Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position. Although any age can be affected, it predominates in the age group of 30-60 years of age with more than 75% of the affected being women. The occurrence of myxomas in left and right atrium are 75% and 20% respectively.The majority of myxomas present with systemic emboli, fever and/or weight loss, or intracardiac obstruction to blood flow.1 A ‘tumor plop’ is a sound that typically occurs during early diastole and is believed to be caused by motion of the tumor striking the wall of the endocardium. The treatment is surgical excision and key aims of anesthesia care include constant monitoring of systemic blood pressure, adequate IV fluids, and judicious use of vasoactive medications to prevent a fall in systemic vascular resistance.3
Preop
A-line/CVP
Assess patient symptomatology: SOB, chest pain, changes in pulse pressure/CVP with positioning, heart sounds
Adequate PIV access
Vasopressors to help with SVR and heart rate control – mass can act as stenotic valve
Intraop
Induction: maintain SVR and consider slowing heart rate if mass blocking valves
Postop
2D TEE: X-plane
2D TEE: color flow through mitral valve
2D TEE: LA myxoma
2D TEE: LA myxoma w color
3D TEE: LA myxoma
From OpenAnaesthesia2D TEE: measurement of stalkResected myxoma
I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!
Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
Perioperative glycemic control is recommended (BS 70-180; [110-150]).
A care bundle of best practices should be performed to reduce surgical site infection.
Goal-directed therapy should be performed to reduce postoperative complications.
A multimodal, opioid-sparing, pain management plan is recommended postoperatively
Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
Post-operative systematic delirium screening is recommended at least once per nursing shift.
An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
Level IIa (Class of recommendation=Moderate Benefit)
Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
Rigid sternal fixation can be useful to reduce mediastinal wound complications.
Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
Early extubation strategies after surgery are reasonable to be employed.
Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
Chemical thromboprophylaxis can be beneficial following cardiac surgery.
Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
Correction of nutritional deficiency, when feasible, can be beneficial.
Level IIb (Class of recommendation=Weak Benefit)
A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
Carbohydrate loading may be considered before surgery.
60-something y/o male patient who isn’t physically active but does ADLs. Scheduled for CABG but has AI, PVD, EF 40%, HTN, HLD. Would you suggest an AVR or not…. along with the CABG?
Transthoracic echo: a beginner’s guide #tte #cardiac #echo #meded
Knowing how to do a quick focused echo exam can be instrumental in diagnosis as well as treatment. This has helped me determine how severe cardiac tamponade has been in an emergent case prior to induction when there was no prior echo. There are so many more useful answers that a bedside echo can provide. Time to get acquainted.
A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF. At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs. After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella. During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.
Fast forward a couple days after getting extubated, the patient was ripe for an LVAD. But which one? (We ended up placing the patient on HeartWare LVAD).
ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.
ROADMAP study: (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Heart Failure Patients) was an observational study of the Thoratec HeartMate II LVAD compared to optimal medical management in patients with advanced heart failure. Thirty day mortality was the same in both groups (1%) while one year survival was 80% in the LVAD group compared to 64% in the medical group (on an as treated basis). Functional status and quality of life improved significantly more in the LVAD group (analyzed by 6 minute walk, health related quality of life, and NYHA class). Unfortunately, adverse events in the LVAD group remained similar to what was previously reported in the DT trial, with bleeding being the most frequent adverse event.
“There’s an emergent case coming for impella placement.”
Impella? I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement. But, I’ve never done an Impella on a critically unstable patient.
