitalization (adjusted hazard ratio, 2.35; 95% confidence interval, 1.15-4.81; P = .019).ICU readmission after LVAD implantation occurred relatively frequently and was significantly associated with 1-year mortality after hospital dismissal. These data can perhaps be used to identify subsets of LVAD patients at risk for ICU readmission and may lead to implementation of practice changes to mitigate ICU readmissions. Future larger and prospective studies are warranted.

Disorders affecting red blood cells (RBCs) are uncommon yet have many important physiologic considerations for patients undergoing cardiac surgery. RBC disorders can be categorized by those that are congenital or acquired, and further by disorders affecting the RBC membrane, hemoglobin, intracellular enzymes, or excessive RBC production. A foundational understanding of the physiologic derangement for these disorders is critical when considering perioperative implications and optimization, strategies for cardiopulmonary bypass, and the rapid recognition and treatment if complications occur. This review systematically outlines the RBC disorders of frequency and relevance with an emphasis on how the disorder affects normal physiologic processes, a review of the literature related to the disorder, and the implications and recommendations for patients undergoing cardiac surgery.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that leads to death due to respiratory failure. This report describes the perioperative characteristics of ALS patients who underwent procedures with anesthesia at our institution. We reviewed perioperative records of ALS patients who underwent procedures with anesthesia from January 1, 2014, through December 31, 2015. Seventy-eight patients underwent 89 procedures (71 procedures with monitored anesthesia care and 18 with general anesthesia), including 45 gastrostomy tube placements and 18 bone marrow biopsies. Three patients had prolonged duration of postoperative intubation related to preexisting respiratory muscle weakness, and one patient with bilateral pneumothorax required tracheal reintubation for respiratory distress. Four patients had prolonged duration of hospitalization. Three patients were hospitalized for ALS-related complications, and one patient was hospitalized for respiratory distress when pneumoperitoneum developed after gastrostomy tube placement. Three of these patients died of complications attributable to ALS within 30 days of the procedure. Twenty-nine (32.6%) procedures required minimal sedation (e.g., bone marrow biopsy, cataract surgery) and were performed on an ambulatory basis. When caring for patients with ALS, the perioperative team must be prepared to treat potentially complex medical conditions that may not be directly related to the procedure and anesthetic management. However, minor procedures performed with minimal sedation may be safely performed on an ambulatory basis.

Background Intrathoracic paragangliomas (PGLs) are rare tumors. Approximately 50% originate from and around cardiac structures. Methods A retrospective review was made of the perioperative course of patients with intrathoracic PGL resection from 2000 through 2015 at Mayo Clinic in Rochester, Minnesota. Results Twenty-two patients underwent PGL resection. Sixteen patients (73%) had functioning tumors (11, noradrenergic; 4, mixed noradrenergic and dopaminergic; 1, dopaminergic). Patients with functioning tumors received preoperative adrenergic blockade: 15 (68%), α 1,2 -adrenergic receptor antagonist; 4 (18%), α 1 -adrenergic receptor antagonists; and 13 (59%) metyrosine. Six patients with nonfunctioning tumors had no adrenergic blockade. Twelve patients had tumor resection without cardiopulmonary bypass—9 for PGL associated with the great vessels, 2 for PGL with pericardial involvement, and 1 for PGL in right atrioventricular groove. Ten patients required cardiopulmonary bypass; for 9, the tumor involved cardiac structures and for 1, it involved ascending aorta and proximal aortic arch. Of these, 1 patient had uncontrollable bleeding and died intraoperatively. Other than this single death, there were no inhospital major cardiac or pulmonary complications. Median follow-up was 8.2 years (range, 2.1 to 17.2). Six patients subsequently had metastatic disease, and of them, 1 died 6 years after the operation. Conclusions In this series, 73% of intrathoracic PGLs were functional and involved noradrenergic, mixed noradrenergic and dopaminergic, or pure dopaminergic secretion. Cardiac and pericardial paraganglioma resection may require cardiopulmonary bypass. Although intraoperative bleeding in most complex cases may be uncontrollable, as for 1 of our patients, those who survived hospital discharge had favorable long-term outcomes.

