Papers by Sergio Bevilacqua
Seminars in Cardiothoracic and Vascular Anesthesia, 2020
In this letter, the authors wonder about the need to apply some of the precautions that have been... more In this letter, the authors wonder about the need to apply some of the precautions that have been repeatedly suggested during the recent COVID-19 (coronavirus disease 19) pandemic not only to suspected or documented cases of infection but also to all the new cases entering the hospital. In this regard, orotracheal intubation has been universally recognized as a maneuver with a high risk of viral transmission. On the other hand, rapid sequence induction, which represents the gold standard for limiting the risk of transmission for health care professionals, implies side effects that can be potentially harmful for patients with impaired hemodynamics. In this regard, the authors report a particular type of rapid induction that they are performing in a systematic way during the recent pandemic in cardiac surgery patients. This is performed after the patient reaches a deep analgesic plan, thanks to the unique characteristics of the opioid remifentanil. This type of induction, already test...
Sedation in Cardiac Surgery Intensive Care Unit
Critical Care Sedation, 2017
In this chapter, an overview is presented of ICU sedation of patients undergoing heart operation.... more In this chapter, an overview is presented of ICU sedation of patients undergoing heart operation. Cardiac patients are particularly vulnerable to the side effects of sedative drugs because of the limited cardiac reserve. Furthermore, patients scheduled for cardiac surgery are becoming increasingly frailer and aged, and thus they present with several associated comorbidities, such as atherosclerosis or neurocognitive dysfunction, which put them at risk to develop postoperative delirium and cognitive disabilities. Sedation has a pivotal role in the cardiac surgery setting, not only for the increasing need to calm delirious patients but also for its potential role, if not correctly managed, in inducing delirium itself. Nevertheless, the advances made by cardiac surgery in the last decades allowed to wean patients early in the postoperative period. Therefore, starting with the assumption that outcome is better if sedation is maintained not too deep and for the shortest time needed, the fast-track model diffused widely in the last 20 years and is nowadays the most common weaning strategy also after heart operations. Although it is not time yet to decide what sedative drug is better for cardiac patients, the most commonly used sedatives in this setting are also discussed.
Additional file 9 of Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol
Additional file 9: Standard technique used to obtain the six views of the simplified TEE protocol.
Additional file 7 of Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol
Additional file 7: Video 2. Acute aortic dissection.
Additional file 4 of Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol
Additional file 4: Video 1d. Mid-esophageal bicaval view (MEbicaval).
Italian journal of anatomy and embryology = Archivio italiano di anatomia ed embriologia, 2014
OBJECTIVE Barlow disease is a still challenging pathology for the surgeon. Aim of the present stu... more OBJECTIVE Barlow disease is a still challenging pathology for the surgeon. Aim of the present study is to report anatomic abnormalities of mitral valve in patients undergoing mitral valve repair. METHODS Between January 1st, 2007, and December 31st, 2010, 85 consecutive patients (54 men and 31 women, mean age 59 +/- 14 years--range: 28-85 years) with the features of a Barlow mitral valve disease underwent mitral repair Forty seven percent of patients were in New York Heart Association functional class III or IV. Preoperative transesophageal echocardiography was compared with anatomical findings at the moment of surgery. RESULTS Transthoracic echocardiography diagnosis of Barlow disease according to the criteria described by Carpentier was confirmed at anatomical inspection. Annular calcifications were found in 28 patients while 7 patients presented single or multiple clefts. A flail posterior mitral leaflet was detected in 32 subjects, while a flail anterior leaflet in 8. Elongation...
The Ultrasound Journal, 2020
Background Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound ... more Background Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest. Objective To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre. Methods Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after...
Background: Body mass index (BMI), age, left atrium (LA) dimensions and left ventricular ejection... more Background: Body mass index (BMI), age, left atrium (LA) dimensions and left ventricular ejection fraction (LVEF) have been linked to post-operative atrial fibrillation (POAF) after cardiac surgery. The aim was to better define the role of these risk factors. Methods: This study evaluated 249 patients (without prior atrial dysrhythmia) undergoing cardiac or aortic surgery . Prior to surgery the following data were collected: age (yrs), BMI (kg/m2), LA diameter (cm), LA area (cm2), LVEF (%), the presence of arterial hypertension (AH) and of diabetes, tyroid stimulating hormone (TSH, mU/L) and, creatinine (mg/dL). Results: Patients with (n. 127, 51%) and without POAF (n. 122, 49%) were compared. No difference was observed for sex, LA diameter, LA area, LVEF, TSH and diabetes. Instead, patients with PoAF had higher values of age, BMI, creatinine and a greater prevalence of AH and Bentall procedures. Multivariable analysis showed that the only independent predictors of PoAF were: age (O...
