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Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery. Because this topic has not been reviewed recently in anesthesia literature, the authors attempted to review relevant epicardial pacemaker specifics, discuss modes and parameters that apply to the perioperative period, present an algorithm for mode selection, describe the potential effects of epicardial pacing on valvulopathies and hemodynamics, and, finally, discuss some postoperative considerations.

This article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief Dr. Kaplan, the Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to continue this series; namely, the highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This third article focuses on the convergent procedure, His-bundle pacing, a comparison of subcutaneous and transvenous defibrillator therapies, the 2020 practice advisory update for the perioperative management of patients with cardiac implantable electronic devices, and a technology update regarding the Micra AV (Medtronic, Moundsview, MN), the EMPOWER leadless pacemaker (Boston Scientific, Marlborough, MA), WiSE-CRT (EBR Systems, Sunnyvale, CA), the Extravascular Implantable Cardioverter Defibrillator (Medtronic, Moundsview, MN), and the BAROSTIM NEO (CVRx Inc, Minneapolis, MN).

This is the final review article in a 4-part series focusing on the perioperative management of the 4 major companies' cardiovascular implantable electronic devices (CIEDs) in the United States. This article presents information pertinent to the perioperative management of Medtronic (Minneapolis, MN) transvenous CIEDs, including responses to magnet application, interpretation of interrogation reports, and basic programming (eg, mode, rate, rate modulation, and tachyarrhythmia therapies). Information regarding the Medtronic Micra (Medtronic, Minneapolis, MN) has been published previously. In addition, it contains an introduction to the concept of magnetic resonance (MR) conditional devices and magnetic resonance imaging (MRI) practices.

This article is the second in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief, Dr. Kaplan, the Associate Editor-in-Chief, Dr. Augoustides, and the editorial board for the opportunity to continue this series, namely the highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This second article focuses on cardiac sympathetic denervation, the management of patients with atrial fibrillation, cerebral oximetry for catheter ablation procedures, advancements in leadless pacemaker and subcutaneous implantable cardioverter defibrillator technology, and the emergence of pulsed field ablation for pulmonary vein isolation.

Pulmonary hemorrhage (PH) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been primarily reported in pediatric patients. We report a case of fatal PH during VA-ECMO for cardiogenic shock after myocardial infarction (MI). PH, in this case, was secondary to a triad of aortic insufficiency, left ventricle distension, and severe laminar mitral regurgitation. This case scenario, previously unreported in adults, illustrates the need for the echocardiographic assessment of left-sided heart valves prior to VA-ECMO initiation after MI as well as management considerations for massive PH in this context.

Previous publications regarding perioperative renal replacement therapy (RRT) have focused on the general care of the RRT-dependent patient and provided a broad overview of the various RRT modalities. The goal of this review article is to provide anesthesiologists with specific practical information regarding the possible intraoperative advantages and limitations of each modality, mandatory equipment to institute intraoperative therapy, and background knowledge necessary to communicate effectively with nephrologists and/or support staff regarding the intraoperative RRT goals.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

This article is the first in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, the associate editor-in-chief, Dr. Augoustides, and the editorial board for the opportunity to start this series, namely the research highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This first article focuses on esophageal thermal injury during radiofrequency ablation, perioperative management of patients presenting for ablation procedures, left atrial appendage occlusion devices, and, finally, heart failure diagnostic devices.

Objective To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. Design A prospective, randomized trial. Setting Single university hospital. Participants Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. Interventions PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. Measurements and Main Results Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. Conclusion TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.

There has been a recent shift in bradycardia pacing and defibrillation therapy to leadless pacemakers and extrathoracic cardioverter-defibrillator technology due to complications associated with transvenous devices. These innovations have implications for anesthesia care, as these novel devices have design and functionality features different from transvenous devices. Current perioperative guidelines do not address management of leadless pacemakers and the subcutaneous implantable cardioverter-defibrillator, although implantation rates are increasing globally. This article addresses the features and capabilities of nontransvenous cardiac implantable electronic devices, such as the Micra and the subcutaneous implantable cardioverter-defibrillator, and provides guidance for perioperative management.

