Journal of cardiothoracic and vascular anesthesia最新文献

Objectives: To determine whether preoperative use of tamsulosin is associated with hypotension during cardiopulmonary bypass (CPB) surgery.

Design: Retrospective observational cohort design.

Setting: A tertiary referral hospital.

Participants: 159 male patients, 40-90 years old, who underwent coronary artery bypass graft or valve replacement surgery at the authors' hospital from April 1, 2021 to May 31, 2022.

Interventions: Preoperative use of tamsulosin in male patients undergoing coronary artery bypass graft or valve replacement surgery.

Measurements and main results: Groups were based on preoperative tamsulosin use: tamsulosin use within 24 hours before bypass (n = 41) versus no tamsulosin use before surgery (n = 118). The primary outcome was vasopressor use in 30-minute time periods during CPB and upon arrival in the intensive care unit (ICU). Unadjusted and adjusted linear mixed-effects models were used to examine vasopressor use over time and across groups. The unadjusted model showed that preoperative tamsulosin users required significantly greater vasopressor support during all bypass time periods (all p ≤ 0.006) and upon ICU arrival (p = 0.014) than did the no tamsulosin group. An effect of preoperative tamsulosin remained after adjusting for risk factors associated with vasoplegia. Compared with nonusers, the tamsulosin group required significantly greater vasopressor support across all bypass time periods (p < 0.001-0.033).

Conclusions: This study suggests that the use of tamsulosin prior to cardiac surgery is associated with an increased requirement for vasoactive support during CPB and upon ICU arrival. Prospective studies are warranted.

Objectives: To assess the predictive value of early postoperative perfusion markers (central venous oxygen saturation, lactate, and alactic base excess [ABE]) and Sequential Organ Failure Assessment (SOFA) scores in identifying patients at increased risk of postoperative complications following cardiac surgery.

Design: Single-center, retrospective observational study.

Setting: Cardiac surgery intensive care unit at a tertiary university-affiliated hospital in Europe.

Participants: 149 adult patients admitted after elective or urgent cardiac surgery.

Interventions: None.

Measurements and main results: Perfusion parameters and scores were recorded at admission, 6-12 hours, and 24 hours. The primary outcome was the occurrence of at least one major postoperative complication. In multivariable logistic regression, urgency of surgery (odds ratio [OR] = 7.214, 95% confidence interval [CI] 2.13-24.433; p = 0.001), occult hypoperfusion at admission (OR = 5.612, 95% CI 1.30-24.222; p = 0.021), hemoglobin at admission (OR = 0.955, 95% CI 0.926-0.985; p = 0.004), and SOFA score at 24 hours (OR = 1.470, 95% CI 1.224-1.764; p < 0.001) were independent predictors. Central venous oxygen saturation was not predictive; lactate showed a univariable association but was omitted from multivariable analysis to avoid collinearity with the composite occult hypoperfusion variable, which had a stronger univariable association. ABE at 24 hours showed a univariable association but was not independently predictive. The base prediction model showed excellent discriminative ability (area under the curve [AUC] = 0.871), good calibration (Hosmer-Lemeshow p = 0.221), and solid explanatory power (Nagelkerke R² = 0.517). In an extended prediction model, adding ABE at 24 hours yielded a similar AUC (0.875) without a significant improvement in discrimination, with modest gains in calibration and explained variance. Among individual variables, SOFA score at 24 hours had the highest AUC (0.79), providing the best balance of sensitivity (70.2%) and specificity (74.5%).

Conclusions: An integrative model combining urgency of surgery, hemoglobin at admission, occult hypoperfusion at admission, and SOFA at 24 hours provides robust day-1 risk stratification after cardiac surgery. These findings support the clinical utility of multimodal monitoring in the postoperative intensive care unit setting. ABE at 24 hours added acid-base and metabolic context, but it was not an independent predictor in this cohort.

Objectives: This study compares the U-Net and You Only Look Once version 8 (YOLOv8) models for identifying internal jugular veins (IJVs) and radial arteries (RAs) in longitudinal and/or transversal ultrasound views, evaluating their vascular recognition capabilities for artificial intelligence-guided cannulation systems under point-of-care ultrasound (POCUS) visualization.

Design: A retrospective study.

Setting: Six teaching hospitals.

Participants: Data from 1,122 ultrasound images (612 IJVs, 510 RAs) between January and December 2024.

Interventions: No intervention.

Measurements and main results: U-Net was employed for pixelwise segmentation with a combined dice-cross-entropy loss, while YOLOv8s-seg incorporated attention mechanisms for object detection. Model performance was evaluated using precision, recall, F1-score, mean average precision at intersection over union (IoU) threshold 0.5 (mAP@0.5), IoU, Dice coefficient, and inference time metrics. YOLOv8 demonstrated superior performance with a precision of 0.996, recall of 1.00, mAP@0.5 of 0.995, IoU of 0.739, Dice coefficient of 0.834, and inference time of 26.3 ms, outperforming U-Net, which achieved a precision of 0.988, recall of 0.998, mAP@0.5 of 0.993, IoU of 0.719, Dice coefficient of 0.816, and inference time of 38.9 ms. In the validation set, YOLOv8 exhibited higher accuracy across all categories, with values of 0.96 for V-S, 0.90 for V-L, 0.89 for A-S, and 0.86 for A-L, compared with U-Net's respective accuracies of 0.81, 0.88, 0.87, and 0.82.

Conclusion: YOLOv8 outperformed U-Net in accuracy, precision, and speed, proving more suitable for real-time vascular localization in clinical settings. These findings provide critical algorithmic foundations for developing automated vascular puncture navigation platforms in the future.

Objective: To determine the impact of surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and reduced ejection fraction (EF).

Design: A propensity-matched, retrospective study of consecutive aortic valve interventions from 2010 to 2023.

Setting: A single institution.

Participants: Patients with severe AS and reduced EF (<50%) undergoing aortic valve intervention.

Interventions: The cohort was dichotomized by SAVR versus TAVR.

Measurements and main results: A total of 1,164 patients underwent an aortic valve intervention for severe AS with reduced EF (<50%), of which 240 (20.6%) had an isolated SAVR and 924 (79.4%) underwent a TAVR. Propensity matching yielded 205 pairs. The 30-day mortality and stroke rates were no different across groups. Paravalvular leak was significantly higher in the TAVR group, and there was a statistically nonsignificant trend toward more pacemakers in the TAVR group (p = 0.093). At 1 year, EF was similar between groups: 48% (IQR: 41-53) in the SAVR group versus 53% (IQR: 37-58) in the TAVR group (p = 0.431). Conversely, at 1 year, mean pressure gradients were higher in the TAVR group (10 [7-15] mmHg v 8 [7-10] mmHg, p = 0.040). The cumulative incidence of heart failure readmissions was higher in the TAVR group, although it was a statistically nonsignificant trend (p = 0.066). The cumulative incidence of aortic valve reintervention was similar across groups (p = 0.564). Kaplan-Meier survival estimates were significantly lower in the TAVR group (p = 0.016).

Conclusions: While surgery may optimize survival after aortic valve replacement in patients with reduced EF, these observational findings need to be verified by prospective randomized controlled comparisons.