Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Mechanical Assist Devices for Heart Failure

Key Points 1. Mechanical circulatory support (MCS) for the failing heart has become a mainstay of the modern management of patients with both acute and chronic heart failure refractory to pharmacologic and other usual interventions. 2. Outcomes with MCS have improved so dramatically that the main focus of this arena has now shifted away from simple survival and toward mitigation of risk and minimization of adverse…

Procedures in the Hybrid Operating Room

Key Points 1. A hybrid operating room combines advanced imaging capabilities with a fully functioning operating suite. 2. Transcatheter aortic valve replacement (TAVR) is recommended for patients with severe symptomatic aortic stenosis who are inoperable or at high risk for needing surgical aortic valve replacement and have a predicted post-TAVR survival of more than 12 months. 3. Vascular complications are the most common complications with the…

Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Key Points 1. The incidence of thromboembolic disease is difficult to estimate because of the nonspecific nature of presenting symptoms and a lack of awareness of the disorder. 2. Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of a pulmonary embolus (PE) or from recurrent PE. 3. The cause of CTEPH after acute PE is not fully understood. Proposed mechanisms include abnormalities in fibrinolytic enzymes…

Anesthesia for Heart, Lung, and Heart-Lung Transplantation

Key Points 1. Cardiac denervation is an unavoidable consequence of heart transplantation, and reinnervation is at best partial and incomplete. 2. Drugs acting directly on the heart are the drugs of choice for altering cardiac physiology after heart transplantation. 3. Allograft coronary vasculopathy remains the greatest threat to long-term survival after heart transplantation. 4. Broadening of donor criteria has decreased time to lung transplantation. 5. Air…

Uncommon Cardiac Diseases

Key Points 1. Cardiac tumors are rare. In general, a cardiac mass is more likely a vegetation or a thrombus than a tumor. Secondary (metastatic) tumors are far more common than primary cardiac tumors. Among primary cardiac tumors, benign lesions are more common than malignant tumors. 2. Cardiac myxomas historically have been considered the most common benign cardiac tumor. Patients with myxomas typically exhibit signs and…

Thoracic Aorta

Key Points 1. Diseases of the thoracic aorta can occasionally be managed with medical treatment and surveillance, whereas others require surgical intervention. Depending on the disease process, some surgeries may be performed electively, whereas others are truly emergency operations. 2. Aortic surgery is complex, and therefore it requires an anesthetic tailored to the specific goals for hemodynamics, neuromonitoring, and cerebral/spinal cord perfusion. 3. Thoracic aortic aneurysms…

Congenital Heart Disease in Adults

Key Points 1. Because of successes in treating congenital cardiac lesions, there are currently as many or more adults than children with congenital heart disease (CHD). 2. These patients may require cardiac surgical intervention for primary cardiac repair, repair following prior palliation, revision of repair due to failure or lack of growth of prosthetic material, or conversion of a suboptimal repair to a more modern operation.…

Valvular Heart Disease: Replacement and Repair

Key Points 1. Although various valvular lesions generate different physiologic changes, all valvular heart disease is characterized by abnormalities of ventricular loading. 2. The left ventricle normally compensates for increases in afterload by increases in preload. This increase in end-diastolic fiber stretch or radius further increases wall tension in accordance with Laplace's law, resulting in a reciprocal decline in myocardial fiber shortening. The stroke volume is…

Anesthesia for Myocardial Revascularization

Key Points 1. Guideline updates emphasize the efficacy of surgical approaches to myocardial revascularization in patients with multivessel coronary artery disease. 2. Perioperative risk reduction includes careful consideration of all of the patient's relevant antihypertensive, antiplatelet, and antianginal medications. 3. Significant valvular abnormalities in patients scheduled for coronary revascularization should be evaluated and considered in surgical planning. 4. Off-pump coronary artery bypass surgery is an established…

Coagulation Monitoring

Key Points 1. Monitoring the effect of heparin is done using the activated coagulation time (ACT), a functional test of heparin anticoagulation. The ACT is susceptible to prolongation because of hypothermia and hemodilution and to reduction because of platelet activation or thrombocytopathy. 2. Heparin resistance can be congenital or acquired. Pretreatment heparin exposure predisposes a patient to altered heparin responsiveness because of antithrombin III depletion, platelet…

