Cardiothorac Vasc Anesth Research Articles

Pro: Early Extubation After Pediatric Cardiac Surgery

IT HAS BEEN a decade since Alghamdi et al. released their meta-analysis on the topic of early extubation of patients after pediatric cardiac surgery. 1 Alghamdi A.A. Singh S.K. Hamilton B.C. et al. Early extubation after pediatric cardiac surgery: Systematic review, meta-analysis, and evidence-based recommendations. J Card Surg. 2010; 25: 586-595 Crossref PubMed Scopus (80) Google Scholar At that time, there was a lack of good quality comparative clinical trials, and the only reasonable conclusions were the association of early extubation with decreased intensive care unit (ICU) and hospital lengths of stay (LOS) and the absence of a difference in mortality or morbidity between strategies. In 2011, DiNardo and Mittnacht debated the topic of early extubation in the Journal of Cardiothoracic and Vascular Anesthesia, and in the absence of robust evidence to support either opinion, the striking difference between the 2 views was clearly driven by institutional practices and experience. 2 Mittnacht A.J. Pro: Early extubation following surgery for congenital heart disease. J Cardiothorac Vasc Anesth. 2011; 25: 874-876 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ,3 DiNardo J.A.Con: Extubation in the operating room following pediatric cardiac surgery. 2011;25:877-9. Google Scholar Since then, several studies have been published that have demonstrated the benefits associated with early extubation. In recent years, several institutions have designed multidisciplinary enhanced recovery after cardiac surgery (ERAS) protocols to reduce hospital LOS and complications. 4 Engelman D.T. Ben Ali W. Williams J.B. et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019; 154: 755-766 Crossref PubMed Scopus (225) Google Scholar As an example, a team from Boston Children's Hospital recently published its initial experience with an enhanced recovery program for congenital cardiac surgery that clearly highlighted the need for the implementation of a multidisciplinary and multimodal strategy that includes early extubation. 5 Roy N., Parra M.F., Brown M.L., et al. Initial experience introducing an enhanced recovery program in congenital cardiac surgery [E-pub ahead of print]. J Thorac Cardiovasc Surg. doi: 10.1016/j.jtcvs.2019.10.049. Accessed June 15, 2020 Google Scholar

MANAGEMENT OF COVID-19 IN PERSPECTIVE OF CARDIOLOGISTS

MANAGEMENT OF COVID-19 IN PERSPECTIVE OF CARDIOLOGISTS

Robotic Adrenalectomy for Pheochromocytoma in a Patient with Fontan Physiology

PHEOCHROMOCYTOMAS ARE rare neuroendocrine tumors that arise from both chromaffin cells in the adrenal medulla and sympathetic ganglion, or nonchromaffin cells in the parasympathetic ganglion. 1 Zhao B Zhou Y Zhao Y et al. Co-occurrence of pheochromocytoma-paraganglioma and cyanotic congenital heart disease: A case report and literature review. Front Endocrinol (Lausanne). 2018; 9: 165 Crossref PubMed Scopus (6) Google Scholar Pheochromocytomas arising from sympathetic tissue more commonly secrete catecholamines than those arising outside sympathetic tissue. 2 Lenders JW Eisenhofer G Mannelli M et al. Phaeochromocytoma. Lancet. 2005; 366: 665-675 Abstract Full Text Full Text PDF PubMed Scopus (1195) Google Scholar A strong association exists between cyanotic congenital heart disease and pheochromocytomas, with a higher- than- normal incidence seen in patients with cyanotic congenital heart disease (incidence reported as high as 2.5%) versus the normal hypertensive population prevalence of 0.2% to 0.6%. 1 Zhao B Zhou Y Zhao Y et al. Co-occurrence of pheochromocytoma-paraganglioma and cyanotic congenital heart disease: A case report and literature review. Front Endocrinol (Lausanne). 2018; 9: 165 Crossref PubMed Scopus (6) Google Scholar ,3 Lenders JW Duh QY Eisenhofer G et al. Pheochromocytoma and paraganglioma: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014; 99: 1915-1942 Crossref PubMed Scopus (1195) Google Scholar Chronic hypoxia has been speculated as a likely pathogenic mechanism related to abnormal activation of the hypoxic pathways located within the chromaffin cells. 4 Opotowsky AR Moko LE Ginns J et al. Pheochromocytoma and paraganglioma in cyanotic congenital heart disease. J Clin Endocrinol Metab. 2015; 100: 1325-1334 Crossref PubMed Scopus (43) Google Scholar , 5 Jochmanova I Yang C Zhuang Z et al. Hypoxia-inducible factor signaling in pheochromocytoma: Turning the rudder in the right direction. J Natl Cancer Inst. 2013; 105: 1270-1283 Crossref PubMed Scopus (111) Google Scholar , 6 Favier J. Pheochromocytomas: The (pseudo)-hypoxia hypothesis. Best Practice Res Clin Endocrinol Metab. 2010; 24: 957-968 Crossref PubMed Scopus (76) Google Scholar Although Fontan is intended to mitigate cyanosis, patients may be exposed to cyanosis before Fontan repair, and patients with failing Fontan physiology may become cyanotic due to fenestration, baffle leaks, and veno-venous collateral circulation. 7 Eagle SS Daves SM. The adult with Fontan physiology: Systematic approach to perioperative management for noncardiac surgery. J Cardiothorac Vasc Anesth. 2011; 25: 320-334 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Further, excess catecholamines secreted by the pheochromocytoma can mimic and induce heart failure and arrhythmias in all patients, particularly those with Fontan physiology.

