Faculty Bibliography

The development of transcatheter aortic valve replacement (TAVR) has transformed the treatment of patients with aortic valve disease. This procedure now is used widely for patients at high and intermediate risk for surgical aortic valve replacement. The rapid acceptance and popularity of TAVR most clearly was enabled by advancements in device technology and procedural experience. Such a dramatic change to the standard medical practice is not without consequence to fields of medicine beyond cardiology and cardiac surgery. Anesthesiologists have witnessed this movement first hand, and while improved anesthetic techniques have contributed to the success of the procedure, in return these improved outcomes likely will result in further changes to perioperative anesthetic management. In this review the authors sought to evaluate the role and responsibility of the cardiac anesthesiologist in the development of TAVR. Future advancements in device technology and considerations of how the anesthetic technique for TAVR may continue to evolve in future years are discussed.

OBJECTIVE: In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. METHODS: Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4-0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. RESULTS: Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. CONCLUSIONS: We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

We describe the use of the Sapien XT, placed in the mitral position using a totally endoscopic robotic approach in a 76-year-old man with extensive circumferential mitral calcifications and severe stenosis. The patient was at high risk for traditional open surgery and a large mitral valve annulus prevented safe transcatheter deployment due to size mismatch. Our novel approach offered a minimally invasive technique for native mitral valve replacement in a high-risk patient with anatomical constraints prohibitive to conventional approaches. doi: 10.1111/jocs.12737 (J Card Surg 2016;31:303-305).

Transcatheter aortic valve replacement is increasingly performed as a minimally invasive treatment option for aortic valve disease. The typical anesthetic management for this procedure was traditionally similar to surgical aortic valve replacement and involved general anesthesia and transesophageal echocardiography. In this review, we discuss the technological advances in transcatheter valve systems that have improved outcomes and allow for use of sedation instead of general anesthesia. We describe an anesthetic protocol that avoids general anesthesia and utilizes transthoracic echocardiography for procedural guidance.

OBJECTIVE: To determine if there is an association between left atrial appendage velocity and the development of postoperative atrial fibrillation (POAF). DESIGN: Single institution retrospective study performed between January 2013 and December 2013. SETTING: Single-institution, university hospital. PARTICIPANTS: Five hundred sixty-two adult patients undergoing cardiac surgery utilizing cardiopulmonary bypass. INTERVENTIONS: No interventions for the purpose of this study. MEASUREMENTS AND MAIN RESULTS: Left atrial appendage velocity, measured by transesophageal echocardiogram, ranged from 8 cm/sec to 126 cm/sec. The development of POAF within the first 3 days after cardiac surgery was 38.3%. The authors found that patients with a lower left atrial appendage velocity had a higher risk of developing POAF. In the adjusted logistic regression model, there was an 11% decrease in the odds of POAF for each 10-unit (cm/sec) increase in the left atrial appendage velocity (p = 0.044). CONCLUSIONS: Decreasing left atrial appendage velocity is an independent predictor of risk for the development of POAF following cardiac surgery with cardiopulmonary bypass.

INTRODUCTION: Tracheal extubation in under 6 hours following cardiac surgery (also known as fast track extubation) is associated with decreased intensive care unit (ICU) length of stay, hospital length of stay and the potential for improved recovery and decreased resource utilization1. This involves a collaborative effort from anesthesiologists, intensivists, critical care nursing and respiratory therapists. The Society of Thoracic Surgeons (STS) reported that postoperative ventilation time was less than 6 hours in 34.3% of cases, which was not being achieved at our institution2. There has been increased interest in the use of checklists for perioperative procedures, which have been shown to reduce morbidity and mortality3. As a result, a multidisciplinary team was formed to create a fast track extubation checklist using clinical assessment, ventilator data and laboratory values (Figure 1). Our goal was to meet the STS benchmark. In this study we review the results of this protocol. METHODS: After IRB approval, we retrospectively reviewed the records of 1,028 adult patients undergoing cardiac surgery at a single institution between January 1 2013 and August 31st, 2014. Patients undergoing cardiac surgery before initiation of the extubation protocol on November 1st, 2013 were compared to those who received surgery after implementation. Descriptive statistics for categorical variables were analyzed using Fisher's exact test and continuous variables were compared using t-sample t tests. RESULTS: A total of 529 patients underwent surgery before and 499 patients after implementation of the extubation protocol. Preoperative data, intraoperative data and procedure type were similar in both groups (Table 1). After implementation, patients were significantly more likely to be extubated in under 6 hours (25.9% vs. 60.1%, p=.001, Table 2). Hospital length of stay was numerically less but not significantly less (9.4 days vs. 8.8 days, p=0.160) however post procedural length of stay was significantly less(8.0 days vs. 7.2 days, p=0.036) after protocol implementation. Reintubation rates remained unchanged (3.9% vs. 2.6%, p=0.295). CONCLUSIONS: Implementation of the multidisciplinary extubation checklist appears safe and may expedite discontinuation of mechanical ventilation and decrease length of stay after cardiac surgery. These have been previously reported to decrease morbidity and financial expense. The extubation rate under 6 hours at our institution now exceeds the STS benchmark. This suggests that our collaborative approach to extubation involving a well-defined checklist may be beneficial at other cardiac centers. (Figure Presented)