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
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
Induction: maintain SVR and consider slowing heart rate if mass blocking valves
There’s always a good reason to review the physiology and reasons for placement of an Intra Aortic Balloon Pump (IABP). We come across these a couple of times a month in our cardiac patients. They’re a great temporary measure to stabilizing and treating the patient.
One of the best explanations that I have ever seen for the IABP is from Dr. Rishi Kumar. He’s a board certified anesthesiologist and is ICU fellowship trained and is pursuing a cardiac anesthesia fellowship as well. This lovely human is no joke. I’ve read his blog and his instagram posts, and he’s a wonderful teacher and mentor to those he reaches. Please click his link for an entry regarding IABPs on his blog.
There’s been a big debate re: who should care for LVAD patients… a general anesthesiologist or a cardiac anesthesiologist? See below for pros and cons of each. Ultimately, I think all anesthesiologists should be comfortable caring for these patients as we’ll see more and more LVAD patients undergoing procedures.
Goals of care for LVAD patients undergoing non-cardiac surgery should be directed at maintaining forward flow and adequate perfusion. Three main factors that affect LVAD flow are preload, RV function, and afterload.
The right ventricle is the primary means of LVAD filling; therefore, maintaining RV function is imperative.
Marked increases in systemic vascular resistance should be avoided.
Generally, decreases in pump flow should first be treated with a fluid challenge. Hypovolemia should be avoided and intraoperative losses should be replaced aggressively. Second line treatment should include inotropic support for the right ventricle.
Low-dose vasopressin (<2.4 U/h) may be the vasopressor of choice due to its minimal effect on pulmonary vascular resistance.
Standard Advanced Cardiovascular Life Support Guidelines should be followed; however, external chest compressions should be avoided during cardiac arrest.
Steep Trendelenburg may increase venous return, risking RV strain. Peritoneal insufflation for laparoscopic surgery also increases afterload and has detrimental effects on preload. Insufflation should utilize minimum pressures and be increased in a gradual, step-wise fashion.
TEE can be extremely valuable in diagnosing the cause of obstruction.
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.
“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.
Surgically, more and more cases are performed through tiny incisions for minimal scarring. Don’t let that underestimate the size of the procedure. For example, mitral valve surgery is still a common procedure that involves a sternotomy (“cracking the chest”) and stopping the heart — it’s a big procedure. However, surgeons have become adept at making smaller incisions while still undergoing the big procedure.