title: Anesthetic management of aortocaval fistula repair associated with aortic valve replacement, severe aortic regurgitation, and bacterial endocarditis.
abstract: We report a case of an adult male who had received a gunshot to the abdomen 12 years earlier. He presented with manifestations of high-output congestive heart failure (CHF), aortic regurgitation (AR), and pulmonary septic embolism. Further investigation revealed an aortocaval fistula (ACF). Following endovascular repair of the ACF, we observed an immediate rise in systemic vascular resistance (SVR), decrease in central venous pressure (CVP), increase in regurgitant flow across the aortic valve, and decrease in central mixed venous oxygenation. A combination of vasodilators and vasopressors was used to maintain hemodynamics. Milrinone infusion was necessary after cardiopulmonary bypass to maintain cardiac output. Even though local anesthesia and light sedation were used for ACF closure, the hemodynamics changed dramatically throughout the procedure. ACF closure under local anesthesia and sedation is preferred because the hemodynamics alterations under local anesthesia are less severe. The rise in SVR and regurgitant flow across aortic valve is less dramatic. As a result, hemodynamic management and separation from cardiopulmonary bypass are easier.
authors.affiliation: VA Western New York Healthcare System, Division of Critical Care and Pain Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA. jahanpor@buffalo.edu
authors.forename: Jahan
authors.initials: J
authors.lastname: Porhomayon
authors.forename: Mahmoud A A
authors.initials: MA
authors.lastname: Hassan
authors.forename: Padmavathi R
authors.initials: PR
authors.lastname: Perala
authors.forename: Nader D
authors.initials: ND
authors.lastname: Nader
mesh_terms: D000758:Anesthesia / Q000379:methods*; D001018:Aortic Diseases / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D001164:Arteriovenous Fistula / Q000601:surgery*; D002496:Central Venous Pressure; D004697:Endocarditis, Bacterial / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D014655:Vascular Resistance; D014682:Vena Cava, Inferior