Journal of cardiothoracic and vascular anesthesia最新文献

Cardiogenic shock (CS) remains one of the leading causes of in-hospital mortality, with an estimated 40,000 to 50,000 patients being treated for CS each year. Despite major advances in mechanical circulatory support and pharmacologic therapy, short-term outcomes remain poor, with 30-day mortality ranging from 30% to 60%. There is significant heterogeneity in clinical trial design and data, as well as variability in management strategies for patients with CS. In this review article, we aim to summarize current definitions, staging systems, landmark trials, and evolving guideline recommendations, while highlighting trends in outcomes and ongoing gaps in care for patients with CS.

Objectives: This study aimed to investigate whether prebypass endogenous melatonin concentrations are associated with perioperative oxidative DNA injury, indexed by urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG), and to explore their relationship with postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in children undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Design: A prospective, observational study.

Setting: A single-center study conducted in a tertiary care hospital.

Participants: Eighty pediatric patients (neonates to 18 years) undergoing corrective cardiac surgery with CPB.

Interventions: No experimental intervention was performed; blood and urine samples were collected perioperatively for biochemical analysis.

Measurements and main results: Serum prebypass and postbypass melatonin levels were measured by enzyme-linked immunosorbent assay; urinary 8-OHdG and NT-proBNP were quantified immediately and 24 hours postoperatively. Postbypass melatonin concentrations correlated positively with age (r = 0.288, p = 0.010) and negatively with surgical duration (r = -0.230, p = 0.040). Higher prebypass melatonin levels tended to be associated with lower postoperative urinary 8-OHdG (r = -0.300, p = 0.007). Postoperative 8-OHdG showed strong linear correlations with NT-proBNP both immediately and 24 hours after surgery (r = 0.516, p < 0.001; r = 0.451, p < 0.001). In multivariable analysis, 8-OHdG remained an independent predictor of NT-proBNP, whereas melatonin did not.

Conclusions: Oxidative DNA injury is strongly associated with postoperative myocardial stress in pediatric patients undergoing CPB. Prebypass melatonin status showed an exploratory, nonindependent relationship with perioperative oxidative stress, while oxidative stress markers were robustly linked to NT-proBNP. These findings delineate a redox-cardiac stress axis in pediatric CPB and support further investigation into the role of endogenous antioxidant capacity in perioperative cardiac stress.

Objectives: Hemorrhagic complications remain a major concern in patients with cardiogenic shock and extracorporeal cardiopulmonary resuscitation. The purpose of this study was to assess the effect of withholding a bolus of unfractionated heparin (UFH) during emergent cannulation of the peripheral venoarterial extracorporeal membrane oxygenator (VA-ECMO) on initial coagulation parameters, and its association with bleeding and thrombotic complications.

Design and setting: Retrospective, single-center, observational study.

Participants and interventions: Adult patients undergoing emergent peripheral VA-ECMO were stratified by receipt of an intravenous UFH bolus at the time of cannulation. Then, systemic UFH perfusion was initiated unless contraindicated.

Measurements and main results: A total of 59 patients were included in the analysis between 2020 and 2024. Mean activated partial thromboplastin time did not differ between groups, with comparable proportions of values within the therapeutic range (15.2% in the bolus group v 13.3% in the nonbolus group; p = 0.776). Major bleeding (Bleeding Academic Research Consortium classification ≥3) within the first 24 hours was more frequent in the UFH bolus group (42.9% v 25.0%) and was associated with a greater need for red blood cell transfusions (median 4 v 2 units; p = 0.003). Multivariate analysis showed similar trends (adjusted odds ratio: 2.26; p = 0.311). Thrombotic event rates were similar between groups (14.3% v 16.7%; p = 0.803), and no device-related thrombosis was observed.

Conclusions: Withholding the UFH bolus during VA-ECMO cannulation results in comparable postimplantation activated partial thromboplastin time values and may reduce early bleeding without increasing thrombotic complications. This limited heparin exposure strategy appears safe and warrants further evaluation in randomized controlled studies.