Implementing a Statistical Model for Protamine Titration

(Abstracted from J Cardiothorac Vasc Anesth, 31:516–21, 2017) Using a fixed protamine-heparin dose (1:1) is the most commonly used method of protamine dosing in cardiopulmonary bypass patients to reverse the effects of heparin. The hemostasis management system (HMS Plus; Medtronic, Minneapolis, Minn) is an accepted alternate point-of-care device to calculate protamine dosing.

Thoracic Anesthesia Intubated Versus Nonintubated General Anesthesia for Video-Assisted Thoracoscopic Surgery—A Case-Control Study

(Abstracted from J Cardiothorac Vasc Anesth, 31:411–417, 2017) Although deemed mandatory to provide safe and optimal operating conditions for surgical manipulation, general anesthesia with endobronchial intubation and 1-lung positive-pressure ventilation for thoracic surgery has been known to cause lung injury. Nonintubated thoracic anesthetic techniques for video-assisted thoracoscopic surgery (VATS) in awake and sedated patients can be an alternate method to decrease the overall invasiveness and surgical stress.

Impact of Focused Intraoperative Transthoracic Echocardiography by Anaesthesiologists on Management in Hemodynamically Unstable High-Risk Noncardiac Surgery Patients

(Abstracted from J Cardiothorac Vasc Anesth, 31:602–609, 2017) Perioperative hemodynamic monitoring and intervention using transthoracic echocardiography (TTE) in high- risk surgery patients can decrease the rates of adverse events, morbidity, and mortality; however, evidence regarding its benefits is required. This prospective interventional study aimed at evaluating the efficacy of intraoperative TTE to alter patient management in high-risk and extensively monitored surgical patients susceptible to hemodynamic instability.

Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-thoracotomy Pain Syndrome After Thoracotomy

(Abstracted from J Cardiothorac Vasc Anesth, 31:159–165, 2017) The purpose of this prospective, randomized, controlled, double-blind trial was to evaluate the effectiveness of the administration of dexmedetomidine paravertebrally as an adjuvant to local anesthetic in limiting the intraoperative anesthetic drug requirement and the occurrence of postthoracotomy pain syndrome. Postthoracotomy pain increases the risk of delayed recovery due to atelectasis, hypoxemia, ventilation/perfusion mismatch, and infection.

Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery

(Abstracted from J Cardiothorac Vasc Anesth, 31:45–53, 2017) The purpose of this single-center retrospective analysis of prospectively collected data was to determine the role of lactate levels in predicting the severity of perioperative circulatory failure in patients recovering from cardiac surgery. Many reports support the link between elevated perioperative lactate levels and postoperative complications including mortality.

