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A case of left atrial dissection after mitral valve replacement
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
S75
Discussion: The study effect of teaching the 11 basic TEE views was similar in all study groups with the best but not significant effect in the simulation group. Therefore, medical simulation is a useful alternative to training in the operation room and is not limited by time factors and the OR schedule.
OP53, PP14 Evaluation of simulator training on transoesophageal echocardiography performance in anaesthesia residents
REFERENCES: 1. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D, Scovotti JC, Chua JH, Ho JK, Mahajan A. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesthesia and Analgesia 2012; 115 (5):1042–1051. 2. Reeves ST, Finley AC, Skubas NJ, Swaminathan M, Whitley WS, Glas KE, Hahn RT, Shanewise JS, Adams MS, Shernan SK; Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. JASE 2013; 26:443-56.
Ulrike Weber, B Zapletal, E Base, M Hambrusch, B Mora
OP54, PP15
Medical University of Vienna, Department of Anaesthesiology, General Intensive Care and Pain Medicine, Vienna, Austria
A case of left atrial dissection after mitral valve replacement
Dheeraj Arora, M Mishra, Y Mehta, N Trehan Introduction: Training in transoesophageal echocardiography (TEE) is based on hands-on training in the operation room which is time consuming and therefore its experience is limited among anaesthesiologists. Medical simulation has been used successfully for training of invasive procedures in many areas. (1) We assessed if there was a difference in the study effect of teaching the 11 basic TEE views (2) in 3 groups of residents with no prior knowledge of echocardiography: the online study group (ON), the simulation group (CAE Vimedix Simulator) (SIM) and the hands-on group in the operation room (OR). Methods: All 3 study groups received a lecture about theoretical knowledge followed by 2 practical study sessions either in the operating room, with the simulation model or online (www.pie.med.utoronto.ca/TEE). They had to complete a theoretical multiple choice test before and after the teaching sessions and a practical test after each training. In the practical test demonstration of the 11 basic TEE views was required. This examination was scored on a scale from 0 to 110 points (up to 10 points for each view). Results: Fifty-one residents were randomized to three groups. In this preliminary analysis forty-one residents completed the training so far. Scores in the theoretical test for all groups were 28,63 7 4,78 before the training and 37,61 7 5,63 after the training (p ¼0,007, n ¼41). Scores in the theoretical test after the training sessions were 35,9 7 4,65 (ON, n¼ 14), 41,8 7 4,36 (SIM, n ¼ 15) and 34,3 7 5,14 (OR, n¼ 12). Scores in the practical test were 106,36 7 4,85 (ON), 108,4 7 2,22 (SIM) and 106,58 7 2,23 (OR). There was no significant difference between the 3 groups.
Medanta The Medicity, Institute of Critical Care & Anaesthesiology, New Delhi, India A 54 year old female case of rheumatic heart disease with severe mitral stenosis (mitral valve area 0.8cm2), moderate mitral regurgitation and moderate pulmonary arterial hypertension, underwent mitral valve replacement with a bioprosthetic valve 25mm. Her intraoperative period and postoperative day (POD) one was uneventful. On POD two she had hypotension with increasing requirement of inotropes. Her central venous pressure (CVP) was 20 mmHg and pulmonary artery pressure (PAP) was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her haemodynamic status she could not be extubated. Transoesophgeal echocardiography (TOE) was done to rule out cardiac tamponade and to evaluate the prosthetic mitral valve. TOE revealed a large cavitating mass occupying the whole of the left atrium (LA) which was obliterating the movement of the mitral valve (MV) leaflets (figure1). There was gradient (peak/mean) of 13/8 mmHg across MV. She was planned for re-exploration and cardiopulmonary bypass was established. Opening of LA revealed dissection of the LA wall. Deroofing of the LA was done and the bioprosthetic valve was checked. The patient was weaned off the CPB with mild inotropes. She was mechanically ventilated for 24 hours and inotropes gradually weaned. Her postoperative period was uneventful. LA dissection is a rare and fatal complication of cardiac surgery with reported incidence of o0.2%. It is primarily seen after mitral valve surgery and due to formation of a cavity between endocardium and epicardium of LA. LA dissection
S76
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
with haemodynamic instability like in this case should be treated promptly with surgical intervention1 following TOE. However; haemodymically stable dissections can be managed medically. Recently it has been reported after transcatheter aortic valve replacement.2
the low hemoglobin group (hemoglobin r median) and the high hemoglobin group (hemoglobin 4 median). Our end point was all-cause mortality, assessed by the Kaplan-Meier method during the first year after transplantation. Log-rank test was used to test for group differences. A P-value o 0.05 was considered significant
REFERENCES: 1. Fukuhara S, Dimitrova KR, Geller CM; et al. Left atrium dissection: an almost unknown entity. Interact Cadiovasc Thorac Surg; 2015; 20(1) :96-100. 2. Sardar MR, Kaddissi GI, Sabir SA, Topalian SK. First case of left atrial dissection after transcatheter aortic valve replacement. Cardio Revasc Med. 2016; 17(4): 279-81.