With the advent of "wireless" endocardial pacing, the subcutaneous implantable cardioverter defibrillator, and leadless pacemakers comes an added layer of complexity to the perioperative management of cardiovascular implantable electronic devices (CIED). Since no formal recommendations currently exist for these new CIED technologies, preoperative identification of these devices, understanding their functionality, and developing an individualized perioperative management plan are imperative for the anesthesiologist. The following review is intended to provide the background information required to devise a successful perioperative management strategy for newer CIEDs.

This article is the second of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to start this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; however, in some cases, these articles will target the use of perioperative echocardiography in general.

Objectives The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO2 during transport and hemodynamic parameters in patients post-cardiac surgery. Design A prospective, randomized trial. Setting A university-affiliated tertiary care hospital. Participants Cardiac surgery patients. Interventions Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO2) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. Measurements and Main Results Outcomes were changes from baseline in end-tidal CO2, hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PAmean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. Conclusions Hand ventilation during transport was associated with greater change from baseline of ETCO2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated.

Low cardiac output after orthotopic heart transplant (OHT) may be attributed to inadequate preload, vasodilation, and/or reduced inotropy. Inadequate preload because of an inferior vena cava (IVC) thrombus is a rare cause of low cardiac output and not frequently described in the literature. Although the use of prothrombin complex (PCC) has been associated with thrombus formation, its contribution to life-threatening IVC thrombosis has yet to be described. This case report describes the use of perioperative ultrasound in the diagnosis and management of a low cardiac output state induced by an IVC thrombus in an OHT recipient who received PCC.

Biotronik cardiovascular implantable electronic devices, specifically Biotronik pacemakers, contain unique features that are relevant to perioperative management. For example, Biotronik pacemakers have a programmable response to magnet application, a default magnet response that does not result in sustained asynchronous pacing, and a unique method of rate adaptation (eg, closed loop stimulation). This review article focuses on these unique features; the interpretation of Biotronik interrogation reports; and the basic programming (eg, mode, rate, rate adaptation, tachyarrhythmia therapies) relevant to the perioperative management of Biotronik cardiovascular implantable electronic devices.

This is a review of the 2017 AHA/ACC/HRS Guidelines with guidance for intraoperative physicians. Ventricular arrhythmias occurring during the perioperative period have the potential for significant morbidity and mortality. Hence, an in-depth knowledge of VA mechanisms, prevention, and management is crucial for all clinicians caring for these at-risk patients in the perioperative period. Perioperative optimization of patients with a known or suspected VA should be tailored to the specific patient population and condition as outlined in this manuscript.

Objectives To assess the change in 3-dimensional (3D) echocardiography–derived right ventricular volumes before and after pulmonary thromboendarterectomy (PTE) and to evaluate the correlation of these variables with right heart catheterization–calculated pulmonary vascular resistance (PVR). Setting Single university hospitals. Participants Patients undergoing elective PTE surgery between November 2016 and February 2018. Methods All patients received a pulmonary artery catheter and arterial line, and transesophageal echocardiographic monitoring was performed. Transesophageal echocardiographic monitoring before surgery (pre-PTE) and postsurgery (post-PTE) included comprehensive 2D examinations and 3D right ventricular data set acquisition for offline volumetric analysis. Right ventricular fractional area of change (RVFAC) was measured from a right ventricular–focused midesophageal 4-chamber view. TomTec-Arena 4D RV-Function 2.0 offline software (TomTec Imaging Systems GmbH, Unterschlessheim, Germany) was used to measure right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), and right ventricular ejection fraction (RVEF). Paired t tests were used to evaluate for differences before and after surgery, and echocardiographic variables versus PVR were analyzed with linear regression. Results Forty patients were scheduled for elective PTE surgery; 35 patients had complete hemodynamic profiles and echocardiographic data sets and were included in the evaluation. Mean pulmonary artery pressure decreased from 40 ± 11 to 28 ± 7 mmHg, and PVR decreased from 708 ± 432 to 285 ± 136 dynes*s/cm5 after PTE. RVEDV decreased from 106 ± 43 to 79 ± 35 cm3 (p Conclusion Even though RVEDV and RVESV displayed a statistically significant change after PTE, this study did not identify a correlation between those variables and PVR. In addition, markers of right ventricular systolic function (eg, RVFAC and RVEF) did not correlate with PVR. Therefore, the authors conclude that even though these echocardiographic measurements quantified a statistically significant change after PVR reduction, they cannot be reliably used as a surrogate marker of success immediately after PTE.

