Relationship among surgical volume, repair quality, and perioperative outcomes for repair of mitral insufficiency in a mitral valve reference center

ObjectiveAlthough it has been demonstrated that the repair rates and quality of the repair of mitral insufficiency are superior in mitral valve reference centers, it has not been studied whether an advantage exists for perioperative morbidity and mortality. We report 1 surgeon's evolution over 7 years, specifically considering the changes in perioperative morbidity and mortality.MethodsWe performed a retrospective review of 1054 patients who had undergone elective, day-of-surgery-admission mitral valve repair by a single surgeon (D.H.A.) at our institution from April 2005 to June 2012. The outcome variables studied were operative mortality (30-day or in-hospital mortality, if longer), length of stay, low cardiac output state after cardiopulmonary bypass, and major morbidity.ResultsThe overall operative mortality was 0.58%. Of the 1054 patients, 31% developed a low cardiac output state postoperatively and 6.52% experienced at least 1 of the composite morbidity events. Increased aortic crossclamp times were significantly and independently associated with a low cardiac output state, length of stay, and morbidity. When divided by service year, a statistically and clinically significant decrease was found in the aortic crossclamp time, despite an increase in the complexity of cases. The morbidity decreased concurrently with the decreases in crossclamp times.ConclusionsAs the number of mitral valve repairs performed each year by a single surgeon at a single institution increased, morbidity, including postoperative heart function and length of stay, decreased. This was demonstrated to occur in large part from a reduction in the aortic crossclamp times, despite an increase in the complexity of the procedures. This further demonstrates the value of reference centers for mitral valve surgery

A case of fetal bradycardia following dexmedetomidine bolus

We report a case of fetal bradycardia immediately following the maternal administration of an intravenous bolus of dexmedetomidine for transesophageal echocardiography. Dexmedetomidine, a central acting selective alpha-2 agonist is increasingly being used for sedation. Little is known regarding placental transfer of dexmedetomide with most reports suggesting minimal transfer. A case of fetal bradycardia resulting from its administration has not been previously reported

Use of Angiotensin II for Post Cardiopulmonary Bypass Vasoplegic Syndrome

© 2019 The Society of Thoracic Surgeons Angiotensin II is a novel vasopressor recently approved for the treatment of vasodilatory shock. We describe a case in which Angiotensin II was used to treat post–cardiopulmonary bypass vasoplegic syndrome in a patient who was refractory to standard vasopressors and other rescue therapies. Despite requiring high-dose vasopressors, the patient was extubated within 24 hours and has met key quality metrics defined by The Society of Thoracic Surgeons

Current approach to diagnosis and treatment of delirium after cardiac surgery

Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options

Tissue oximetry during cardiac surgery and in the cardiac intensive care unit: A prospective observational trial

Background: Cerebral oximetry using near-infrared spectroscopy (NIRS) has well-documented benefits during cardiac surgery. The authors tested the hypothesis that NIRS technology can be used at other sites as a tissue oximeter during cardiac surgery and in the Intensive Care Unit (ICU). Aims: To establish feasibility of monitoring tissue oximetry during and after cardiac surgery, to examine the correlations between tissue oximetry values and cerebral oximetry values, and to examine correlations between oximetry values and mean arterial pressure (MAP) in order to test whether cerebral oximetry can be used as an index organ. Settings and Designs: A large, single-center tertiary care university hospital prospective observational trial of 31 patients undergoing cardiac surgery with cardiopulmonary bypass was conducted. Materials and Methods: Oximetry stickers were applied to both sides of the forehead, the nonarterial line forearm, and the skin above one paraspinal muscle. Data were collected from before anesthesia induction until extubation or for at least 24 h in patients who remained intubated. Statistical Analysis: Categorical variables were evaluated with Chi-square or Fisher's exact tests, while Wilcoxon rank-sum tests or student's t-tests were used for continuous variables. Results: The correlation between cerebral oximetry values and back oximetry values ranged from r = 0.37 to 0.40. The correlation between cerebral oximetry values and forearm oximetry values ranged from r = 0.11 to 0.13. None of the sites correlated with MAP. Conclusions: Tissue oximetry at the paraspinal muscle correlates with cerebral oximetry values while at the arm does not. Further research is needed to evaluate the role of tissue oximetry on outcomes such as acute renal failure, prolonged need for mechanical ventilation, stroke, vascular ischemic complications, prolonged ICU and hospital length of stay, and mortality in cardiac surgery

Feasibility of subcutaneous implantable cardioverter-defibrillator implantation with opioid sparing truncal plane blocks and deep sedation

Introduction: The subcutaneous implantable cardioverter-defibrillator (S-ICD) is most commonly implanted under general anesthesia (GA), due to the intraoperative discomfort associated with tunneling and dissection. Postoperative pain can be substantial and is often managed with opioids. There is a growing interest in transitioning away from the routine use of GA during S-ICD implantation, while also controlling perioperative discomfort without the use of narcotics. As such, we assessed the feasibility of a multimodal analgesia regimen that included regional anesthesia techniques in patients undergoing S-ICD implantation. Methods and Results: Twenty patients received truncal plane block (TBL) immediately before S-ICD implantation. The first 10 patients were implanted under general anesthesia (GA + TBL), and the next 10 patients were implanted under deep sedation (DS + TBL). Additionally, the DS + TBL patients were also prescribed a structured regimen of nonopioid analgesics in the perioperative period. Opioid consumption was calculated as milligram morphine equivalents (MME). In-hospital opioid consumption was significantly lower in the patients implanted with DS + TBL (MME = 0) as compared with patients receiving GA + TBL (MME = 60; P = 0.004). Conclusions: Subcutaneous ICD implantation with anesthesia-delivered DS and a multimodal anesthetic regimen that includes TBL is feasible and associated with significantly less perioperative opioid consumption