Seminars in Cardiothoracic and Vascular Anesthesia

Over the past 3 decades, the standard surgical management for acute DeBakey type I aortic dissection has not significantly changed. Most patients undergo ascending aortic replacement with an interposition graft under hypothermic circulatory arrest with selective root replacement. Nevertheless, with the improvement in overall patient care, acute surgical outcomes continue to improve. The frozen elephant trunk (FET) technique was introduced as a modification to conventional elephant trunk to treat extensive degenerative and chronic dissecting aneurysms involving the aortic arch and the proximal descending aorta. The FET technique converts the conventional elephant trunk procedure—an inherently 2-stage operation—into a 1-stage repair in selected patients and greatly facilitates more distal aortic repair, for others. The surgical strategy is tailored to address individual pathology, based on each patient’s aortic anatomy and disease. FET technique in acute DeBakey type I aortic dissection extends the surgical repair into and beyond the arch with the potential to address some of the limitations of the conventional type I aortic dissection repair, but it has not been widely adopted yet. Only a limited number of institutions have embraced this modality during the acute phase of aortic dissection out of concern that it may be too complicated during an emergency situation. We have developed a simplified technique that has evolved over the past several years and the purpose of this report is to describe it.

Evidence exists on the morbiduty and mortality associated with both massive blood loss and transfusion in cardiac surgical patients. Monitoring of the vesicoelastic properties of blood using rotational thromboelastometry and thromboelsatography (TEG) has been a major step towards ameliorating the risks associated with these 2 evils by providing trageted goal-directed blood product resuscitation. Point of care ROTEM and TEG overcome many of the current limitatons of conventional laboratory coagulation testing. Despite the peaking interest and widespread use there is a lack of consensus whetehr the use of these devices to guide blood product resucistation is associated with a reduction in mortality. Also, both ROTEM and TEG suffer from some limitations resulting in a lack of agreement on the duperiority of one device versus the other. In this concise review we discuss the operational charecteristics of both devices and the pro-side of the use of ROTEM in cardiac surgery backed with the most recent evidence.

Since their introduction into clinical practice in the early 1960s, viscoelastic point-of-care (POC) testing—thromboelastrography (TEG) and thromboelastrometry (ROTEM)—has become increasingly popular in intensive care units, operating rooms, and emergency room settings. As TEG has been an established POC viscoelastic testing modality for many years, there has been more research and analysis of its utility and ability to reduce transfusions in the general, cardiac, and liver surgical sectors compared with ROTEM. The role of TEG versus ROTEM has been greatly disputed, although both continue to be utilized in the cardiac suite to guide transfusion in cardiac surgery as these procedures produce a profoundly different form of bleeding compared to other surgical interventions.

We present the case of a patient with transient ischemic attacks who was being investigated for multiple embolic strokes. Initial workup, including brain computed tomography, computed tomography angiography, and transthoracic echocardiography (TTE) were negative for a source until transesophageal echocardiography (TEE) found a mass in the left atrium. The TEE differentiated the mass as a rare cardiac papillary fibroelastoma on the left atrial free wall confirmed by postsurgical pathology. This case highlights the importance of TEE as a diagnostic tool for its ability to more accurately differentiate and characterize the tumor compared with TTE. This case underscores that a negative TTE does not equate to zero risk of the presence of a cardiac tumor. It is prudent for the clinician to be cognizant that it may be beneficial to perform a TEE even with a negative TTE workup.

Atrioventricular septal defect results from a failure of normal endocardial cushion fusion during embryologic cardiac development. This developmental aberration results in defects in the atrial and/or ventricular septum and malformation of the atrioventricular valves. The pathophysiology of atrioventricular septal defect is variable, and ranges from mild left to right shunting similar to a simple atrial septal defect to complex single-ventricle heart disease. This review focuses on the spectrum of atrioventricular septal defect from partial to complete, without associated cardiac defects.

Atrioventricular canal defects represent a diverse and challenging group of defects. Timing and surgical technique is greatly dependent on morphology of the valve as well as symptoms. Surgical options for repair of these defects are reviewed and presented below.

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

Anesthesia for orthotopic liver transplantation (OLT) is challenging for any anesthesiologist as the patients undergoing this procedure are among the most critically ill. Adding to the underlying complexity of OLT management is the rare complication of an intracardiac thrombus (ICT). Intracardiac thrombi can present following liver allograft reperfusion resulting in high morbidity and mortality. Currently there is no consensus treatment for ICT, and the gold standard for diagnosis is intraoperative transesophageal echocardiography (TEE); these 2 factors lead to a dangerous amalgam of the difficulty in diagnosing and treating the disease. We describe 2 separate cases in detail of ICT formation during OLT that were recognized and diagnosed with intraoperative TEE. These 2 cases highlight the important role of TEE in the management of ICT. A thorough literature review that follows analyzes our current understanding of ICT during OLT and the vital function of TEE by every anesthesiologists regardless of formal TEE training. Broader use of TEE during all OLTs can help narrow the anesthesiologist’s differential diagnosis during the acute phases of transplantation and should be considered in all liver transplant surgeries.

In living donor liver transplantation, optimal graft size is estimated from values like graft volume/standard liver volume and graft/recipient body weight ratio but the final functional hepatic mass is influenced by other donor and recipient factors. Grafts with insufficient functional hepatic mass can produce a life-threatening condition with rapidly progressive liver failure called small-for-size syndrome (SFSS). Diagnosis of SFSS requires careful surveillance for signs of inadequate hepatocellular function, residual portal hypertension, and systemic inflammation that suggest rapidly progressive liver failure. Early diagnosis, symptom control, and addressing the cause of SFSS may prevent the need for retransplantation. With increased attention to avoiding donor risk, intensivists will be confronted with more SFSS recipients. In this review, we aim to outline a systematic approach to the medical management of patients with SFSS by providing a concise synopsis of general supportive care—neurological, cardiovascular, and renal support, mechanical ventilation, nutritional support, infection control, and tailored immunosuppression—with an aim to avoid end-organ damage or death and a review of current interventions including liver support devices, portal flow modulating drugs, and other experimental interventions that aim to preserve existing hepatic mass and improve conditions for hepatic regeneration. We examine evidence for SFSS interventions to provide the reader with information that may assist in clinical decision making. Points of controversy in care are purposefully highlighted to identify areas where additional experimental work is still needed. A full understanding of the pathophysiology of SFSS and measures to support liver regeneration will guide effective management.