The Effect of Dexmedetomidine on Outcomes of Cardiac Surgery in Elderly Patients

(Abstracted from J Cardiothorac Vasc Anesth, 30(6):1502–1508, 2016) The purpose of this retrospective investigation was to study the effects of the perioperative use of dexmedetomidine (Dex) on outcomes in elderly patients undergoing cardiac surgery. Dexmedetomidine, a highly selective α2-adrenergic agonist, controls the activity of the sympathetic nervous system by binding to the α2-receptors present in both the central and peripheral nervous systems and inhibiting the release of norepinephrine, thus modulating sympathetic activity.

Etomidate and the Risk of Complications After Cardiac Surgery

(Abstracted from J Cardiothorac Vasc Anesth, 30(6):516–1522, 2016) The primary aim of this retrospective cohort study was to compare the incidence of atrial arrhythmia, duration of care, and major complications in cardiac surgery patients who received etomidate and those who received other induction agents.

Prognosis of Prolonged Intensive Care Unit Stay After Aortic Valve Replacement for Severe Aortic Stenosis in Octogenarians

(Abstracted from J Cardiothorac Vasc Anesth 30(6):1555–1561, 2016) Aortic stenosis (AS) is the most frequent heart valve disease in octogenarians, and aortic valve replacement (AVR) remains the primary treatment for AS. This observational study conducted in the postoperative surgical intensive care unit (ICU) of a tertiary care facility in Paris, France, aimed to evaluate the mortality rate of octogenarians experiencing prolonged hospitalization in the ICU following cardiac surgery and to define the best cutoff for prolonged ICU length of stay (LOS).

PP33 - Lung abscess isolation using double lumen tubes combined with bronchial blockers: a case series

Thoracic surgery in patients with lung infections is an absolute indication to isolate healthy lung or lobes. Different methods have been described, including the double-lumen endotracheal tube (DLT) or a variety of bronchial blockers (BBs) (1). However, when an abscess is present in only one lobe and lobectomy is planned, the insertion of a DLT alone or a single tube plus a BB may not be sufficient to prevent the spread of infection to an ipsilateral lobe. We present three cases with lung infection in which the isolation was made by combining DLT with a BB. Case 1: 22-years-old man diagnosed with lung aspergilloma within the residual tuberculous cavity in the upper left lobe. The surgeon requested selective resection of this lobe. Case 2: 50-year-old man diagnosed with lung abscess in the left lower lobe with suspected neoplasia, proposed to lobectomy. Case 3: 45-year-old woman diagnosed with lung abscess in the left upper lobe with suspected neoplasia/infection, proposed for lobectomy. In all three cases, airway management was a combination of left DLT (two Robertshaw type DL and one VivaSight DL®) with a BB, using the flexible fiberoptic scope as a guide to place the BB to the lobe that was being isolated. In case 1 a Cohen BB was used; in case 2 and 3, an Arndt BB was chosen. After BB placement, the corresponding lobes were isolated, ventilation in the rest of the ipsilateral lung was initiated. The lobes remained isolated until the bronchus resection. In thoracic anaesthesia providing satisfactory surgical exposure and maintaining adequate oxygenation is a challenge. But in these cases, isolation was even more important. Several devices are used to perform lung/lobe isolation: some experts recommend DLT for its shorter insertion time and less need for repositioning; others suggest that the BB have lower complication rates with the same efficiency (2). However, in thoracic surgery involving lung abscess the combination of both devices (DLT and BB) provides excellent isolation and results. This method prevented the spread of infection to the healthy lung with the DLT and to non-affected areas of the ipsilateral lung with the BB during airway and surgical manipulation with a favourable clinical-surgical outcome. 1. Narayanaswamy M, et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double lumen tubes. Anest Analg 2009; 108(4):1097-101. 2. Clayton-Smith A, et al. A comparison of the efficacy and adverse effects of double lumen endobronchial tubes and bronchial blockers in thoracic surgery: A systematic review and meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth 2015; 29(4):955-66.

