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Quadriceps tendon rupture is an incapacitating injury that usually requires surgical repair. Traditional repair methods involve transpatellar suture tunnels, but recent reports have introduced the idea of using suture anchors to repair the ruptured tendon. We present 5 cases of our technique of using suture anchors to repair the ruptured quadriceps tendon.

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Left ventricular assist device (LVAD) insertion is an increasingly common treatment of advanced heart failure. Insertion guidelines suggest regurgitant lesions of the mitral valve should not be addressed. However, recent evidence suggests that mitral regurgitation may not necessarily improve with LVAD insertion, and such patients may have worse outcomes. Thus, practice variability is high given the discrepancy between traditional thinking and new evidence that unrepaired mitral regurgitation may increase perioperative mortality. Additionally, the challenges of LVADs can make transesophageal echocardiography evaluation and assessment of mitral valve pathology difficult.

Objective: The authors hypothesized that average precardiopulmonary bypass (pre-CPB) transesophageal echocardiographic (TEE) mean gradient (PG m ) and aortic valve area (AVA) values would be significantly different from preoperative transthoracic (TTE) values in the same patients and that these changes would affect pre-CPB TEE grading of aortic stenosis (AS).Design: Retrospective, observational design. Setting: Single university hospital. Participants: The study comprised 92 patients who underwent aortic valve replacement with or without coronary artery bypass grafting between 2000 and 2012 at Duke University Hospital and who had PG m and AVA values recorded in both pre-CPB TEE and preoperative TTE reporting databases.Interventions: None. Measurements and Main Results: PG m with pre-CPB TEE was lower by 6.6 mmHg (95% confidence interval, -4.0 to -9.3 mmHg; p o 0.001), whereas AVA was higher by 0.10 cm 2 (95% confidence interval, 0.04 to 0.15 cm 2 ; p o 0.001), compared with preoperative TTE values. When using PG m , pre-CPB TEE generated an AS severity 1 grade lower 39.1% of the time and revealed no difference 55.4% of the time compared to preoperative TTE. When using AVA by continuity, pre-CPB TEE generated an AS severity 1 grade lower 14.1% of the time and revealed no difference 81.5% of the time compared to preoperative TTE. When using either PGm or AVA, preoperative TTE exhibited moderate or severe AS for all study patients, whereas, pre-CPB TEE demonstrated mild AS in 5.4% (n ¼ 92) of patients.Conclusions: The authors confirmed their hypothesis that pre-CPB TEE generates different PG m and AVA values compared with preoperative TTE. These differences often underestimate AS severity. Hemodynamic standardizations or adjustments of pre-CPB TEE PG m and AVA values may be necessary in anesthetized patients before assigning an AS grade using these parameters. & 2016 Elsevier Inc. All rights reserved.KEY WORDS: aortic stenosis, aortic valve area, discordance, mean gradient, precardiopulmonary bypass (intraoperative) transesophageal echocardiography P RECARDIOPULMONARY BYPASS (pre-CPB) transesophageal echocardiography (TEE) is essential for intraoperative assessment and surgical guidance during cardiac surgery. Although many patients come to the operating room with an extensive cardiac workup, pre-CPB TEE aortic valve assessment can affect surgical decision-making based on new findings during planned or emergency surgeries. According to a large retrospective review of 3,835 patients undergoing isolated coronary artery bypass grafting (CABG), 3.3% of patients had an unplanned aortic or mitral valve procedure added to the surgery based on pre-CPB TEE findings. 1 Of 1,823 patients undergoing mitral valve surgery, 1.0% of patients underwent an unplanned aortic valve procedure based on incidental findings during pre-CPB TEE. 1 Given that surgical decisions can be based on pre-CPB TEE findings, accurate interpretation of grading parameters during the pre-CPB period is imperative.The validated mean gradient (PG m ) and aor...

Patients with pulmonary hypertension (PH) remain challenging to care for in the perioperative period. This update will review the most current definitions, the acute and chronic treatment options for PH, including the rationale for various therapeutic agents, the potential side effects and optimization strategies. Anesthetic techniques, which may be affected by PH and/or the medications used to treat PH, are discussed as well as the intraoperative management of PH with suggestions for addressing adverse events. Specific hemodynamic and metabolic stressors during thoracic surgery, including one-lung ventilation, are emphasized with discussion about the options for intraoperative monitoring. Safe and efficacious care of patients with PH requires expert cardiovascular management with close attention to medication interactions and hemodynamic perturbations.

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Discordance in Grading Aortic Stenosis by Pre-CPB TEE aortic valve. For this reason, AVA calculation is prone to error compared with a ΔP m measurement.Although inconsistencies for grading AS with AVA and ΔP m are well known for preoperative TTE, they are routinely used for grading AS in the pre-cardiopulmonary bypass (pre-CPB) context. In this study, we investigate the frequency of discordance between grading AS with ΔP m measurements and AVA calculations during pre-CPB transesophageal echocardiography (TEE) to provide insight into their reliability for pre-CPB assessment of AS severity. Conventional AS severity cutoffs were derived from TTE studies performed in awake, spontaneously breathing patients.14-18 However, cardiac anesthesiologists perform pre-CPB TEE in anesthetized patients receiving positive pressure ventilation. Because general anesthesia and positive pressure ventilation may influence cardiac loading conditions, we hypothesized that grading discordance by pre-CPB TEE would be higher than previously reported for TTE by others. METHODSWe obtained Duke University IRB approval, which granted waiver of consent to perform a retrospective database study for information collected between January 1, 2000, and December 31, 2012. This study was an investigator-initiated, single-center, retrospective review of the Duke University, Department of Anesthesiology perioperative echocardiography-reporting database. This database includes all adult patients who have undergone cardiac surgery at Duke University Medical Center and had a TEE report generated electronically since January 1, 2000. The Duke Health Information Technologies Solutions (DHTS) Perioperative Development Group (PDG) maintains the reporting system. A cardiothoracic anesthesiology fellow, attending, or both, generated TEE reports as part of a dedicated perioperative echocardiography training program. All imaging and reports were subsequently reviewed offline by an independent cardiothoracic anesthesiologist to confirm the accuracy of the report. Subject SelectionWe reviewed all patients in the database, who underwent AVR with or without coronary artery bypass grafting from January 1, 2000, until December 31, 2012. Patients were included if the echocardiographer reported both a pre-CPB ΔP m and an AVA. Patients were excluded if they had emergency surgery or repeat sternotomy. Patients were also excluded if they had an ejection fraction <55%, moderate or severe mitral regurgitation (MR), or severe aortic insufficiency (AI). Definitions of Variables Statistical AnalysisIRB approval was obtained in early 2013; therefore, we collected retrospective data as far as possible, up through December 31, 2012. Pre-CPB TEE ΔP m and AVA values were extracted for all patients meeting clinical inclusion criteria. These values were grouped according to AS severity (mild, moderate, and severe) and compared for discordance rates based on current grading guidelines for ΔP m and AVA. Values were considered "discordant" if there was disagreement between severities bas...