Although ambulatory surgery offers patients convenience and reduced costs, same-day cancellation of ambulatory surgery negatively affects patient experiences and operational efficiency. We conducted a retrospective analysis to determine the frequency and reasons for same-day cancellations in an outpatient surgery center at a large academic tertiary referral center. Of 41 389 ambulatory surgical procedures performed, same-day cancellations occurred at a rate of 0.5% and were usually unforeseeable in nature. Focusing on foreseeable cancellations offers opportunities for enhanced patient satisfaction, improved quality of care, and systems-based practice improvements to mitigate cancellations related to areas such as scheduling or patient noncompliance.

Objective To compare outcomes following inactive prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa) administration during cardiac surgery. Design Retrospective propensity-matched analysis. Setting Academic tertiary-care center. Participants Patients undergoing cardiac surgery requiring cardiopulmonary bypass who received either rFVIIa or the inactive 3-factor PCC. Interventions Outcomes following intraoperative administration of rFVIIa (263) or factor IX complex (72) as rescue therapy to treat bleeding. Measurements and Main Results In the 24 hours after surgery, propensity-matched patients receiving PCC versus rFVIIa had significantly less chest tube outputs (median difference –464 mL, 95% confidence interval [CI] –819 mL to –110 mL), fresh frozen plasma transfusion rates (17% v 38%, p = 0.028), and platelet transfusion rates (26% v 49%, p = 0.027). There were no significant differences between propensity-matched groups in postoperative stroke, deep venous thrombosis, pulmonary embolism, myocardial infarction, or intracardiac thrombus. Postoperative dialysis was significantly less likely in patients administered PCC versus rFVIIa following propensity matching (odds ratio = 0.3, 95% CI 0.1-0.7). No significant difference in 30-day mortality in patients receiving PCC versus rFVIIa was present following propensity matching. Conclusions Use of rFVIIa versus inactive PCCs was significantly associated with renal failure requiring dialysis and increased postoperative bleeding and transfusions.

Coagulopathy and bleeding are common in patients undergoing cardiac surgery, with a perioperative transfusion rate in excess of 50%. The mechanism of coagulopathy associated with cardiac surgery using cardiopulmonary bypass is multifactorial. Historically, coagulation factor-mediated bleeding in such instances has been treated with allogeneic plasma transfusion. Coagulation factor concentrate use for treatment of hemophilia, congenital factor deficiencies and, more recently, emergency warfarin reversal is common. Formulations of factor concentrates include single and multifactor concentrates and both human and recombinant-derived products. Off-label use of factor concentrates for coagulopathy and bleeding associated with cardiac surgery has been described for decades; however, sound clinical research with regard to this practice is limited. This review highlights the literature discussing the use of factor concentrates in patients undergoing cardiac surgery and provides an overview of reasonable uses or lack thereof for factor concentrates in clinical practice.

Author(s): Sandefur, Benjamin J.; Oliveira J. e Silva, Lucas; Lohse, Christine M.; Goyal, Kiran A.; Barbara, David W.; Castaneda-Guarderas, Ana; Liu, Xiao-wei; Campbell, Ronna L. | Abstract: Introduction: Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology.Methods: This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema.Results: Among 450 adult angioedema patients, the mean +/- standard deviation age was 57 +/- 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16-160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87-18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02-0.15), dyspnea (OR [0.23]; 95% CI, 0.08-0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08-0.79 and OR [0.32]; 95% CI, 0.13-0.79, respectively).Conclusion: As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies.

Neuromuscular blockade (NMB) reversal with neostigmine and glycopyrrolate has been reported to cause cardiac arrest in patients with a history of cardiac transplantation. The purpose of this study was to examine the safety of NMB reversal with acetylcholinesterase inhibitors and muscarinic anticholinergics in these patients.We queried the medical records of a large tertiary referral center for patients with a history of prior heart transplantation who underwent anesthesia including receipt of NMB reversal. Patient records were reviewed to investigate maximal decrease in heart rate (HR) after NMB reversal and incidence of death and cardiac arrest.Seventy-seven heart transplant patients underwent 118 subsequent anesthetics during which they received neostigmine and glycopyrrolate for NMB reversal. No patients had active pacemakers at the time of their anesthetics. Mean time from heart transplantation to NMB reversal was 2.9 ± 3.2 (median, 1.9; range, 0.01- 12.5) years. After NMB reversal, no patients received atropine or epinephrine, suffered cardiac arrest, or died within 30 days. Mean HR decrease, defined as the difference between the HR immediately before NMB reversal and the lowest HR within 5 minutes thereafter, after NMB reversal was 0.5 ± 3.2 with median 0 (range, -8 to 17) beats per minute. Mean HR decrease was not associated with transplantation type (biatrial versus bicaval, P = 0.2029) or with increasing duration of time from cardiac transplantation (P = 0.0874).Although rare cases of cardiac arrest after NMB reversal have been reported, our experience would support the safety of neostigmine and glycopyrrolate in cardiac transplantation patients.

