Journal of cardiothoracic and vascular anesthesia最新文献

Objectives: Extracorporeal life support, including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB), triggers a pronounced inflammatory response and has been linked to postoperative liver dysfunction. Such dysfunction may negatively affect clinical outcomes after lung transplantation. Given that double-lung transplantation increasingly involves venoarterial ECMO, this work was designed to analyze the incidence of liver injury post-transplant and its impact on outcomes, specifically duration of intensive care unit (ICU) stay and 1-year mortality.

Design: Retrospective analysis.

Setting: Single university hospital.

Interventions: None.

Participants: Data from 1,350 consecutive patients who underwent lung transplantation between January 2009 and April 2023 were analyzed.

Measurements and main results: Hepatic injury occurring within the first 12 postoperative days was classified as hypoxic liver dysfunction, drug-induced liver injury, or cholestasis. The corresponding incidences were 4%, 23%, and 52%, respectively. All were associated with an increased length of ICU stay. Owing to the multiple medications these patients receive post-transplantation, a clear distinction between drug-induced liver injury and a mild form of hypoxic liver dysfunction is difficult. However, only the latter was independently linked with increased 1-year mortality amounting to 35%. Patients who developed hypoxic liver dysfunction were more frequently operated on CPB or required prolonged ECMO support.

Conclusion: Lung transplantation involving CPB or extended perioperative ECMO support significantly increases the risk of severe postoperative liver dysfunction associated with poorer outcomes. However, brief intraoperative ECMO deployment does not appear to carry this risk.

Objective: To evaluate the outcomes of percutaneous dilatational tracheostomy (PDT) versus surgical tracheostomy (ST) in critically ill patients, focusing on complications, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay, and mortality.

Design: Retrospective trial SETTING: Single tertiary center PARTICIPANTS: A total of 119 patients receiving invasive MV in a medical ICU INTERVENTIONS: PDT (n = 55) or ST (n = 64) methods MEASUREMENTS AND MAIN RESULTS: The 2 groups showed comparable outcomes in terms of MV duration (36 days for PDT vs 35 days for ST; p = 0.72), ICU stay (43 days for PDT vs 37 days for ST; p = 0.17), and all-cause mortality (71% for PDT vs 64% for ST; p = 0.42). PDT was associated with significantly lower rates of subcutaneous emphysema (0% vs 16%; p = 0.01). Multivariate analysis showed no statistically significant association between tracheostomy technique and ICU mortality or overall complication rates after adjustment for confounders.

Conclusion: PDT and ST yield comparable outcomes in critically ill ICU patients, with no significant difference in overall complication rates or mortality. The fewer specific complications for PDT, such as subcutaneous emphysema, highlight its advantages in suitable cases. Individualized patient assessment remains crucial, and further studies are needed to refine tracheostomy practices.

Objectives: The effect of perioperative hyperoxia on microcirculation after cardiac surgery remains inconclusive. We evaluated the relationship between intraoperative fractional inspired oxygen and microcirculation after off-pump coronary artery bypass grafting (OPCAB).

Design: Exploratory secondary analysis of a multicenter cluster-randomized trial.

Setting: Three teaching hospitals.

Participants: Adult patients who underwent OPCAB.

Interventions: Seven postoperative microcirculatory parameters, including De Backer scores and the proportion of perfused vessels via sublingual microscopy (from all and small vessels), and thenar muscle tissue oxygenation, occlusion slope, and recovery slope via the vascular occlusion test, were compared between patients receiving 30% and 80% oxygen intraoperatively. Generalized estimating equations were used to account for intracluster correlation.

Measurements and main results: The analysis included 52 and 51 patients from the 30% and 80% oxygen groups, respectively, for sublingual microscopy and 59 and 53 patients for the vascular occlusion test. Although all microcirculatory parameters were similar between groups, the 80% oxygen group had higher De Backer scores for all vessels (mean, 9.8 ± 2.9 mm^-1 vs. 8.7 ± 2.0 mm^-1; p = 0.011) and small vessels (4.0 ± 1.8 mm^-1 vs. 3.4 ± 1.1 mm^-1; p = 0.024) than the 30% oxygen group at the end of surgery. The 80% oxygen group also exhibited greater thenar muscle tissue oxygenation immediately before vascular occlusion (78.4% ± 10.5 vs. 74.0% ± 9.3; p = 0.031) and a higher recovery score (4.1%·s^-1 ± 1.7 vs. 3.2%·s^-1 ± 1.4; p = 0.001).

Conclusions: Patients receiving 80% oxygen during OPCAB had significantly better postoperative microcirculatory profiles than those receiving 30% oxygen. These findings highlight the potential for optimizing perioperative oxygenation to improve or mitigate microcirculatory impairment, thereby reducing postoperative complications.

Objectives: To examine the association and magnitude of agreement between intraoperative transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (CMR) on aortic diameter measurements, to guide perioperative decision making for ascending aortic aneurysms.

Design: This prospective study included patients with an ascending aortic aneurysm undergoing surgical ascending aortic repair using a prosthetic graft between February 2018 and December 2019. Intraoperative TEE in 2-dimensional (2D) and 3-dimensional (3D) views were obtained and assessed relative to preoperative cine-CMR and contrast-enhanced 3D magnetic resonance angiography.

Setting: Weill Cornell Medicine, a single large academic medical center.

Participants: Thirty patients undergoing ascending aortic repair using a prosthetic graft (polyethylene terephthalate [Dacron]) without severe aortic valve disease (stenosis or regurgitation).

Interventions: CMR, TEE, and ascending aortic repair using prosthetic grafts.

Measurements and main results: TEE-derived measurements correlated significantly with CMR at all aortic segments: root (r = 0.94-0.97; p < 0.001 for all), ascending (r = 0.95-0.98; p < 0.001 for all), arch (r = 0.88; p < 0.001), and descending (r = 0.91; p < 0.001). Bland-Altman analyses showed small mean differences between 2D and 3D TEE versus CMR (range, 0.05-0.22 cm and 0.04-0.18 cm, respectively), with narrow limits of agreement at all segments, although TEE underestimated CMR-derived measurements.

Conclusions: This study demonstrates the feasibility of intraoperative TEE to accurately measure aortic diameters in patients with ascending aortic aneurysms. The excellent correlations with CMR and small mean differences with narrow limits of agreement support intraoperative TEE to guide surgical decision making for possible aortic replacement.