e8 Letter to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) e1–e16
whether M-mode is used or not.8,9 Furthermore, in addition to
assessing diaphragmatic excursion, the thickness of the dia-
phragm also can be measured throughout the respiratory cycle
using ultrasound, giving clues to the chronicity of the
condition.
Assessment of diaphragmatic dysfunction, including the mea-
surement of inspiratory excursion, thickness, and thickening
fraction, makes it a feasible and highly reproducible tool to detect
diaphragm dysfunction and extubation success or failure.10
We did not elaborate on ultrasound assessment of the
diaphragm to determine phrenic nerve injury because thoracic
ultrasound still is underused as a bedside exploration technique
and still is not considered a standard of care for assessment of
phrenic nerve injury. Although nerve conduction study
remains the gold standard for diagnosing phrenic nerve
dysfunction, difficulty in extubation and an elevated hemi-
diaphragm on chest x-ray are often the first signs of pathology.
When performed by an experienced practitioner, thoracic
ultrasound can be a powerful and safe diagnostic tool not
only to identify phrenic nerve palsy, but also to identify
myriad other lung pathologies, which are beyond the scope of
our review. By being reproducible and portable and avoiding
ionizing radiation, thoracic ultrasound is gaining popularity as
an excellent alternative to chest radiography in identifying and
monitoring diaphragmatic dysfunction. We advocate for for-
mal training and increased utilization of thoracic ultrasound as
a diagnostic tool. As more practitioners become facile with this
technology, it will be helpful in all critical care units and
especially in the cardiovascular intensive care unit.
Mina Oftadeh, DO
W. Scott Jellish, MD, PhD
Department of Anesthesiology
Loyola University Medical Center
Maywood, IL
References
1 Gersovich EO, Cronan M, McGahan JP. Ultrasonographic evaluation of
diaphragmatic motion. J Ultrasound Med 2001;20:597–604.
2 Mozzini C, Pasini AMF, Garbin U, et al. Lung ultrasound in internal
medicine: Training and clinical practice. Crit. Ultrasound J 2016;8:10.
3 Tutino L, Cianchi G, Francesco B, et al. Time needed to achieve
completeness and accuracy in bedside lung ultrasound reporting in
Intensive Care Unit. Scand J Trauma Resusc Emerg Med 2010;18:44.
4 Qureshi NR, Rahman NM, Gleeson FV. Thoracic ultrasound in the
diagnosis of malignant pleural effusion. Thorax 2009;64:139–43.
5 Silva S, Aissa DA, Cocquet P, et al. Combined thoracic ultrasound
assessment during a successful weaning trial predicts postextubation
distress. Anesthesiology 2017;127:666–74.
6 Picano E, Frassi F, Agricola E, et al. Ultrasound lung comets: A clinically useful
sign of extravascular lung water. J Am Soc Echocardiogr 2006;19:356–63.
7 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by M-mode
ultrasonography. Chest 2009;135:391–400.
8 Houston JG, Fleet M, Cowan MD, McMillan NC. Comparison of
ultrasound with fluoroscopy in the assessment of suspected hemidiaphrag-
matic movement abnormality. Clin Radiol 1995;50:95–8.
9 Lloyd T, Tang YM, Benson MD, King S. Diaphragmatic paralysis: The use of
M mode ultrasound for diagnosis in adults. Spinal Cord 2006;44:505–8.
10 Zambon M, Greco M, Bocchino S. Assessment of diaphragmatic dysfunc-
tion in the critically ill patient with ultrasound: A systematic review.