Background We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. Material/methods Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. Results Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10-37] vs. 12 [7-21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressure pre-intubation (per 5 mmHg decrease) (p-value=0.04; 95% CI 1.01-1.55); 2) administration of neuromuscular blockers (p-value=0.03; 95% CI 1.12-6.53); and 3) intubation complication (p-value=0.03; 95% CI 1.16-15.57). Conclusions Post-intubation hypotension was common in the ICU and was associated with increased in-hospital mortality and length of stay. These patients were more likely to have had lower mean arterial pressure prior to intubation, received neuromuscular blockers, or suffered a complication during intubation.

SummaryBackground Bardet–Biedl syndrome (BBS) is a rare genetic condition with manifestations that can impact anesthetic and perioperative care. There is a void of literature describing the perioperative anesthetic management in this complex patient population. Objectives The purpose of this retrospective series was to describe the perioperative care of patients diagnosed with BBS at a large academic tertiary referral center with experience in caring for these patients. Methods All patients receiving anesthesia during the time between July 10, 1997 and Jan 1, 2015 were identified. Anesthetic and perioperative records were reviewed in detail for demographic, echocardiographic, preoperative, intraoperative, and postoperative data. Results We identified 12 patients with BBS undergoing 40 anesthetics at our institution. The study identified a high risk for difficult airway with need for advanced airway techniques (67% of patient's ≥18 years of age required either awake fiberoptic or video laryngoscopy techniques), cardiac abnormalities, renal impairment, morbid obesity, and intellectual disability as the main syndrome manifestations of interest to the anesthesiologist. No patient had perioperative complications directly related to BBS; however, each underwent thorough perioperative evaluation with emphasis on the systemic comorbidities associated with the syndrome. This report illustrates that patients with BBS can safely undergo anesthesia, but a detailed and often multidisciplinary preoperative evaluation is prudent.

Objective The objective of this retrospective review was to evaluate the perioperative and procedural management of patients with pulmonary alveolar proteinosis (PAP) who presented for whole-lung lavage (WLL). Design The records of all adult patients with PAP who underwent WLL between January 1, 1988 and August 20, 2017 were reviewed and pertinent demographic, preoperative, anesthetic, procedural, and postoperative data were recorded. Setting Large academic tertiary referral center. Participants Forty patients with PAP underwent 79 WLL procedures. Interventions Patients with PAP undergoing WLL. Measurements Successful WLL, defined by visual clearing of lavage fluid, was completed in 91% of cases. Whole-lung lavage was terminated prematurely in 9% of cases (refractory hypoxia most common), while 8% of cases were found to have 30-day complications. There were no cases of intraoperative death, hemodynamic collapse, pneumothorax or hydrothorax, or need for emergent reintubation. Postoperative clinical follow-up at the authors’ institution within 6 months of WLL showed 68% of patients reported improvement in symptoms and/or functional status. Conclusion The authors here present a retrospective study describing the perioperative and procedural management of PAP patients undergoing WLL to help familiarize providers with the management of this population (Fig 1). The findings of this study outline a successful and consistent approach to WLL using a multidisciplinary team experienced in this procedure. Even in experienced hands, procedural complications and 30-day postoperative complications emphasize the risk in this complex patient population.