Results: A total of 719 patients have been transplanted during the study period. Mean hemoglobin level at arrival on the ICU was 11.9 7 1.5 g/dL and median was 11.9 g/dL. Kaplan Meier analysis is shown in Figure 1. The log-rank test for the difference between the two groups gave a p-value of 0.00018.
OP55, PP21
Discussion: This may indicate that patients arriving on the ICU with a higher level of hemoglobin have a significantly better chance to survive the first year after transplantation. A different transfusion policy might therefore be required for patients undergoing double lung transplantation in comparison to patients undergoing general cardiothoracic surgery.
Intraoperative red blood cell transfusion trigger in double lung transplantation: the higher the better?
Johannes Menger, S Koch, P Jaksch, M Dworschak Medical University of Vienna, Department of Anaesthesia, Critical Care and Pain Medicine, Vienna, Austria Introduction: Transfusion of packed red blood cells (PRBC) during double lung transplantation seems to have no effect on allcause mortality of recipients [1]. This stands in contrast to general cardiothoracic surgery where low transfusion triggers are seen as a viable way to reduce the risks associated with the transfusion of PRBC [2]. We therefore investigated the effect of postoperative hemoglobin levels on mortality after lung transplantation. Method: We conducted a retrospective cohort study investigating data from our institutional lung transplant database that comprised the time frame from January 2009 through July 2015. Hemoglobin levels immediately after surgery at arrival on the ICU were used to calculate mean and median values and patients were stratified into two groups:
REFERENCES: 1. Ong LP et al. Allogeneic blood transfusion in bilateral lung transplantation: impact on early function and mortality. Eur J Cardiothorac Surg (2016) 49 (2): 668-674. 2. Reeves BC et al. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr Opin Cardiol (2008) 23 (6): 607–612
S75
Discussion: The study effect of teaching the 11 basic TEE views was similar in all study groups with the best but not significant effect in the simulation group. Therefore, medical simulation is a useful alternative to training in the operation room and is not limited by time factors and the OR schedule.
OP53, PP14 Evaluation of simulator training on transoesophageal echocardiography performance in anaesthesia residents
REFERENCES: 1. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D, Scovotti JC, Chua JH, Ho JK, Mahajan A. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesthesia and Analgesia 2012; 115 (5):1042–1051. 2. Reeves ST, Finley AC, Skubas NJ, Swaminathan M, Whitley WS, Glas KE, Hahn RT, Shanewise JS, Adams MS, Shernan SK; Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. JASE 2013; 26:443-56.
Ulrike Weber, B Zapletal, E Base, M Hambrusch, B Mora
OP54, PP15
Medical University of Vienna, Department of Anaesthesiology, General Intensive Care and Pain Medicine, Vienna, Austria
A case of left atrial dissection after mitral valve replacement
Dheeraj Arora, M Mishra, Y Mehta, N Trehan Introduction: Training in transoesophageal echocardiography (TEE) is based on hands-on training in the operation room which is time consuming and therefore its experience is limited among anaesthesiologists. Medical simulation has been used successfully for training of invasive procedures in many areas. (1) We assessed if there was a difference in the study effect of teaching the 11 basic TEE views (2) in 3 groups of residents with no prior knowledge of echocardiography: the online study group (ON), the simulation group (CAE Vimedix Simulator) (SIM) and the hands-on group in the operation room (OR). Methods: All 3 study groups received a lecture about theoretical knowledge followed by 2 practical study sessions either in the operating room, with the simulation model or online (www.pie.med.utoronto.ca/TEE). They had to complete a theoretical multiple choice test before and after the teaching sessions and a practical test after each training. In the practical test demonstration of the 11 basic TEE views was required. This examination was scored on a scale from 0 to 110 points (up to 10 points for each view). Results: Fifty-one residents were randomized to three groups. In this preliminary analysis forty-one residents completed the training so far. Scores in the theoretical test for all groups were 28,63 7 4,78 before the training and 37,61 7 5,63 after the training (p ¼0,007, n ¼41). Scores in the theoretical test after the training sessions were 35,9 7 4,65 (ON, n¼ 14), 41,8 7 4,36 (SIM, n ¼ 15) and 34,3 7 5,14 (OR, n¼ 12). Scores in the practical test were 106,36 7 4,85 (ON), 108,4 7 2,22 (SIM) and 106,58 7 2,23 (OR). There was no significant difference between the 3 groups.