Rotational Thromboelastometry–Guided Hemostatic Therapy for Management of Cerebrospinal Fluid Catheter in Patients Undergoing Endovascular Aortic Repair
Regional Anesthesia and Pain Medicine, 2015
Central neuraxial techniques are typically avoided in patients with underlying coagulopathy or ab... more Central neuraxial techniques are typically avoided in patients with underlying coagulopathy or abnormal coagulation tests. Vertebral canal hematoma is a rare but devastating complication of those procedures. Although the sensitivity and specificity of standard laboratory tests in predicting this event are rather poor or unknown, these tests are commonly used to allow or advise against the insertion of an epidural or spinal catheter. Furthermore, the role of viscoelastic point-of-care tests, which are widely used to monitor coagulation in the perioperative setting, is unexplored. We report a patient presenting for endovascular repair of a dissecting thoracoabdominal aortic aneurysm, in which we placed a subarachnoid catheter for continuous cerebrospinal fluid drainage because of the high risk of spinal cord ischemia associated with the procedure. Unfortunately, the patient presented with an overt consumption coagulopathy that would have advised against performing any central neuraxial technique. Bedside monitoring, diagnosis, and goal-directed hemostatic therapy guided by thromboelastometry documented improved coagulation both at the time of insertion and removal of the subarachnoid device. No catheter-related complications occurred. Thromboelastometry proved useful to guide hemostatic therapy before subarachnoid catheter placement and extraction in a patient with severe coagulopathy when standard coagulation tests were of less benefit.
A complex triple valve repair in a young rheumatic patient
Italian heart journal : official journal of the Italian Federation of Cardiology, 2003
We report a case of a 22-year-old Ethiopian female presenting with multiple rheumatic valve disea... more We report a case of a 22-year-old Ethiopian female presenting with multiple rheumatic valve disease. She was admitted to hospital because of dyspnea at rest. She underwent open mitral commissurotomy associated with splitting of the postero-medial papillary muscle, aortic right-coronary-left coronary commissural resuspension with resection of fibrous tissue from the free-edge cusps and open tricuspid commissurotomy of all three commissures completed with chordal shortening of the anterior leaflet. The postoperative course was uneventful. The patient was asymptomatic without recurrence of symptoms at 2 months. Echocardiography confirmed the satisfactory outcome of the multiple repair with no residual insufficiency. Multiple repair is advisable for patients living in many areas of the Third World, where the safety of long-term anticoagulation cannot be assured.
Interactive CardioVascular and Thoracic Surgery, 2009
Pulse contour methods (PCM) for the measurements of cardiac output (CO) are gaining popularity in... more Pulse contour methods (PCM) for the measurements of cardiac output (CO) are gaining popularity in intensive care settings but their reliability during hemodynamic instability has been questioned. Pressure-recording-analytical-method (PRAM) is a newly developed uncalibrated hemodynamic monitor and its capability in measuring CO during hemodynamic instability is still under investigation. Dobutamine (2.5 and 5 mgykgymin), vasoconstriction (arginine-vasopressin 4, 8 and 16 IUyh), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in eight swine. CO by means of thermodilution (CO ), transesophageal ThD echocardiography (CO ) and PRAM (CO ) were contemporarily registered. R , bias, and percentage error were used to compare the 2 TEE PRAM methods. Comparison between CO and CO resulted in: r s0.87; biass-0.006 lymin; precisions"0.87 lymin; percentage errors22.8%. 2 PRAM ThD Comparison between CO and CO resulted in: r s0.85; biass-0.007 lymin; precisions"0.86 lymin; percentage errors22%. Sub-group 2 PRAM TEE analysis revealed disagreement between methods only during the last two steps of hemorrhage: CO vs. CO : r s0.67, biass-0.37 2 PRAM ThD lymin, precisions"1.04 lymin, limits of agreements-1.39q0.66 lymin, and percentage errors45%; CO vs. CO : r s0.38, biass0.4 2 PRAM TEE lymin, precisions"1.42 lymin, limits of agreements-0.99q1.79 lymin, and percentage errors62%. PRAM resulted to be accurate in measuring CO during hemodynamic stability, tachycardia, and vasoconstriction. When volemia was reduced by )35%, disagreement between methods was observed.