Paediatric lung isolation

### Key points Lung isolation is required for a wide variety of pathology in paediatric patients. The varying size of the paediatric airway and size limitations of each lung isolation device poses a challenge to paediatric anaesthesiologists. The need for lung isolation includes: the prevention of contamination of one lung from the other due to haemorrhage or infection, the need to control the distribution of ventilation secondary to a bronchopulmonary fistula, a lung cyst or bullae, or severe hypoxaemia from unilateral lung disease. Extensive bronchopulmonary lavage may also necessitate lung isolation. Although lung isolation can assist in surgical exposure, in the paediatric population, surgical exposure for lung resections, mediastinal exposure, and thorascopy can often be accomplished by the CO2 pneumothorax and retraction of the operative lung without the need for lung isolation. This is most common in the young patient (<2 yr of age). Slinger1 teaches that there are the ‘ABCs’ of adult lung isolation: anatomy, bronchoscopy, and chest imaging. In paediatric lung isolation, there are still all the same ‘ABC’ considerations, with the addition of ‘D’—the varying diameter of the paediatric airway with age. ### Anatomy It has been long established that there are differences between the paediatric …

Transpharyngeal Imaging With Transesophageal Echocardiography as an Adjunct for Optimizing Retrograde Cerebral Perfusion

NEUROLOGIC PROTECTION DURING aortic arch surgery is challenging. Hypothermic circulatory arrest, retrograde cerebral perfusion, and antegrade cerebral perfusion are a few strategies that have evolved to minimize the neurologic injury that occurs from hypoperfusion. 1 Seco M. Edelman J.J. Van Boxtel B. et al. Neurologic injury and protection in adult cardiac and aortic surgery. J Cardiothorac Vasc Anesth. 2015; 29: 185-195 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Monitoring adequacy of cerebral perfusion is of paramount importance despite the strategy that is adopted. Retrograde cerebral perfusion is an established technique in patients undergoing aortic arch surgery with atheromatous cervical branches. 2 Ueda Y. A reappraisal of retrograde cerebral perfusion. Ann Cardiothorac Surg. 2013; 2: 316-325 PubMed Google Scholar This case report highlights the clinical adoption of transpharyngeal ultrasonography as a surrogate marker for assessing adequacy of retrograde cerebral perfusion in a patient who underwent successful surgery for acute type-A aortic dissection. Approval of this study was obtained from the Institutional Medical Ethics and Scientific Research Committee (MESRC number 73/2016), and written consent to publish data was obtained from the patient.

Erratum to Regional Tolerance to Acute Normovolemic Hemodilution: Evidence That the Kidney May Be at Greatest Risk J Cardiothorac Vasc Anesth(2015)29:320-327

Erratum to Regional Tolerance to Acute Normovolemic Hemodilution: Evidence That the Kidney May Be at Greatest Risk J Cardiothorac Vasc Anesth(2015)29:320-327

An Unusual Incidental Finding in a Patient With Colon Perforation

Question: A 74-year old man presented to our emergency department with acute abdominal pain and rectal bleeding. One week before admission, he underwent endoscopic laser therapy because of colonic angiodysplasia and polyposis. On clinical examination, his abdomen was painful in the right paraumbiblical region. CT was performed (Figure, transverse [A], coronal [B, C], and sagittal [D] reconstruction). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT revealed free intraabdominal air and fluid (Figure E-H). Additionally, thickening of the cecal wall is also seen. Furthermore, a long metallic line extending from the heart via the diaphragm into the stomach and duodenum was detected (Figure E-H, arrows). A further metallic line was identified in the pelvis. Intraoperatively, a large perforation of the cecum owing to local ulcerations as complication of the previous laser therapy was diagnosed and a right hemicolectomy was performed. Furthermore, both metallic lines were also removed. The line was sheared below the diaphragm. The intragastral/intraduodenal part of the line was extracted without difficulty. No surgical suture was necessary to close the small gastric perforation. Additional investigation of the lines revealed 2 temporary epicardial pacing wires (Figure I). The postoperative course was uneventful and the patient was discharged from the hospital 3 weeks later. A requestioning of the patient revealed a history of aortic valve implantation and coronary artery bypass grafting with placement of temporary epicardial pacing wires, 9 years before the admission. Temporary epicardial pacing wires (TEPW) are used routinely in open heart operations for therapeutic as well as diagnostic purposes.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar TEPW tips are placed intramuscular in the anterior wall of the right ventricle, and the distal ends are localized epicutaneously.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although the use of TEPW is safe and simple, placement of removal of TEPW can be associated with rare but serious complications, such as heart failure, cutaneous abscesses, or fistula formation.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Some reports have described complications caused by dislocation of TEPW.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 2Guerrieri Wolf L. Scaffa R. Maselli D. et al.Intraaortic migration of an epicardial pacing wire: percutaneous extraction.Ann Thorac Surg. 2013; 96: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar For example, Guerrieri Wolf et al2Guerrieri Wolf L. Scaffa R. Maselli D. et al.Intraaortic migration of an epicardial pacing wire: percutaneous extraction.Ann Thorac Surg. 2013; 96: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar reported a case of intraaortic migration of TEPW. Colonic perforation during placement of TEPW has been also reported previously.3Salami M.A. Coleman R.J. Buchan K.G. Colonic injury from temporary epicardial pacing wires.Ann Thorac Surg. 2012; 93: 1309-1311Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In our case, clinically silent diaphragm and stomach perforation by TEPW occurred. To our best of knowledge, this constellation has not been reported previously.

