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To determine if decreases in the Karnofsky Performance Score (KPS) while on the waitlist predict decreased survival after lung transplantation (LTx).A retrospective evaluation of the United Network for Organ Sharing database. The KPS was evaluated at the time of listing for transplant and at the time of transplantation. Group I consisted of patients having a decrease in KPS during the time on the waiting list (from the time of listing to the time of transplant), and Group II consisted of patients whose KPS stayed the same or increased during the same period. The authors used propensity-score weighting for comparisons of these groups.Retrospective observational database review.Adult patients undergoing lung transplantation.None. Patients were stratified according to a change in their KPS.Patient and graft survival of patients with decreasing or not decreasing KPS were compared. Of the 27,558 subjects included in the analysis, 17,986 (65%) had worsening KPS, which was associated with worse graft (p = 0.0003) and patient (p = 0.0019) survival after LTx. Using multivariate regression, a decrease in KPS of ≥40 was associated with decreased survival, and an increase of ≥40 was associated with improved survival (HR = 1.245, 95% CI [1.181-1.312], p0.0001 and HR = 0.866, 95% CI [0.785, 0.955], respectively). Among patients with a KPS40 at the time of transplant, those with a decrease in KPS of ≥40 had decreased graft and patient survival compared with those with a smaller decrease (p = 0.0002 and p = 0.0021, respectively).Deterioration of KPS on the waiting list for LTx is associated with significantly greater postoperative mortality in patients after LTx. These results should be taken into consideration when allocating organs. Strategies to increase or to prevent a decrease in KPS before LTx should be evaluated.

Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked—diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.

Objectives To determine if hemodynamic changes secondary to propofol administration are a result of direct myocardial depression as measured by global longitudinal strain (GLS). The authors hypothesized that propofol would cause a significant worsening in GLS, indicating direct myocardial depression. Design Prospective, observational. Setting Endoscopy suite at a single academic medical center. Participants Patients undergoing outpatient, elective endoscopic procedures at an outpatient clinic of a single tertiary care academic medical center. Interventions None. Measurements and Main Results Limited transthoracic echocardiograms were performed before and after patients received propofol for endoscopic procedures. Post-processing measurements included GLS, 2D (dimensional) ejection fraction (2D EF), and 3D EF. Using paired sample Student’s t test, no statistically significant change in GLS, 2D EF, or 3D EF was found despite statistically significant hypotension. In fact, there was a trend toward more negative GLS (improved myocardial function) in patients after receiving propofol. Conclusion We found propofol did not cause a reduction in systolic function as measured by GLS, a sensitive measure of myocardial contractility. Therefore, decreases in blood pressure after a propofol bolus in spontaneously breathing patients are likely due to decreased vascular tone and not impaired left ventricular systolic function. These results should be considered in the management of propofol-induced hypotension for spontaneously breathing patients.

Objective Transcatheter aortic valve replacement (TAVR) with monitored anesthesia care (MAC) is well-tolerated and is growing in popularity. Differences in outcomes based on anesthetic agent choice with MAC has received less attention. The authors sought to determine whether differences in outcomes and cost exist based on whether patients receive dexmedetomidine or propofol when undergoing TAVR with MAC. Design Retrospective cohort study. Setting The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Participants The study comprised 161 patients who underwent TAVR with MAC between May 2014 and March 2019. Interventions None. Measurements and Main Results A propofol-only (n = 58) group and dexmedetomidine-only (n = 103) group were identified. No differences in in-hospital mortality or complication rate were identified when evaluating for stroke, transfusion, new arrhythmia, cardiac arrest, or bleeding and vascular complications (p > 0.05, all). Thirty-day outcomes were also equivalent, with no differences in mortality, stroke, vascular complication, new arrhythmia, or myocardial infarction (p > 0.05, all). The average amount of epinephrine, norepinephrine, or phenylephrine used intraoperatively was not significantly different. Overall median hospitalization costs were equivalent ($57,554.31 with dexmedetomidine v $58,538.08 with propofol, p = 0.97). Conclusions There were no significant differences in in-hospital outcomes, 30-day outcomes, or total cost of the patient's hospitalization, based on the use of dexmedetomidine versus propofol in patients undergoing TAVR.

