No abstract

An analgesic regimen including thoracic PVB resulted in a rapid recovery without opioid-related side effects and early reinitiation of anticoagulation therapy. Our case illustrates the effective application of thoracic PVB in congenital heart disease patients for non-cardiac-related surgery.

Paravertebral block (PVB) is feasible for postoperative analgesia in patients who undergo cardiac surgery with unilateral thoracotomy. Postoperative continuous PVB is as effective as thoracic epidural anesthesia and is less likely to cause hypotension. However, the intraoperative utility and safety of PVB remains unclear. Therefore, the present study was conducted to determine the efficacy and hemodynamic influence of intraoperative paravertebral bolus injection during cardiac surgery. We retrospectively compared intraoperative medication use and blood pressure measurements between patients who underwent transapical transcatheter aortic valve implantation (TA-TAVI) with (PVB group, n = 46) or without (non-PVB group, n = 15) intraoperative PVB. Remifentanil administration was lower by more than 40 % in the PVB group compared with that in the non-PVB group (728 ± 319 µg vs. 1240 ± 488 µg, P < 0.001). The average and variability of intraoperative blood pressure showed no significant differences between groups. The duration of hypotension (blood pressure less than 80 % of baseline) was 25.1 ± 21.5 % and 25.4 ± 18.1 % of the entire anesthesia time in the non-PVB and PVB groups, respectively (P = 0.74). The use of inotropic and vasopressor agents was comparable between groups. Intraoperative paravertebral bolus injection decreased remifentanil administration without causing hypotension during TA-TAVI in hemodynamically unstable patients. This result suggests the intraoperative utility of PVB in cardiac surgery.

BACKGROUNDVocal cord paralysis (VCP) is a rare complication of thoracic cardiovascular surgery. In severe cases, life-threatening airway obstruction may occur.OBJECTIVETo evaluate the incidence and severity of VCP among patients who underwent thoracic cardiovascular surgery and to identify possible risk factors.DESIGNSingle-centre retrospective review of adult patients.SETTINGOsaka University Hospital, Suita, Japan, from January 2013 to August 2015.PATIENTSWe included 688 patients in the final analysis. Preoperative, intraoperative and postoperative data were collected from medical records. Patients with preoperative VCP or tracheostomy prior to extubation were excluded. The VCP severity in relation to functional recovery was graded using the following categories: absent; mild, remission at 6 months; moderate, partial or persistent VCP at 6 months; or severe, airway obstruction after extubation requiring reintubation. An otolaryngologist diagnosed all VCP cases.MAIN OUTCOME MEASURESThe incidence and severity of VCP after extubation.RESULTSThe incidence (number) of VCP was 4.7% (32), with those of mild, moderate and severe VCP being 1.7% (12), 1.5% (10) and 1.5% (10), respectively. The ICU stay was significantly longer in patients with severe VCP than in patients without VCP [12.5 days (interquartile range 5.5 to 25.5) vs. 3 days (interquartile range 2 to 5), P = 0.0002]. In our multivariable analysis, type 2 diabetes mellitus [odds ratio (OR) 1.853, P = 0.009], intubation period (OR per 24 h 1.136, P = 0.014), ascending aortic arch surgery with brachiocephalic artery reconstruction (OR 8.708, P < 0.001) and ventricular assist device implantation (OR 3.460, P = 0.005) were independent predictors for VCP.CONCLUSIONThe identification of these risk factors may facilitate screening for VCP before extubation and possibly help anaesthesia personnel to be prepared to treat VCP-related airway obstruction should it occur.

Rapid ventricular pacing (RVP) is used during transcatheter aortic valve implantation (TAVI). RVP disturbs myocardial oxygen balance, and when prolonged, it may cause procedure-related myocardial injury (PMI). This study investigated whether a longer duration of RVP increased the occurrence of PMI or worsened long-term mortality after TAVI. We retrospectively analyzed data from 188 patients who underwent TAVI in our institute from January 2013 to July 2015. Myocardial injury was represented by the peak value of creatine kinase-myocardial band (CK-MB) within 72 h after the procedure; an increase greater than 5 times the upper reference limit was regarded as PMI. There was no difference in RVP time (RVPT) between patients with and without PMI (median [range]: 57 [9-189] s vs. 54 [0-159] s, p = 0.9). A higher peak CK-MB was significantly correlated with the apical approach for the procedure (p < 0.001) but not with total RVPT (p = 0.22). A subanalysis of 133 patients whose troponin I was tested within 72 h postprocedurally showed no correlation between the peak value and RVPT (p = 0.40). Shortening RVPT did not result in myocardial protection; thus, RVPT during TAVI should be sufficient to optimize valve placement.