Intensive Care Med 2017;43:29–38.
https://doi.org/10.1053/j.jvca.2018.04.053
The Evolution of Transcatheter Aortic Valve
Replacement—A Perspective From a
High-Volume Private Practice
To the Editor:
We enjoyed the recent article in the Journal of Cardio-
thoracic and Vascular Anesthesia about the evolution of
transcatheter aortic valve replacement (TAVR) at high-volume
academic centers in Europe and the United States.1 It might be
of interest to the readers to learn about the evolution in TAVR
practice at a high-volume private practice. The first TAVR was
performed at the Heart Center of Indiana in 2011, being the
first TAVR in the state of Indiana. This procedure was
performed in the hybrid operating room suite with a multi-
disciplinary heart team, including interventional cardiologists,
cardiac surgeons, and cardiac anesthesiologists.1 Since that
first experience, the TAVR team has gained expertise with the
current volume of 6 to 8 cases per week. In 2017, this heart
team performed 303 TAVRs. The preferred anesthetic
approach is still general endotracheal anesthesia.
Refining the Clinical Process
Initially, all our cardiac anesthesiologists were involved in
our TAVR practice, but over time a core group of 5 cardiac
anesthesiologists evolved with slow steady growth thereafter
as new consultants joined the private practice. This concept of
a core group that is dedicated and invested in this clinical
service line has been the experience elsewhere.1,2 The initial
general endotracheal anesthetic technique included a large
peripheral intravenous line, a radial arterial line, and large-bore
central venous access. When needed, a temporary pacing was
floated via the right internal jugular vein.
In this early phase of our TAVR practice, anesthetic induction
consisted of a balanced technique with low-dose fentanyl,
titrated propofol, and neuromuscular blockade. Anesthetic main-
tenance was with titrated volatile anesthetic. An intravenous
infusion of phenylephrine or norepinephrine also was titrated to
preserve systemic vascular resistance. The transesophageal
echocardiography examinations for the TAVR procedures were
performed by cardiac anesthesiologists. The typical goals for
transfemoral TAVR included tracheal extubation in the hybrid
operating room. In the setting of transapical TAVR, patients at
times recovered in the intensive care unit using a fast-track
sedation protocol with propofol and dexmedetomidine.
The evolution of the anesthetic technique for transfemoral
TAVR away from general anesthesia to sedation prompted a
lively debate within the heart team about the merits of both
anesthetic approaches.1–6 After extensive discussion among all
 Letter to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) e1–e16
the stakeholders, the heart team has decided to retain general
endotracheal anesthesia as the primary anesthetic technique for
TAVR. The merits of a specific anesthetic technique have been
analyzed extensively in recent editorials within the journal.7,8
The Current Clinical Paradigm
The heart team currently performs TAVRs on Tuesdays and
Thursdays starting at 7 AM, typically finishing with the fourth
case before 4 PM. Patients typically are admitted to hospital on
the day of their procedure. For TAVR procedures in the
cardiac catheterization laboratory, the current anesthetic
approach is conscious sedation combined with a field block.
As the TAVR devices continue to improve at a fast rate, the
heart team anticipates switching to conscious sedation with
clinical drift away from general anesthesia.1,2
During this evolution of clinical practice in TAVR, there has
been a process of continuous quality improvement that has
affected pacing mode choices, communication styles, and
anesthetic technique. The anesthetic approach has been stream-
lined with a departure away from central venous access, minimal
vasopressor administration, and lighter anesthetic dosing.
In conclusion, the TAVR experience in our practice remains
busy and challenging. The journey ahead includes sedation as
a routine, diverting cases to the cardiac catheterization
laboratory, as well as expanding transcatheter interventions
for the mitral and tricuspid valves.
Mark Kyker, MD*
John G.T. Augoustides, MD, FASE, FAHA†
n
St. Vincent Medical Group
St. Vincent Heart Center
Indianapolis, IN
†
Department of Anesthesiology and Critical Care
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
References
1 Patel PA, Ackerman AM, Augoustides JG, et al. Anesthetic evolution in
transcatheter aortic valve replacement: Expert perspectives from high-
volume academic centers in Europe and the United States. J Cardiothorac
Vasc Anesth 2017;31:777–90.
2 Marcantuono R, Gutsche J, Burke-Julien M, et al. Rationale, development,
implementation and initial results of a fast-track protocol for transfemoral
transcatheter aortic valve replacement (TAVR). Catheter Cardiovasc Interv
2015;35:648–54.