BACKGROUND Aorto-atrial fistulas (AAFs) are rare lesions typically associated with paravalvular abscesses or aortic aneurysms. Iatrogenic AAFs have been described after cardiac surgery. While these lesions are often asymptomatic, they can cause shunting and volume overload. Diagnosis of AAFs can be challenging. Transesophageal echocardiography plays a critical role in their diagnosis. CASE REPORT A 91-year-old man undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis had extreme tortuosity of the aorta and iliofemoral vessels. The patient developed a fistula from the non-sinus of Valsalva to the right atrium during the procedure. After the procedure, the patient developed stroke and retroperitoneal hematoma. CONCLUSIONS This case represents the first full report of an aorta to right atrial fistula after TAVR. The anatomy of the aortic root in relation to the right atrium and ventricle may make aorta to right ventricle fistulas more common than aorta to right atrial fistulas. This patient's vascular tortuosity may have played a role in the development of this lesion. Blood flow in an aorta to right atrial fistula occurs during both systole and diastole, making both right and left ventricle overload possible. Echocardiography is essential to the diagnosis of these lesions. Both vascular injury and landing zone rupture are possible during TAVR, although the observed timing and anatomy of this lesion suggest that it was caused during retrograde access of the left ventricular outflow tract via the ascending aorta.

The use of transesophageal echocardiography (TEE) in the operating room and intensive care unit can provide invaluable information on cardiac as well as abdominal organ structures and function. This approach may be particularly useful when the transabdominal ultrasound examination is not possible during intraoperative procedures or for anatomical reasons. This review explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine. We describe several reported applications using 10 views that can be used in the diagnosis of relevant abdominal conditions associated with organ dysfunction and hemodynamic instability in the operating room and the intensive care unit.

Surgical ventricular remodeling (SVR) is an invasive method of treating patients with heart failure who also have ischemic cardiomyopathy and reduced ejection fraction (EF). Introduced in the mid-1980s, this technique was met with varying success and relatively high morbidity and mortality despite its theoretical benefits. The development of the BioVentrix Revivent TC System (BioVentrix, Inc., San Ramon, CA) as a less-invasive method of surgical ventricular remodeling has created a novel, multidisciplinary approach to heart failure management, which necessitates multiple subspecialties. Currently in the trial phase in the United States and widely used in Europe, the positive results to date appear promising for the rapid adoption of this procedure. For the cardiac anesthesiologist, a thorough understanding of the patient population, procedural goals, and intraoperative management is essential. This overview discusses the advancement in surgical ventricular remodeling, the pertinent surgical steps of the BioVentrix Revivent TC System placement, and specific anesthetic considerations for this novel procedure.

Background and Objectives: The hand-off process between pediatric anesthesia and intensive care unit (ICU) teams involves the exchange of patient health information and plays a major role in reducing errors and increasing staff satisfaction. Our objectives were to (1) standardize the hand-off process in children&rsquo, s ICUs, and (2) evaluate the provider satisfaction, efficiency and sustainability of the improved hand-off process. Methods: Following multidisciplinary discussions, the hand-off process was standardized for transfers of care between anesthesia-ICU teams. A pre-implementation and two post-implementation (6 months, &gt, 2 years) staff satisfaction surveys and audits were conducted to evaluate the success, quality and sustainability of the hand-off process. Results: There was no difference in the time spent during the sign out process following standardization&mdash, median 5 min for pre-implementation versus 5 and 6 min for post-implementation at six months and &gt, 2 years, respectively. There was a significant decrease in the number of missed items (airway/ventilation, venous access, medications, and laboratory values pertinent events) post-implementation compared to pre-implementation (p &le, 0.001). In the &gt, 2 years follow-up survey, 49.2% of providers felt that the hand-off could be improved versus 78.4% in pre-implementation and 54.2% in the six-month survey (p &lt, 0.001). Conclusion: A standardized interactive hand-off improves the efficiency and staff satisfaction, with a decreased rate of missed information at the cost of no additional time.

Objectives Effective communication among health care providers is critically important for patient safety. Handoff of patient care from the operating room (OR) to the intensive care unit (ICU) is particularly prone to errors. The process is more complicated in an academic environment in which junior clinicians are being trained. Standardization of, and training in, transitions of care can be a crucial means to improve patient safety. Study design Pre- and postintervention surveys of health care providers. Methods Based on a workflow analysis and qualitative needs assessments, we developed a 3-step protocol to standardize the handoff of care from the OR to the ICU for adult patients after cardiac surgery and to provide an effective learning environment. The process starts during surgery, continues when the patient leaves the OR, and concludes with the actual face-to-face transfer of care between providers, at the bedside, in the ICU. We conducted pre- and postimplementation surveys among physician trainees and nursing staff regarding their perception of the handoff process. Results We surveyed 42 clinicians before and 33 after implementation of the handoff process. Prior to implementation, most clinicians expressed a need to improve the current process; this perceived need was significantly greater in health care professionals with 4 or fewer years of experience. Post implementation, clinicians saw a significant improvement in information provided, efficiency, relevance to patient care, and psychological safety, a concept in which participants feel accepted and respected in a group setting without fear of negative consequences or judgement. Conclusions Our workflow-oriented, standardized process for handoff of care from the OR to the ICU can improve perceived communication and psychological safety, especially for junior clinicians.