Medanta The Medicity, Institute of Critical Care & Anaesthesiology, New Delhi, India A 54 year old female case of rheumatic heart disease with severe mitral stenosis (mitral valve area 0.8cm2), moderate mitral regurgitation and moderate pulmonary arterial hypertension, underwent mitral valve replacement with a bioprosthetic valve 25mm. Her intraoperative period and postoperative day (POD) one was uneventful. On POD two she had hypotension with increasing requirement of inotropes. Her central venous pressure (CVP) was 20 mmHg and pulmonary artery pressure (PAP) was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her haemodynamic status she could not be extubated. Transoesophgeal echocardiography (TOE) was done to rule out cardiac tamponade and to evaluate the prosthetic mitral valve. TOE revealed a large cavitating mass occupying the whole of the left atrium (LA) which was obliterating the movement of the mitral valve (MV) leaflets (figure1). There was gradient (peak/mean) of 13/8 mmHg across MV. She was planned for re-exploration and cardiopulmonary bypass was established. Opening of LA revealed dissection of the LA wall. Deroofing of the LA was done and the bioprosthetic valve was checked. The patient was weaned off the CPB with mild inotropes. She was mechanically ventilated for 24 hours and inotropes gradually weaned. Her postoperative period was uneventful. LA dissection is a rare and fatal complication of cardiac surgery with reported incidence of o0.2%. It is primarily seen after mitral valve surgery and due to formation of a cavity between endocardium and epicardium of LA. LA dissection
S76
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
with haemodynamic instability like in this case should be treated promptly with surgical intervention1 following TOE. However; haemodymically stable dissections can be managed medically. Recently it has been reported after transcatheter aortic valve replacement.2
the low hemoglobin group (hemoglobin r median) and the high hemoglobin group (hemoglobin 4 median). Our end point was all-cause mortality, assessed by the Kaplan-Meier method during the first year after transplantation. Log-rank test was used to test for group differences. A P-value o 0.05 was considered significant
REFERENCES: 1. Fukuhara S, Dimitrova KR, Geller CM; et al. Left atrium dissection: an almost unknown entity. Interact Cadiovasc Thorac Surg; 2015; 20(1) :96-100. 2. Sardar MR, Kaddissi GI, Sabir SA, Topalian SK. First case of left atrial dissection after transcatheter aortic valve replacement. Cardio Revasc Med. 2016; 17(4): 279-81.
Results: A total of 719 patients have been transplanted during the study period. Mean hemoglobin level at arrival on the ICU was 11.9 7 1.5 g/dL and median was 11.9 g/dL. Kaplan Meier analysis is shown in Figure 1. The log-rank test for the difference between the two groups gave a p-value of 0.00018.
OP55, PP21
Discussion: This may indicate that patients arriving on the ICU with a higher level of hemoglobin have a significantly better chance to survive the first year after transplantation. A different transfusion policy might therefore be required for patients undergoing double lung transplantation in comparison to patients undergoing general cardiothoracic surgery.
Intraoperative red blood cell transfusion trigger in double lung transplantation: the higher the better?
Johannes Menger, S Koch, P Jaksch, M Dworschak Medical University of Vienna, Department of Anaesthesia, Critical Care and Pain Medicine, Vienna, Austria Introduction: Transfusion of packed red blood cells (PRBC) during double lung transplantation seems to have no effect on allcause mortality of recipients [1]. This stands in contrast to general cardiothoracic surgery where low transfusion triggers are seen as a viable way to reduce the risks associated with the transfusion of PRBC [2]. We therefore investigated the effect of postoperative hemoglobin levels on mortality after lung transplantation. Method: We conducted a retrospective cohort study investigating data from our institutional lung transplant database that comprised the time frame from January 2009 through July 2015. Hemoglobin levels immediately after surgery at arrival on the ICU were used to calculate mean and median values and patients were stratified into two groups:
REFERENCES: 1. Ong LP et al. Allogeneic blood transfusion in bilateral lung transplantation: impact on early function and mortality. Eur J Cardiothorac Surg (2016) 49 (2): 668-674. 2. Reeves BC et al. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr Opin Cardiol (2008) 23 (6): 607–612