Background Small bowel bleeding (SBB) accounts for 30% of gastrointestinal bleeding (GIB) episodes in patients with a left ventricular assist device (LVAD). The aim of this study was to determine the outcomes of conservative therapy (CT) compared to balloon-assisted enteroscopy (BAE) in the management of SBB in LVAD patients. Methods A retrospective review was performed of a prospectively maintained LVAD database from January 2003 to July 2015. LVAD patients with SBB were classified into a BAE group or a CT group according to whether they did or did not undergo BAE. Results Forty-two patients (22 BAE, 20 CT) with mean age 66±9.3 years (79% male) were included. The yield of BAE was 64% without reported complications. Overt re-bleeding occurred in 40% of the BAE group compared to 22% of the CT group. The BAE group had a higher mean number of GIB hospitalizations per month compared to the CT group (0.07 vs. 0.03; incidence rate ratio [IRR] 2.72, 95% CI 1.06-6.98; P=0.04). There was no significant difference between the BAE and the CT groups in the number of packed red blood cell (pRBC) transfusions per month (0.42 vs. 0.18; IRR 2.31, 95% CI 0.88-6.04; P=0.09) or all-cause mortality (61% in the CT group and 42% in the BAE group; P=0.90). Conclusion BAE is safe in LVAD patients and has a moderate therapeutic yield. In our cohort of patients, BAE did not appear to improve re-bleeding rate, GIB-related hospitalizations, pRBC transfusions or mortality compared to CT. However, future prospective trials with larger sample sizes are needed to confirm these findings.

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.

Background: Numerous studies have reported predictors of new-onset postoperative atrial fibrillation (POAF) following cardiac surgery, which is associated with increased length of stay, cost of care, morbidity, and mortality. The purpose of this study was to examine the association between preoperative diastolic function and occurrence of new-onset POAF in patients undergoing a variety of cardiac surgeries at a single institution. Methods: Using data from a prospective study from November 2007 to January 2010, a retrospective review was conducted. The diastolic function of each patient was determined from preoperative transthoracic echocardiograms. Occurrence of new-onset POAF was prospectively noted for each patient in the original study. Demographic and operative characteristics of the study population were analyzed to determine predictors of POAF. Results: Of 223 patients, 91 (40.8%) experienced new-onset POAF. Univariate predictors of POAF included increasing age, male gender, operations involving mitral valve repair/replacement, nonsmoking, hypertension, increased intraoperative pulmonary artery pressure, grade I diastolic dysfunction, abnormal diastolic function of any grade, decreased medial e', elevated medial E/e', and increased left atrial volume. Multivariate predictors of POAF included increasing age, increased left atrial volume, and elevated initial intraoperative pulmonary artery pressure. Even after exclusion of patients with hypertrophic obstructive cardiomyopathy or those undergoing mitral valve operations, diastolic dysfunction was not a multivariate predictor of POAF. Conclusions: In the patient population studied here, preoperative diastolic dysfunction was not predictive of POAF. In addition to increasing age, initial intraoperative pulmonary artery systolic pressure and left atrial volume were both significant multivariate predictors of POAF.

Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease.A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed.Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT.Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.

Raghib defect and double-orifice tricuspid valve are two rare congenital heart defects. We report a case of a 42-year-old man with both Raghib defect and DOTV. The patient underwent reroofing of the coronary sinus with an intra-atrial baffle and annuloplasty of the tricuspid and mitral valves via median sternotomy.

Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) use is known to alter platelet activation and aggregation leading to impairment in hemostasis. Previous studies are ambiguous with regard to bleeding, transfusion, and perioperative complications in patients undergoing cardiac surgery. The purpose of this study was to evaluate the risk of perioperative bleeding, transfusion, morbidity, and mortality in cardiac surgical patients taking SSRI/SNRIs compared with propensity-matched controls.Adult patients undergoing cardiac surgery with cardiopulmonary bypass at our institution between January 1, 2004, and December 31, 2014, were eligible for study inclusion. Patients taking SSRI/SNRI medications at the time of surgery were identified and compared against all other patients not taking SSRI/SNRI medications to produce well-matched groups via propensity score analysis. Patients taking SSRI/SNRI medications were matched in a 1:1 ratio to control patients not taking these medications based on an internally estimated propensity score. Primary outcomes included perioperative blood transfusion, chest tube output, and reoperation for bleeding. Secondary outcomes included postoperative complications (renal failure, stroke or transient ischemic accident, prolonged mechanical ventilation, and perioperative myocardial infarction), intensive care unit (ICU) and hospital length of stay (LOS), and 30-day mortality.A total of 1417 pairs of SSRI/SNRI patients and matched controls were retained for analysis. Between SSRI/SNRI patients and matched controls, there was no significant difference in postoperative chest tube output (median, 750.0 vs 750.0 mL; P = .860) or reoperation for bleeding (2.8% vs 2.5%; P = .892). Perioperative transfusion rates across all time points and blood product type were not significantly different between groups, with the overall perioperative transfusion rate for SSRI/SNRI patients 66.5% vs 64.9% for matched controls (P = .697). Patients in the SSRI/SNRI group had a higher rate of prolonged mechanical ventilation (13.1% vs 8.6%; P = .002), longer ICU LOS (median, 25.5 vs 23.8 hours; P.001), and longer hospital LOS (median, 6.0 vs 5.0 days; P.001). Remaining mortality and outcome data were similar between groups.SSRI/SNRI use was not associated with an increased risk of bleeding or transfusion in patients undergoing cardiac surgery. While there was prolonged mechanical ventilation and increased ICU/hospital LOS in the SSRI/SNRI group, it is unclear that this finding is the result of such medications or rather associated with the underlying psychiatric condition for which they are prescribed. The results of this study suggest that perioperative interruption of SSRI/SNRIs to reduce the risk of perioperative bleeding and transfusion is unwarranted and may risk destabilization of patients' psychiatric condition.

