Background: Transcatheter Aortic Valve Replacement (TAVR) is a new minimally-invasive surgical procedure in which a bioprosthetic aortic valve is placed via a small skin incision in the groin, over either the left or ...Background: Transcatheter Aortic Valve Replacement (TAVR) is a new minimally-invasive surgical procedure in which a bioprosthetic aortic valve is placed via a small skin incision in the groin, over either the left or right iliac artery. TAVR was recently approved by the FDA as a treatment option for aortic stenosis in patients who may be too frail to undergo open heart surgery. Anesthetic management of TAVR is complicated by the fact that rapid left ventricular pacing (to at least 180 beats per minute) is required at multiple points throughout the procedure. Aim: This rapid pacing creates a profound pathophysiologic stress on the heart, sometimes leading to severe left ventricular dysfunction and resultant complete hemodynamic collapse. We report that the use of prophylactic infusion of epinephrine and/or norepinephrine in patients undergoing TAVR results in improved recovery from rapid pacing as reflected by intraoperative trends in systolic systemic blood pressure and systolic pulmonary arterial pressure. Cases: Here we report three cases. During the first of these, we reacted to intraoperative hemodynamic changes by administering boluses of vasoactive medications as needed. During the other two cases, we preemptively infused vasopressors to facilitate a more rapid recovery from some of the hemodynamic disturbance associated with either TAVR or rapid pacing. Conclusion: The two patients in this series who were managed with a preemptive strategy had higher ratios of systemic systolic blood pressure to pulmonary arterial systolic blood pressure at the end of the case than did the patient who was managed reactively. This suggests that the preemptive strategy may lead to decreased left ventricular impairment and improved overall cardiac function after TAVR.展开更多
We present a case of occult hemothorax, a rare but dangerous complication resulting from cannulation of the internal jugular vein. To date we are not aware of any case reports of bleeding sequelae resulting from direc...We present a case of occult hemothorax, a rare but dangerous complication resulting from cannulation of the internal jugular vein. To date we are not aware of any case reports of bleeding sequelae resulting from direct parenchymal lung injury. The insidious nature of this complication, in which the clinical presentation occurred several hours after central venous cannulation, provides an important reminder for clinicians to follow up central line placement with imaging studies. In this case, the latent period prior to the appearance of clinical manifestations of hemorrhage along with the patient’s subsequent acute decompensation raises questions as to the nature of the underlying injury and mechanisms of both detection and prevention. The patient underwent two right video-assisted thoracoscopic surgical explorations, the first revealed ongoing venous bleeding from within the parenchyma of the right upper lobe which was controlled by a wedge resection. She was ultimately discharged home and, as of the time of this writing, appears to have recovered completely, suffering no long-term sequelae as a result of this complication.展开更多
文摘Background: Transcatheter Aortic Valve Replacement (TAVR) is a new minimally-invasive surgical procedure in which a bioprosthetic aortic valve is placed via a small skin incision in the groin, over either the left or right iliac artery. TAVR was recently approved by the FDA as a treatment option for aortic stenosis in patients who may be too frail to undergo open heart surgery. Anesthetic management of TAVR is complicated by the fact that rapid left ventricular pacing (to at least 180 beats per minute) is required at multiple points throughout the procedure. Aim: This rapid pacing creates a profound pathophysiologic stress on the heart, sometimes leading to severe left ventricular dysfunction and resultant complete hemodynamic collapse. We report that the use of prophylactic infusion of epinephrine and/or norepinephrine in patients undergoing TAVR results in improved recovery from rapid pacing as reflected by intraoperative trends in systolic systemic blood pressure and systolic pulmonary arterial pressure. Cases: Here we report three cases. During the first of these, we reacted to intraoperative hemodynamic changes by administering boluses of vasoactive medications as needed. During the other two cases, we preemptively infused vasopressors to facilitate a more rapid recovery from some of the hemodynamic disturbance associated with either TAVR or rapid pacing. Conclusion: The two patients in this series who were managed with a preemptive strategy had higher ratios of systemic systolic blood pressure to pulmonary arterial systolic blood pressure at the end of the case than did the patient who was managed reactively. This suggests that the preemptive strategy may lead to decreased left ventricular impairment and improved overall cardiac function after TAVR.
文摘We present a case of occult hemothorax, a rare but dangerous complication resulting from cannulation of the internal jugular vein. To date we are not aware of any case reports of bleeding sequelae resulting from direct parenchymal lung injury. The insidious nature of this complication, in which the clinical presentation occurred several hours after central venous cannulation, provides an important reminder for clinicians to follow up central line placement with imaging studies. In this case, the latent period prior to the appearance of clinical manifestations of hemorrhage along with the patient’s subsequent acute decompensation raises questions as to the nature of the underlying injury and mechanisms of both detection and prevention. The patient underwent two right video-assisted thoracoscopic surgical explorations, the first revealed ongoing venous bleeding from within the parenchyma of the right upper lobe which was controlled by a wedge resection. She was ultimately discharged home and, as of the time of this writing, appears to have recovered completely, suffering no long-term sequelae as a result of this complication.