Feelings of trepidation or uncertainty regarding cardiovascular implantable electronic devices (CIEDs) in the perioperative period can often be mitigated by a thorough knowledge of societal recommendations, recommended management options, and familiarity with CIEDs. Given that effective interpretation of an interrogation report is vital to determining perioperative management options and applying societal recommendations, the creation and interpretation of St. Jude CIED interrogation reports are discussed. In an effort to increase the familiarity with St. Jude transvenous CIEDs amongst anesthesiologists, basic programming of a St. Jude pacemaker and implantable cardioverter defibrillator (ICD) also are described.

Objective To assess the feasibility of pulmonary artery catheter placement using transesophageal echocardiography inclusive of a description of the technique. Design A prospective, proof-of-concept study. Setting Single university hospital. Participants Twenty patients with chronic thromboembolic pulmonary hypertension scheduled for pulmonary thromboendarterectomy. Interventions Pulmonary artery catheters were placed in 20 patients solely by transesophageal echocardiographic guidance. Measurements and Main Results Placement of the pulmonary artery catheter in the pulmonary artery with transesophageal echocardiography guidance in fewer than 10 minutes was considered successful placement. The time to placement was measured from advancement of the pulmonary artery catheter in the superior vena cava (20 cm) to a final location at the junction of the right pulmonary artery and main pulmonary artery. All 20 pulmonary artery catheters were placed successfully using transesophageal echocardiography guidance and the median time to placement was 43 seconds. In 9 of the 20 patients (45%), the catheter was placed successfully on the first attempt without any adjustments. However, in 9 others (45%), the catheter required manipulation under transesophageal echocardiography vision. In 3 patients (15%), the pulmonary artery catheter was observed to be coiled in the right atrium and in 1 instance (5%) manipulation of the catheter in the right ventricle was required to enter the outflow tract. Conclusions Transesophageal echocardiography is a viable adjunctive method to conventional pressure waveform placement of pulmonary artery catheters in potentially difficult patients.

The ability to identify imaging artifacts and normal anatomic variants commonly encountered during a TEE exam can be as important as identifying normal anatomy and function. Lack of knowledge regarding these anatomic structures and imaging artifacts can result in misdiagnoses and adverse effects for patients. Anatomic variants commonly encountered in a TEE exam include Lambl’s Excrescences, Eustachian Valve, Chiari Network, Moderator Band, Crista Terminalis, Nodules of Arantius, and the Coumadin Ridge. Imaging artifacts that result from the violation of the basic assumptions of ultrasound physics include Dropout, Acoustic Shadowing, Side Lobes, Reverberation, and Mirroring. The focus of this chapter will be the identification of the aforementioned anatomic variants/imaging artifacts and the general techniques the echocardiographer can utilize to distinguish them from pathology.

Open surgical repair of iliac arteriovenous fistulas is associated with significant morbidity and mortality, making endovascular repair an attractive alternative. This report describes a 39-year-old man who was admitted with two-pillow orthopnea, edema, and fatigue. He had sustained a gunshot wound to the pelvis 13 years previously. Six years after the gunshot wound, he was diagnosed with cardiomegaly and high-output congestive heart failure. A magnetic resonance angiography documented a large pelvic arteriovenous fistula. A diagnostic contrast angiogram confirmed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein. A Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) was used to repair this large, high-flow internal iliac artery-common iliac vein arteriovenous fistula.

A 37-year-old female with a history of Takayasu arteritis was admitted for repair of a descending thoracic aortic aneurysm with penetrating ulcer and left ventricular outflow track (LVOT) pseudoaneurysm. A unique regurgitant jet was subsequently identified by transesophageal echocardiography after induction of anesthesia and endotracheal intubation. How to cite this article Cronin B, Golts E, Pretorius V. Unique Regurgitant Jet in a Patient with Takayasu Arteritis. J Perioper Echocardiogr 2015;3(2):66-67.