584 Functional improvement after mitral surgery in patients undergoing radiofrequency ablation of AF is related to long-term maintenance of SR
European Journal of Heart Failure Supplements, 2007
Extracorporeal Membrane Oxygenation-Assisted Esophagectomy
Journal of Cardiothoracic and Vascular Anesthesia, 2014
CASE REPORTA 41-year-old man required an esophagectomy due to multipleareas of stenoses. His past... more CASE REPORTA 41-year-old man required an esophagectomy due to multipleareas of stenoses. His past surgical history included multiple esoph-ageal surgeries and dilation procedures in his childhood due toesophageal atresia and, later, tracheobronchial reconstruction for aniatrogenic trachea-esophageal fistula. His medical history was otherwisenoncontributory. To allow right lung collapse and to enable surgicalaccess to the esophagus via a right thoracotomy, one-lung ventilation(OLV) traditionally is required. However, OLV obtained via conven-tional measures (double-lumen endobronchial tube or bronchialblocker) was not feasible given the past surgical modification of histracheobronchial bifurcation. Moreover, the complex anatomic relation-ship between the airway and digestive tract required the availability oftotal extracorporeal ventilatory support if needed (ie, if surgicalcircumstances would not allow for mechanical ventilation). Ultra-lowtidal volume ventilation and VV- ECMO assistance via the rightinternal jugular vein was then planned, and a written informed consentto perform the surgery in this manner was obtained from the patient.Anesthesia was induced with 3 mg/kg of propofol and 1 μg/kg ofsufentanil. After the administration of 0.9 mg/kg of rocuronium, thetrachea was intubated under fiberoptic guidance with a 6.5-mm(internal diameter) oral-tracheal tube, with the tip positioned just belowthe vocal cords. Anesthesia was maintained with 4-to-6 mg/kg/h ofpropofol and 0.1-to-0.2 μg/kg/min of remifentanil; 0.1-0.3 mg/kg/hr ofrocuronium was administered according to the train-of-four monitoring.The American Society of Anesthesiologists standard monitoring wasimplemented with MostCare (Vygon, Vytech, Padova, Italy), a pulsecontour-based system for cardiac output estimation that received itsarterial waveform via the left radial artery with a standard pressuretransducer. The MostCare system provides hemodynamic data byanalyzing the arterial waveform at high sampling rate (1000 Hz) and,therefore, is not influenced by the VV-ECMO. In fact, the VV-ECMOdrains and injects blood into the right side of the cardiovascular systemwithout modifying, at steady state, right and left ventricular preload. A27-Fr double-lumen Avalon (Avalon Labs, Rancho Dominguez, CA)ECMO cannula was inserted into the right internal jugular vein undertransthoracic echography guidance using the subcostal approach. Afterthe administration of 5,000 IU of unfractionated heparin and radiologicconfirmation of proper placement, the cannula was connected to anheparin-coated ECMO circuit (Rotaflow System, Maquet Cardiopul-monary AG; GmbH & Co. KG; Rastatt, Germany) and primed withlactated Ringer’s solution. Activated partial thromboplastin time wastargeted to 50 to 70 seconds, and no further heparin administration wasnecessary throughout the case. During the thoracic portion of thesurgery, the mean pump flow was 2.06 L/min (SD 0.1; range 1.96-2.24). Mean inspired oxygen fraction (F
An unusual case of cardiac tamponade
Journal of Cardiovascular Medicine, 2006
A case of a 67-year-old woman with cardiac tamponade caused by toothpick ingestion is presented. ... more A case of a 67-year-old woman with cardiac tamponade caused by toothpick ingestion is presented. At clinical presentation, it mimicked postinfarction ventricular free wall rupture and the diagnosis was not made until the operation. Ingested toothpicks have often been reported as a cause of intestinal injuries, but in this rare case the toothpick migrated into the pericardium and caused laceration of the right coronary artery.
The Journal of Thoracic and Cardiovascular Surgery, 2005
Patient Cooperation During General Anesthesia for Combined Carotid and Coronary Artery Surgery
Journal of Cardiothoracic and Vascular Anesthesia, 2009
To the Editor: Patients with concomitant carotid and coronary artery disease present a surgical d... more To the Editor: Patients with concomitant carotid and coronary artery disease present a surgical dilemma, and the literature regarding their management is controversial. In these patients, intraoperative cerebrovascular accidents, difficult to detect during surgery, are relatively common1,2 and are associated with high mortality. We read with interest the article by Turkoz et al3 who assessed, in a case series (44 patients), the patient’s neurologic status after carotid endarterectomy (CEA) by means of a wake-up test to identify stroke before the beginning of coronary artery bypass graft surgery. The authors suggested that such evaluation may make a contribution to increasing the safety of combined surgical procedures in patients with coronary and carotid artery disease. Conversely, we describe an anesthetic technique, performed in an 82-year-old man undergoing combined carotid and coronary artery surgery, that allowed the clinical monitoring of cerebral function during the whole time of carotid artery clamping. General anesthesia was induced, after preoxygenation, with remifentanil, 1 g/kg, and propofol, 0.5 mg/kg, followed by additional boluses of 10 mg every 10 seconds until abolition of response to verbal commands and loss of the eyelash