Objectives: The objective of this study was to compare visually assisted techniques (flexible bronchoscope and video laryngoscope) versus blind insertion of the transesophageal echocardiography (TEE) probe. The primary objective was to evaluate the first-attempt success rate of probe insertion. Secondary objectives were to evaluate the time required for probe insertion, the number of attempts required for successful insertion, hemodynamic perturbation immediately after and at 3 minutes after probe insertion, operator satisfaction, and the incidence of complications related to probe insertion.

Design: A randomized controlled study.

Setting: A single-institution tertiary center.

Participants: One hundred thirty-five adult patients undergoing elective cardiac surgery.

Interventions: Patients were randomized into 3 equal groups of 45 patients each: blind insertion of the TEE probe (group B), video laryngoscopy-assisted insertion of the TEE probe (group VL), and flexible bronchoscopy-assisted insertion of the TEE probe (group FB).

Measurements and main results: One hundred twenty-four patients completed the study (group B, n = 42; group VL, n = 41; group FB, n = 41). The first-attempt success rate was significantly better with visually assisted techniques: 92.7% in group VL and 95.1% in group FB versus 78.6% in group B (p = 0.042). Time to probe insertion was significantly longer in group FB versus both groups VL and B (p = 0.001). The number of attempts required for successful probe insertion was significantly lower in the visually assisted groups (p = 0.01). The increases in heart rate and mean arterial pressure were significantly lower in group FB versus groups VL and B immediately following probe insertion and at 3 minutes. However, there was no difference in hemodynamics between groups VL and B. Operator satisfaction was comparable among the groups. The incidence of complications such as blood at the tip of the probe was significantly lower with visually guided techniques (p = 0.005), whereas the incidence of probe-related injuries was comparable across the groups (p = 0.09).

Conclusions: Flexible bronchoscopy-assisted TEE probe insertion provides similar performance characteristics to video laryngoscopy-assisted insertion albeit with less hemodynamic perturbation and is superior to blind insertion of the TEE probe.

Objectives: This study aimed to compare the analgesic efficacy of a combined deep and superficial serratus anterior plane block (SAPB) with deep SAPB alone in patients undergoing video-assisted thoracoscopic surgery (VATS).

Design: A prospective, randomized clinical trial.

Setting: Single-center, academic hospital.

Participants: Sixty patients undergoing elective VATS.

Interventions: One group received a combined deep and superficial SAPB (each 15 mL of 0.375% bupivacaine with epinephrine 5 µg/mL injected both deep to and above the serratus anterior muscle) (group DS), while the other group received 30 mL of the same solution deep into the serratus anterior muscle only (group D). Additionally, 5 mL of 0.25% bupivacaine was infiltrated at the chest tube insertion site in all patients. Standardized multimodal analgesia included intravenous morphine (0.1 mg/kg), paracetamol (1,000 mg), and ibuprofen (800 mg), administered 30 minutes before the end of surgery. Postoperative analgesia was maintained with intravenous patient-controlled fentanyl.

Measurements and main results: Demographic and operative characteristics were comparable between the groups. Total postoperative opioid consumption within 24 hours, expressed in morphine milligram equivalents, was 27.12 ± 16.67 mg in group D and 32.84 ± 19.86 mg in group DS, with no significant difference between groups (p = 0.137). The total amount of rescue analgesia was 11.67 ± 11.47 mg in group D and 16.33 ± 12.45 mg in group DS, with no statistically significant difference between the groups (p = 0.141). Postoperative pain scores and the incidence of opioid-related adverse effects were similar between groups (p > 0.05 for all).

Conclusions: This study demonstrates that a single deep SAPB provides equivalent postoperative analgesia to combined single and deep SAPB. Both techniques offered comparable postoperative analgesia and safety profiles.