Central Nervous System Monitoring

Key Points 1. Electroencephalography can detect both cerebral ischemia or hypoxia and seizures and can measure hypnotic effect. 2. Middle-latency auditory-evoked potentials objectively document inadequate hypnosis. 3. Somatosensory-evoked potentials may detect developing injury in cortical and subcortical brain structures and peripheral nerves. 4. Transcranial electric motor–evoked potentials monitor function of the descending motor pathways. 5. Transcranial Doppler ultrasound examination assesses the direction and character of blood…

Basic Intraoperative Transesophageal Echocardiography

Key Points 1. An ultrasound beam is a continuous or intermittent train of sound waves emitted by a transducer or wave generator that is composed of density or pressure. Ultrasound waves are characterized by their wavelength, frequency, and velocity. 2. Doppler frequency shift analysis can be used to obtain blood-flow velocity, direction, and acceleration of red blood cells, in which the magnitude and direction of the…

Monitoring of the Heart and Vascular System

Key Points 1. Patients with severe cardiovascular disease and those undergoing surgery associated with rapid hemodynamic changes should be adequately monitored at all times. 2. Standard monitoring for cardiac surgery patients includes invasive blood pressure, electrocardiography, central venous pressure, urine output, temperature, capnometry, pulse oximetry, and intermittent blood gas analysis. 3. Additional monitoring is based on specific patient, surgical, and environmental factors. 4. The Society of…

Electrocardiographic Monitoring

Key Points 1. The electrocardiogram reflects differences in transmembrane voltages in myocardial cells that occur during depolarization and repolarization within each cycle. 2. Processing of the electrocardiogram occurs in a series of steps. 3. Where and how electrocardiographic (ECG) electrodes are placed on the body are critical determinants of the morphology of the ECG signal. 4. ECG signals must be amplified and filtered before display. 5.…

Cardiovascular Pharmacology

Key Points 1. Ischemia during the perioperative period demands immediate attention by the anesthesiologist. 2. Nitroglycerin is indicated in most cases of perioperative myocardial ischemia. Mechanisms of action include coronary vasodilation and favorable alterations in preload and afterload. Nitroglycerin is contraindicated in cases of hypotension. 3. Perioperative β-blockade may reduce the incidence of perioperative myocardial ischemia by several mechanisms when initiated at an appropriate time in…

Pharmacology of Anesthetic Drugs

Key Points 1. In patients, the observed acute effect of a specific anesthetic agent on the cardiovascular system represents the net effect on the myocardium, coronary blood flow (CBF), and vasculature; electrophysiologic behavior; and neurohormonal reflex function. Anesthetic agents within the same class may differ from one another quantitatively and qualitatively. The acute response to an anesthetic agent may be modulated by the patient's underlying pathology…

Molecular and Genetic Cardiovascular Medicine and Systemic Inflammation

Key Points 1. The rapid development of molecular biologic and genetic techniques has greatly expanded the understanding of cardiac functioning, and these techniques are beginning to be applied clinically. 2. Cardiac ion channels form the machinery behind the cardiac rhythm; cardiac membrane receptors regulate cardiac function. 3. Sodium, potassium, and calcium channels are the main ion channel types involved in the cardiac action potential. Many subtypes…

Coronary Physiology and Atherosclerosis

Key Points 1. To care for patients with coronary artery disease in the perioperative period safely, the clinician must understand how the coronary circulation functions in health and disease. 2. Coronary endothelium modulates myocardial blood flow by producing factors that relax or contract the underlying vascular smooth muscle. 3. Vascular endothelial cells help maintain the fluidity of blood by elaborating anticoagulant, fibrinolytic, and antiplatelet substances. 4.…

Cardiac Physiology

Key Points 1. The cartilaginous skeleton, myocardial fiber orientation, valves, blood supply, and conduction system of the heart determine its mechanical capabilities and limitations. 2. The cardiac myocyte is engineered for contraction and relaxation, not protein synthesis. 3. The cardiac cycle is a highly coordinated, temporally related series of electrical, mechanical, and valvular events. 4. A time-dependent, two-dimensional projection of continuous pressure and volume during the…

Cardiac Electrophysiology: Diagnosis and Treatment

Key Points 1. Cardiac arrhythmias are common and result from an ectopic focus or a reentry circuit. 2. Surgical and catheter-based ablative therapies can abolish the origins of arrhythmias by interposition of scar tissue along the reentrant pathway or by isolating an ectopic area. 3. Supraventricular arrhythmias can be hemodynamically unstable, especially in the setting of structural heart disease. In some cases, persistent tachycardia can lead…