Pro: bronchial blockers should be used routinely for providing one-lung ventilation.

ONE-LUNG VENTILATION (OLV) traditionally has been provided with the use of a double-lumen tube (DLT). The use of bronchial blockers (BBs) to provide lung isolation has grown in recent years. Despite the development of BBs specifically designed for lung separation, the DLT has remained the preferred technique for providing lung isolation. A recent survey in the United Kingdom revealed a 98% preference rate for the DLT, 1 Shelley B. Macfie A. Kinsella J. Anesthesia for thoracic surgery: A survey of UK Practice. J Cardiothorac Vasc Anesth. 2011; 25: 1014-1017 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar and 64% of respondents reported rarely using a BB to provide lung isolation. A number of arguments have been advanced to support the notion that a DLT is superior to a BB and should be used routinely for providing OLV. In reality, some of these arguments are myths while others are valid, as will be presented in the discussion below. Double-Lumen Tubes for Tracheostomized PatientsJournal of Cardiothoracic and Vascular AnesthesiaVol. 29Issue 3PreviewWe thank Dr. Steven N. Neustein for his precise and concise article in the section, Pro and Con, entitled “Pro: Bronchial Blockers Should Be Used Routinely for Providing One-Lung Ventilation.”1 Full-Text PDF

Electrical bioimpedance cardiography: an old technology with new hopes for the future.

THE POSITIVE IMPACT of early goal-directed hemodynamic therapy on postoperative outcome increasingly has been investigated over the last few years in high-risk patients undergoing noncardiac and cardiac surgeries. 1 Phan T.D. Ismail H. Herior A.G. et al. Improving perioperative outcomes: Fluid optimization with the esophageal Doppler monitor, a meta-analysis and review. J Am Coll Surg. 2008; 207: 935-941 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar , 2 Hamilton M. Cecconi M. Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011; 112: 1392-1402 Crossref PubMed Scopus (593) Google Scholar , 3 Aya H.D. Cecconi M. Hamilton M. et al. Goal-directed therapy in cardiac surgery: A systematic review and meta-analysis. Br J Anaesth. 2013; 110: 510-517 Crossref PubMed Scopus (156) Google Scholar , 4 Goepfert M.S. Richter H.P. Eulenburg C.Z. et al. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: A prospective, randomized controlled study. Anesthesiology. 2013; 119: 824-836 Crossref PubMed Scopus (120) Google Scholar However, these preemptive strategies require advanced hemodynamic monitoring to assess cardiac output and stroke volume. The classic available tools (intermittent pulmonary arterial or transpulmonary thermodilution or esophageal Doppler), either invasive or operator-dependent and necessitating a learning curve, are not convenient for routine practice. Therefore, they remain insufficiently used among North American and European anesthesiologists. 5 Cannesson M. Pestel G. Ricks C. et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: A survey among North American and European anesthesiologists. Crit Care. 2011; 15: R197 Crossref PubMed Scopus (208) Google Scholar Besides, new mini-invasive cardiac output devices have been developed commercially over the last decade. 6 Marik P.E. Noninvasive cardiac output monitors: A state-of the-art review. J Cardiothorac Vasc Anesth. 2013; 27: 121-134 Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar Less accurate but more convenient and easy to use, they potentially could help the practitioners in promoting advanced hemodynamic monitoring and early goal-directed therapy at the bedside in high-risk patients in an attempt to further improve postoperative outcome. Among these mini-invasive technologies, thoracic electrical bioimpedance (TEB) has major theoretical advantages and could be of great clinical utility in the settings of anesthesiology, cardiology, and perioperative medicine. Despite extensive literature published over the last 50 years, TEB remains scarcely used by practitioners.