3 Oguri A, Yamamoto M, Mouillet G, et al. Clinical outcomes and safety of
transfemoral aortic valve implantation under general versus local anesthesia:
Subanalysis of the French Aortic National CoreValve and Edwards
2 registry. Circ Cardiovasc Interv 2014;7:602–10.
4 Villablanca PA, Mohananey D, Nikolic K, et al. Comparison of local versus
general anesthesia in patients undergoing transcatheter aortic valve replace-
ment: A meta-analysis. Catheter Cardiovasc Interv 2018;91:330–42.
5 Neuburger PJ, Patel PA. Anesthetic techniques in transcatheter aortic valve
replacement and the evolving role of the anesthesiologist. J Cardiothorac
Vasc Anesth 2017;31:2175–82.
6 Maldonado Y, Baisden J, Villablanca PA, et al. General anesthesia versus
conscious sedation for transcatheter aortic valve replacement: An analysis of
current outcome data. J Cardiothorac Vasc Anesth 2018;32:1081–6.
e9
7 Neuberger PJ, Patel PA, Williams MR. Anesthetic technique for TAVR: More
than just “tube” or “no tube”. J Cardiothorac Vasc Anesth 2018;32:672–4.
8 Lester L, Brady MB, Brown CH. Sedation versus general anesthesia for TAVR:
Where do we go from here? J Cardiothorac Vasc Anesth 2017;31:2055–7.
https://doi.org/10.1053/j.jvca.2018.04.039
Continuous Erector Spinae Block for
Postoperative Analgesia After Thoracotomy in
a Lung Transplant Recipient
To the Editor:
Post-thoracotomy pain control in lung transplant recipients
is suggested to have a direct impact on short- and long-term
outcomes, and is thus a very important component of patient
care.1 Thoracic epidural analgesia is considered the gold
standard for the post-thoracotomy pain; however, multiple
challenges specific to the lung transplant recipients, including
hypotension combined with the need for restrictive fluid
strategy, the potential need for full systemic heparinization,
and timing and coordination of the transplant, make it a less
than ideal choice.2 Paravertebral blocks have been used as an
alternative to the epidural with similar efficacy and fewer side
effects; however, high failure rate has been proposed as a
reason for a lack of widespread adoption of this technique.3,4
A relatively novel addition to our armamentarium for treat-
ment of post-thoracotomy pain is the erector spinae plane
(ESP) nerve block. The ESP block first was described as a
modality for treatment of chronic thoracic neuropathic pain.5,6
Since then, its successful use has been reported in a number of
case reports, including acute postsurgical pain after thoracot-
omy, video-assisted thoracoscopy, major abdominal surgery,
breast surgery, and radical retropubic prostatectomy.7–10 In
addition to targeting both dorsal and ventral rami of the spinal
nerves as they exit the intervertebral foramina, it has been
suggested that the ESP block also can affect the rami
communicantes to the sympathetic ganglia, potentially result-
ing in both somatic and visceral analgesia.11
We successfully employed a continuous ESP analgesia in a
68-year-old patient who underwent a posterolateral thoracot-
omy for a single lung transplant. The ESP block and catheter
placement was performed after completion of the surgery with
the patient still under general anesthesia. The patient was
placed in a right lateral decubitus position. Using an aseptic
technique, a high-frequency (12-15 MHz) linear array trans-
ducer (GE Cares InSite) was placed in a parasagittal plane
longitudinally, and the transverse processes T3 to T5 were
identified on the left by first identifying the first rib and T1
transverse process and moving the probe caudally. A 17G 3.5''
Touhy needle was inserted in plane under direct visualization
in the craniocaudal direction at the level of the T3 transverse
process and advanced below the erector spine muscle with the
tip contacting the T5 transverse process (Fig 1). Fifteen mL of
0.25% bupivacaine was injected into the interfascial plane
deep to the erector spinae muscle, and lifting of the muscle
off the transverse process with craniocaudal spread of the