Background Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures. Methods A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation. Results Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation. Conclusions Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population.

Limited data exist regarding the outcomes of non-cardiac procedures (NCPs) in adult patients after Fontan operations (Fontan patients).To compare procedural outcomes after NCPs in Fontan patients with outcomes for two matched control groups: patients with repaired congenital heart disease and biventricular circulation (CHD-BiV) and patients with no heart disease (NHD). We defined cyanosis as oxygen saturation90% and procedural hypoxia as saturation80% or a decrease in saturation10% from baseline.There were 538 NCPs in 154 Fontan patients (mean age, 30 years) performed in 1990-2015. Sedation and anaesthesia types were monitored anaesthesia care (256,48%), general anaesthesia (51,9%), minimal sedation (105,20%), local anaesthesia (75,14%) and regional anaesthesia (51,9%). Ninety-three complications occurred in 79 procedures (15%) and included arrhythmia requiring intervention (9), hypotension (14), bradycardia (8), hypoxia (38), heart failure requiring intravenous diuretics (2), acute kidney injury (3), bleeding requiring blood transfusion (1), unplanned procedures for dialysis catheter placement (2), readmission (2), unplanned hospitalisation for hypoxia (8) and unplanned transfer to intensive care unit (1). Baseline cyanosis was the only multivariable risk factor for complications (HR, 1.87 (95% CI 1.14 to 3.67), p=0.04). Procedural complications were more common in the Fontan group (18%) than in the CHD-BiV (5%) and NHD groups (1.4%) (p=0.001).Complications after NCPs were more common in Fontan patients, and baseline cyanosis was a risk factor for complications. All-cause mortality was low and may be related to the multidisciplinary care approach used for Fontan patients at our centre.

A 33-year-old man previously underwent replacement of a stenotic bicuspid aortic valve with a pulmonary autograft (Ross procedure) as a teenager with subsequent development of severe neoaortic valve regurgitation and ascending neoaorta aneurysm. During performance of a modified Bentall procedure, adhesions of the aneurysmal ascending neoaorta prevented safe dissection and re-resection of …

Due to familiarity, short half-life, ease of monitoring, and the availability of a reversal agent, heparin remains the anticoagulant of choice for cardiac operations requiring cardiopulmonary bypass (CPB). However, occasionally patients require CPB but should not receive heparin, most often because of acute or subacute heparin-induced thrombocytopenia (HIT). In these cases, if it is not feasible to wait for the disappearance of HIT antibodies, an alternative anticoagulant must be selected. A number of non-heparin anticoagulant options have been explored. However, current recommendations suggest the use of a direct thrombin inhibitor such as bivalirudin. This review describes the use of heparin alternatives for the conduct of CPB with a focus on the direct thrombin inhibitors.