Study Objective. Our objectives were to estimate the incidence of symptoms of peripheral nerve injury (sPNI) in thoracic surgical patients undergoing video-assisted thoracic surgery or open thoracotomy and to determine whether intraoperative somatosensory evoked potentials (SSEPs) waveform changes correlate with postoperative peripheral neuropathic symptoms. Methods. We conducted a prospective observational study in the operating room of a tertiary hospital. We measured SSEPs intraoperatively and assessed patients for sPNI postoperatively. Results. Forty-four patients consented. Six were excluded from analysis. We found that 42% (95% confidence interval [CI] = 26% to 57%) of patients undergoing thoracic surgery had significant changes in SSEP amplitude and latency. Furthermore, 16% (95% CI = 4% to 28%) of patients had new postoperative symptoms of sensory or motor deficits in an upper extremity. We calculated a sensitivity of 66.7% (95% CI = 29.0% to 100%) and a specificity of 50% (95% CI = 33% to 67.3%) for the identification of sPNI based on automated intraoperative SSEP changes. Conclusions. We identified the incidence of SSEP changes in thoracic surgery (42%) and the incidence of postoperative sPNI after thoracic surgery (16%). We identified a positive correlation between intraoperative SSEP changes and postoperative sPNI, which after multivariate analysis was not significant given the small sample size of the study. By the time sensory and/or motor changes are detected postoperatively, it may be too late to reverse the nerve damage. Future versions of the EPAD device could provide anesthesiologists a way to monitor for the development of sPNI, and make changes before a potential injury becomes permanent.

Patient: Male, 44 Final Diagnosis: Heparin-induced thrombocytopenia Type II Symptoms: Congestive heart failure • short of breath Medication: — Clinical Procedure: LVAD explantation • TAH insertion Specialty: Anesthesiology Objective: Rare co-existance of disease or pathology Background: Heparin-induced thrombocytopenia (HIT) is a rare but life-threatening complication of heparin administration. It can present a major clinical dilemma for physicians caring for patients requiring life-saving urgent or emergent cardiac surgery. Studies have been published examining the use of alternative anticoagulants for patients undergoing cardiopulmonary bypass (CPB), however, evidence does not clearly support any particular approach. Presently, there are no large-scale, prospective randomized studies examining the impact of alternative anticoagulants on clinical outcomes for HIT-positive patients requiring cardiac surgery. Case Report: We present the case of a patient who underwent SynCardia Total Artificial Heart (TAH) implantation following a recent left ventricular assist device (LVAD) placement. The patient was receiving argatroban for type II HIT with anuric renal failure, and developed a thrombus which occluded the inflow cannula of the LVAD. Based on a published study and after establishing consensus with the surgical, anesthesiology, perfusion, and hematology teams, we decided to use tirofiban as an antiplatelet agent to inhibit the platelet aggregation induced by heparin, and ultimately used heparin as the anticoagulant for cardiopulmonary bypass. Conclusions: When selecting anticoagulation for a HIT-positive patient requiring CPB, so that benefits outweigh risks, it is of paramount importance that the decision be based on a multitude of factors. The team caring for the patient should have a shared mental model and be familiar with the pharmacology, devices used, and local practices. These three elements should be integrated with patient-specific comorbidities along with local monitoring capabilities to ensure safe, efficient patient care.

Objective To assess the concordance between transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) measures of right ventricular (RV) function by standard two-dimensional and Doppler methods. We hypothesized that there would be significant disagreement in tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), right-sided index of myocardial performance (RIMP), and tricuspid annular systolic velocity (S`). Design Prospective observational Setting Cardiac operating room at a single academic medical center Participants All adult patients undergoing elective cardiac surgery at a single tertiary care academic medical center over the course of six months. Interventions None. Measurements and Main Results We measured fractional area change, tricuspid annular systolic velocity, tricuspid annular systolic plane excursion, right-sided index of myocardial performance and tricuspid annular diameter by transesophageal echocardiography and transthoracic echocardiography. We assessed for concordance by concordance correlation coefficient and paired t-tests, including 95% confidence limits. We found that quantitative measures of right ventricular function by transesophageal echocardiography correlate poorly with transthoracic echocardiography measurements in close temporal proximity under similar hemodynamic conditions. Conclusions When performing an assessment of RV function, transesophageal echocardiographers should exercise caution when extrapolating data validated by TTE to transesophageal studies. Measures of right ventricular function by TEE tend to have fair agreement to TTE measurements obtained in close temporal proximity under similar hemodynamic conditions. Most importantly, our study showed that TAPSE and S` values obtained from the modified transgastric RV inflow view tend to have lower values than those measured by TTE. Given the propensity for underestimating measurements from the modified transgastric RV inflow view, we conclude that values equal to or greater than established norms for tricuspid annular motion may be utilized to establish normal, but not abnormal, RV function.