Tricuspid Valve: An Intraoperative Echocardiographic Perspective

FUNCTIONAL TRICUSPID REGURGITATION (FTR) is the most frequent presentation of tricuspid valve (TV) disease and often coexists with left-sided valve disorders. 1 Hung J. The pathogenesis of functional tricuspid regurgitation. Seminars in thoracic and cardiovascular surgery. 2010; 22: 76-78 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar There is considerable variation in the surgical approach to FTR during left-sided surgery from expectant management to TV repair in the presence of annular dilation. 2 Fawzy H, Fukamachi K, Mazer CD, et al: Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry. J Thorac Cardiovasc Surge 141:1037-1043 Google Scholar , 3 Gualis J. Castano M. Martinez-Comendador J.M. et al. Placement of a rigid tricuspid annuloplasty ring over a flexible ring for the treatment of recurrent tricuspid Regurgitation. J Cardi Surg. 2012; 27: 549-550 Crossref Scopus (1) Google Scholar , 4 Spinner E.M. Buice D. Yap C.H. et al. The effects of a three-dimensional, saddle-shaped annulus on anterior and posterior leaflet stretch and regurgitation of the tricuspid valve. Ann Biomed Eng. 2012; 40: 996-1005 Crossref PubMed Scopus (40) Google Scholar , 5 Ton-Nu T.T. Levine R.A. Handschumacher M.D. et al. Geometric determinants of functional tricuspid regurgitation: Insights from 3-dimensional echocardiography. Circulation. 2006; 114: 143-149 Crossref PubMed Scopus (264) Google Scholar The prognostic benefit of surgical treatment of FTR during left-sided valve surgery now is clearly established. 6 Sagie A. Schwammenthal E. Newell J.B. et al. Significant tricuspid regurgitation is a marker for adverse outcome in patients undergoing percutaneous balloon mitral valvuloplasty. J Ameri Coll Cardiol. 1994; 24: 696-702 Abstract Full Text PDF PubMed Scopus (114) Google Scholar , 7 Hornick P. Harris P.A. Taylor K.M. Tricuspid valve replacement subsequent to previous open heart surgery. J Heart Valve Dis. 1996; 5: 20-25 PubMed Google Scholar , 8 McCarthy P.M. Bhudia S.K. Rajeswaran J. et al. Tricuspid valve repair: Durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004; 127: 674-685 Abstract Full Text Full Text PDF PubMed Scopus (540) Google Scholar Hence, there has been a resurgence of interest in the structure and function of the TV, which once was considered the “Cinderella” of cardiac valves. 2 Fawzy H, Fukamachi K, Mazer CD, et al: Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry. J Thorac Cardiovasc Surge 141:1037-1043 Google Scholar , 9 Ring L. Rana B.S. Kydd A. et al. Dynamics of the tricuspid valve annulus in normal and dilated right hearts: A three-dimensional transoesophageal echocardiography study. Eur Heart J Cardiovasc Imaging. 2012; 13: 756-762 Crossref PubMed Scopus (45) Google Scholar Assessment of tricuspid regurgitation (TR) severity generally is used as the basis of surgical decision-making during left-sided valve surgery. 10 Shiran A. Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009; 53: 401-408 Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar However, echocardiographic assessment of TR is challenging in that it is load-dependent. Furthermore, the severity of TR is known to decrease after induction of general anesthesia. Whereas the presence of TR is considered a late sign of right ventricular (RV) dysfunction, tricuspid annular (TA) dilation is an early sign of potentially reversible RV dysfunction. 10 Shiran A. Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009; 53: 401-408 Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar Due to the leaflets being poorly echogenic, the TA has been used to quantify the magnitude of valve remodeling due to chronic volume overload. 11 Maslow A.D. Schwartz C. Singh A.K. Assessment of the tricuspid valve: A comparison of four transesophageal echocardiographic windows. J Cardiothorac Vasc Anesth. 2004; 18: 719-724 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar

Methylene Blue: Between Scylla (Meta-Analysis) and Charybdis (Propensity)

Methylene Blue: Between Scylla (Meta-Analysis) and Charybdis (Propensity)