Background: Left ventricular systolic dysfunction (LVSD) and LV diastolic dysfunction (LVDD) are commonly seen in severe sepsis and septic shock; however, their role in patients with concurrent invasive mechanical ventilation (IMV) is less well defined. Methods: This was a prospective observational study on all patients admitted to all the intensive care units (ICUs) at Mayo Clinic, Rochester from August 2007 to January 2009. All adult patients with severe sepsis and septic shock and concurrent IMV without prior heart failure underwent transthoracic echocardiography within 24 hours. Patients with active pregnancy, prior congenital or valvular heart disease, and prosthetic cardiac valves were excluded. Left ventricular systolic dysfunction was defined as LV ejection fraction (LVEF) 15. Primary outcome was hospital mortality, and secondary outcomes included IMV duration, ICU length of stay (LOS), and total LOS. Two-tailed P value of Results: In a total of 106 patients, 58 (54.7%) met our inclusion criteria, with 17 (29.3%), 11 (19.0%), and 5 (8.6%) having LVSD, LVDD, and both, respectively. The cohorts with and without LVSD and LVDD did not differ significantly in their baseline characteristics and laboratory and ventilatory parameters. Compared to those without LVSD, patients with LVSD had higher LV end-systolic diameters but were not different in their left atrial diameters or E/e′ ratio. Patients with LVDD had a higher E velocity and E/e′ ratio compared to those without LVDD. Hospital mortality was not different in patients with and without LVSD (8 [47%] vs 21 [51%], P = 1.00) and LVDD (8 [73%] vs 21 [45%], P = .18). Secondary outcomes were not different between the 2 groups. Conclusion: Left ventricular systolic or diastolic dysfunction did not influence in-hospital outcomes in patients with severe sepsis and septic shock and concurrent IMV.

Introduction: Surgery and childbirth can trigger attacks of hereditary brachial plexus neuropathy (HBPN), and inflammation was suggested as a component of the pathogenesis. Methods: HBPN patients who underwent surgery or parturition from January 1, 1996 to December 31, 2009 were studied. Results: Twenty-five HBPN patients underwent 48 surgeries or parturitions. Seventeen patients (68%) had attacks, including 13 periprocedural and 7 postpartum by varied anesthesia types. Three patients who had 8 earlier combined attacks (after thyroidectomy, laminectomy, and Caesarean section) were given prophylactic immunosuppressive therapy (corticosteroids ± immunoglobulin). None suffered postoperative attacks, which is uncharacteristic of their prior experience. Five had perioperative attacks as their first HBPN manifestation. Median follow-up was 11 months (3–48 months). Attacks occurred in the operated limb (n = 6) or distant (n = 7) to surgical sites. All attacks interfered with daily living, with frequent incomplete recovery. Five patients had a SEPT9 mutation. Conclusions: Corticosteroids may prevent parturition and surgical HBPN attacks in some patients. Diverse surgeries, anesthesia, and childbirth frequently trigger HBPN attacks. Muscle Nerve, 2013

Summary Objectives To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery. Background The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery. Methods We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described. Results Thirty-nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long-term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%). Conclusion It may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of

Background Ebstein's anomaly has been described extensively in autopsy material. However, there have been no large surgical pathology series of this malformation. Objective To review clinical and surgical pathologic features of a large number of cases of Ebstein's anomaly from a single institution. Methods Review of medical histories, surgical reports, and surgical pathology reports at the Mayo Clinic (2000–2005). Results Among 104 patients, the mean age was 31 years (2 months–79 years), and 57% were female. Common ECG abnormalities included right bundle branch block (58%), first-degree heart block (31%), preexcitation (18%), and nonspecific intraventricular conduction delay/block (15%). Moreover, 74% had inter-atrial communication, 13% mitral valve prolapse, and 5% bicuspid aortic valve. Clinically, all had tricuspid regurgitation (severe in 74%), and 17% of anterior leaflets were fenestrated. No tricuspid valve was calcified. Surgically, tricuspid tissue was removed during replacement in 99% and repair in 1%. The anterior tricuspid leaflet was resected in 98%, and its length was 0.81–9.3 cm/m 2 body surface area (mean, 3.3). Characteristically, leaflets were large and had irregular shapes and numerous short cordal or direct myocardial insertions. One tricuspid valve had two papillary fibroelastomas. None had clinical or pathologic evidence of active or healed endocarditis. Conclusions Among patients with Ebstein's malformation, tricuspid valve tissue almost exclusively was removed during valve replacement and represented the anterior leaflet. Valve tissue was generally large, irregularly shaped, and associated with insertion of short cords or myocardial stumps. Interestingly, although appreciably deformed, Ebstein valves were not associated with infective endocarditis.