Postoperative cognitive dysfunction (POCD) occurs in 20–50% of postsurgical patients with a higher prevalence in elderly patients and patients with vascular disease and heart failure. In addition, POCD has been associated with many negative outcomes, such as increased hospital length of stay, increased rates of institutionalization, and higher patient mortality. This brief review discusses select evidence suggesting an association between neuroinflammation and POCD and whether the use of dexmedetomidine, a short-acting alpha 2 agonist, may ameliorate the incidence of POCD. We review the recent evidence for neuroinflammation in POCD, dexmedetomidine’s properties in reducing inflammatory-mediated brain injury, and clinical studies of dexmedetomidine and POCD. There is evidence to support the anti-inflammatory and immunomodulatory effects of dexmedetomidine in animal models. Several clinical investigations have demonstrated favorable outcomes using dexmedetomidine over placebo for the reduction of postoperative delirium. Few studies have used high-quality endpoints for the assessment of POCD and no demonstrable evidence supports the use of dexmedetomidine for the prevention of POCD. While evidence exists for the neural anti-inflammatory properties of dexmedetomidine, human trials have yielded incomplete results concerning its use for the management of POCD. Dexmedetomidine may reduce acute postoperative delirium, but further studies are needed prior to recommending the use of dexmedetomidine for the direct reduction of POCD.

Background The optimal method for closing gastrotomies after transgastric instrumentation has yet to be determined. Objective To compare gastrotomy closure with endoscopically delivered bioabsorbable plugs with no closure. Design Prospective, controlled study. Setting Animal laboratory. Subjects Twenty-three dogs undergoing endoscopic transgastric peritoneoscopy between July and August 2007. Interventions Endoscopic anterior wall gastrotomies were performed with balloon dilation to allow passage of the endoscope into the peritoneal cavity. The plug group (n = 12) underwent endoscopic placement of a 4 × 6-cm bioabsorbable mesh plug in the perforation, whereas the no-treatment group (n = 11) did not. Animals underwent necropsy 2 weeks after the procedure. Main Outcome Measurements Complications related to gastrotomy closure, gastric burst pressures, relationship of burst perforation to gastrotomy, and the degree of adhesions and inflammation at the gastrotomy site. Results After the gastrotomy, all dogs survived without any complications. At necropsy, burst pressures were 77 ± 11 mm Hg and 76 ± 15 mm Hg ( P = .9) in the plug group and no-treatment group, respectively. Perforations occurred at the site of the gastrotomy in 2 of 12 animals in the plug group and in none of the 11 dogs in the no-treatment group ( P = .5). Finally, there were minimal adhesions in all dogs (11/11) in the no-treatment group and minimal adhesions in 3 and moderate adhesions or inflammatory masses in 9 of the 12 animals in the plug group ( P = .004). Limitations Small number of subjects, animal model, no randomization. Gastrotomy trauma during short peritoneoscopy may not be applicable to longer procedures. Conclusions After endoscopic gastrotomy, animals that were left untreated did not show any clinical ill effects and demonstrated adequate healing, with fewer adhesions and less inflammation compared with those treated with a bioabsorbable plug.

The repair of gastric perforation commonly involves simple suture closure using an open or laparoscopic approach. An endolumenal approach using prosthetic materials may be beneficial. The role of bioprosthetics in this instance has not been thoroughly investigated, thus the authors evaluated the feasibility of gastric perforation repair using a bioabsorbable device and quantified gross and histological changes at the injury site. Twelve canines were anesthetized and underwent open gastrotomy. A 1-cm-diameter perforation was created in the anterior wall of the stomach and plugged with a bioabsorbable device. Intralumenal pH was recorded. Canines were sacrificed at one, four, six, eight, and 12 weeks. The stomach was explanted followed by gross and histological examination. The injury site was examined. The relative ability of the device to seal the perforation was recorded, as were postoperative changes. Tissue samples were analyzed for gross and microscopic tissue growth and compared to normal gastric tissue in the same animal as an internal control. A scoring system of -2 to +2 was used to measure injury site healing (-2= leak, -1= no leak and minimal ingrowth, 0= physiologic healing, +1= mild hypertrophic tissue, +2= severe hypertrophic tissue). In all canines, the bioprosthesis successfully sealed the perforation without leak under ex vivo insufflation. At one week, the device maintained its integrity but there was no tissue ingrowth. Histological healing score was -1. At 4-12 weeks, gross examination revealed a healed injury site in all animals. The lumenal portion of the plug was completely absorbed. The gross and histological healing score ranged from -1 to +1. The application of a bioabsorbable device results in durable closure of gastric perforation with physiologic healing of the injury site. This method of gastrotomy closure may aid in the evolution of advanced endoscopic approaches to perforation closure of hollow viscera.