reflex. Neuromuscular blockade was achieved with cisatracurium, 0.2 mg/kg. The patient’s trachea was intubated, and anesthesia was maintained with propofol, 2.5 mg/kg/h, and remifentanil, 0.25 g/kg/min. Ventilation was accomplished by synchronized volume-controlled ventilation (Primus apparatus; Drager, Lubeck, Germany) and was adjusted to maintain an end-tidal carbon dioxide concentration between 4.5 and 5.5 kPa. The surgical strategy, arranged by both vascular and cardiac surgeons, was based on performing CEA before cardiac surgery. In order to perform neurologic monitoring during CEA, the residual neuromuscular block was antagonized with neostigmine, 35 g/kg, and atropine, 20 g/kg, and when the train-of-4 showed complete reversal, the propofol infusion was stopped. The rate of remifentanil infusion was gradually decreased at 3-minute intervals of 0.03 g/kg/min , from 0.25 g/kg/min to 0.12 g/kg/min. At this infusion rate, the patient remained calm and tolerated the surgical maneuvers and the tracheal tube without coughing, and was still able to obey verbal commands. In this setting, clinical neurologic monitoring was feasible with the patient quiet and stable. During the lightening of anesthesia, heart rate increased from 47 to 60 beats/min and systolic arterial pressure from 130 to 170 mmHg. No neurovegetative signs or motor responses to nociceptive stimulation were detectable. The patient was asked to tighten the hand of the anesthesiologist before carotid artery clamping and then every minute during the 35 minutes of clamping. Thus, close, continuous neurologic monitoring was performed, and the development of early neurologic deficits was clearly excluded. General anesthesia was then resumed, and coronary artery bypass graft surgery was performed immediately afterwards. The day after surgery, the patient was interviewed to determine what he could remember of the operation. He had no explicit memory of any event, pain, or discomfort during surgery and said that he was satisfied with anesthesia. The postoperative course was uneventful, and the patient was discharged from the hospital without complications 8 days later. To our knowledge, this is the first report in which conscious sedation and analgesia were used during combined carotid and coronary artery surgery. Our method was different from the technique described by Turkoz et al, 3 who assessed the neurologic status only at the end of the CEA; we performed close neurologic monitoring during the whole period of carotid artery clamping by lightening the hypnotic component of general anesthesia. In our opinion, this approach, besides permitting clinical neurologic monitoring during surgery (ie, alter the shunt strategy and change the surgical plan), may offer the advantage of hemodynamic stability in the patient with coronary artery disease. Madi-Jebara et al 4 described a staged anesthetic approach characterized by the combination of regional anesthesia for CEA followed immediately by general anesthesia for coronary artery bypass graft surgery. Our technique appears simpler and more reliable. Furthermore, it allows the absolute control of ventilatory pattern and the easy, prompt, and safe use of general anesthesia whenever required during the operation.
Difficult Intubation in Pediatric Cardiac Surgery
Journal of Cardiothoracic and Vascular Anesthesia, 2006
Journal of Cardiothoracic and Vascular Anesthesia, 2010
International Journal of Cardiology, 2013
European Journal of Cardio-Thoracic Surgery, 2008
Background: Recombinant activated factor VII (rFVIIa) has been increasingly used to stop life-thr... more Background: Recombinant activated factor VII (rFVIIa) has been increasingly used to stop life-threatening bleeding following cardiac operations. Nonetheless, the issue of dosing, given the expense and potential for thrombotic complications, is still of major concern. We report our experience with small-dose rFVIIa in patients with refractory bleeding after cardiac surgery. Methods and results: From September 2005 to June 2007, 40 patients (mean age 70.1 AE 9.2 years, 52.5 males) received a low dose of rFVIIa (median: 18 mg/kg, interquartile range: 9-16 mg/kg) for refractory bleeding after cardiac surgery. Forty propensity score-based greedy matched controls were compared to the study group. Low dose of rFVIIa significantly reduced the 24-h blood loss: 1610 ml [ 1285-1800 ml] versus 3171 ml [2725-3760 ml] in the study and control groups, respectively ( p < 0.001). Thus, hourly bleeding was 51.1 ml [34.7-65.4 ml] in patients receiving rFVIIa and 196.2 ml/h [142.1-202.9 ml] in controls ( p < 0.001). Furthermore, patients receiving rFVIIa showed a lower length of stay in the intensive care unit ( p < 0.001) and shorter mechanical ventilation time ( p < 0.001). In addition, the use of rFVIIa was associated with reduction of transfusion requirements of red blood cells, fresh frozen plasma and platelets (all, p < 0.001). Finally, treated patients showed improved hemostasis with rapid normalization of coagulation variables (partial thromboplastin time, international normalized ratio, platelet count, p < 0.001). In contrast, activated prothrombin time and fibrinogen did not differ between groups ( p = ns). No thromboembolic-related event was detected in our cohort. Conclusions: In our experience low-dose rFVIIa was associated with reduced blood loss, improvement of coagulation variables and decreased need for transfusions. Our findings need to be confirmed by further larger studies.
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Papers by Sergio Bevilacqua