The diagnosis of heart failure during pregnancy has important management implications for the parturient and her fetus. A 19-year-old primigravida developed eclampsia at 29 weeks' gestation. Echocardiography demonstrated normal left ventricular size and ejection fraction of 35% with reverse apical ballooning (reverse takotsubo pattern). Under general anesthesia with invasive monitoring, she underwent urgent cesarean delivery of a preterm infant. Follow-up echocardiography 4 weeks after delivery showed complete normalization of her ejection fraction (56%). This case of eclampsia-related stress-induced cardiomyopathy is a distinct entity from peripartum cardiomyopathy. Using echocardiography, the diagnoses should be differentiated with appropriate management and counseling.

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.

The number of patients with left ventricular assist devices (LVADs) continues to increase, and gastrointestinal (GI) endoscopy is commonly required in this patient population. We retrospectively reviewed the experience of a single tertiary care center in managing patients with LVADs undergoing GI endoscopy between 2006 and 2013. After hospital dismissal from the LVAD placement, 53 patients underwent 172 GI endoscopic procedures. Gastrointestinal bleeding was the indication for endoscopy in 73.8% of patients. Median age at endoscopy was 66 years, and median time from LVAD implantation to initial endoscopy was 271 days (range, 31-1681 days). Anticoagulation or antiplatelet therapy was present within 1 week before 120 of 172 endoscopies (70%) and was withheld or actively reversed in 91 of 120 cases (76%). For sedation/anesthesia during endoscopy, 63 involved care by an anesthesiology team and 109 were performed with nursing sedation protocols. Noninvasive blood pressure techniques (conventional automated cuffs or Doppler pulses) were used for hemodynamic monitoring in 84%, arterial lines in 10%, and no blood pressure recordings documented/charted as inaccurate in 6%. Six patients died within 30 days of endoscopy with one death because of aspiration of blood and multiorgan failure. Patients with LVADs may safely undergo GI endoscopy with various individualized anesthetic/sedation models. Complications after endoscopy likely represent the acuity of this patient population.

Background Hyperlactatemia is relatively common in the cardiac surgical patient and is usually considered a marker of illness severity. The frequency and impact of severe hyperlactatemia after elective cardiac surgery has not been described, and prognosis may be different compared with that for other surgical or medical critically ill patient populations. Methods We conducted a retrospective study to evaluate the hospital course and outcomes of patients who developed severe postoperative hyperlactatemia (SPHL; lactate >10 mmol/L) after elective cardiac surgery, from January 1, 2008 to December 31, 2012, at a large, academic, tertiary referral center. Results Of 9580 cardiac surgical patients who met inclusion criteria, 121 (1.26%) developed SPHL. The most common cause was cardiogenic shock (53.8%). In-hospital mortality was 40.5% but varied widely based on the cause of the SPHL. All patients with definite mesenteric ischemia (n = 5) or extremity compartment syndrome (n = 6) at the time of SPHL died in the hospital. Forty patients (33.1%) were discharged to home, whereas 32 (26.4%) were discharge to a skilled-care facility. Conclusions Severe postoperative hyperlactatemia is rare after elective cardiac surgery. Although this phenomenon continues to be associated with mortality, >50% of patients survived to hospital discharge, a more favorable prognosis, compared with other patient populations based on lactate levels alone. Important exceptions were patients who had extremity compartment syndrome or mesenteric ischemia, which were associated with in-hospital death in all cases. In all other etiologic groups, a substantial proportion of patients were discharged to home.

This case discusses the pharmacokinetic interaction between felodipine, carbamazepine, and phenytoin, resulting in decreased antihypertensive efficacy. Felodipine is a cytochrome P450 3A4 substrate and carbamazepine and phenytoin are 3A4 inducers.

Prader-Willi syndrome (PW) is a rare genetic disorder with multi-organ system involvement. These patients present many perioperative challenges including sleep-related breathing disorders, morbid obesity, thick salivary secretions, mental retardation, and difficult intravenous access. PW has been suggested to be associated with central adrenal insufficiency. We report a novel case of persistent severe hypotension from previously undiagnosed and asymptomatic adrenal insufficiency in a pediatric patient with Prader-Willi syndrome during spine surgery that resolved upon treatment with hydrocortisone. doi: http://dx.doi.org/10.4021/jocmr1039w