Journal of cardiothoracic and vascular anesthesia最新文献

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: To compare the effectiveness and safety of topical versus intravenous tranexamic acid (TXA) in patients undergoing cardiac surgery.

Design and setting: A systematic review and meta-analysis were conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Web of Science, and Scopus databases were searched for randomized controlled trials (RCTs) comparing topical and intravenous TXA in cardiac surgery.

Participants: Only RCTs involving pediatric and/or adult patients undergoing cardiac surgery were included. Six RCTs encompassing 3,577 patients (1,792 topical TXA; 1,785 intravenous TXA) met the inclusion criteria.

Interventions: Topical versus intravenous TXA administration in cardiac surgery.

Measurements and main results: Outcomes included postoperative blood loss, hemoglobin levels, transfusion requirements, and clinical and safety outcomes. The overall analysis revealed no significant difference in total postoperative blood loss between the two groups (mean difference = -16.66, 95% confidence interval = -41.01 to 7.69, p = 0.18). Subgroup analysis showed that topical TXA significantly reduced blood loss at 48 hours in pediatric patients (mean difference = -8.63, 95% confidence interval = -16.77 to -0.49, p = 0.04), but no significant difference was observed at 24 hours in adults. No significant differences were found in hemoglobin level changes, transfusion requirements, or clinical outcomes. Safety analyses showed comparable rates of mortality, reoperation, seizures, infections, respiratory failure, intensive care unit length of stay, and ventilation duration.

Conclusion: The findings suggest that topical and intravenous TXA demonstrate similar efficacy in reducing perioperative bleeding in cardiac surgery, with no significant differences in safety outcomes. However, topical TXA may have a delayed benefit in pediatric patients. Larger, high-quality RCTs are warranted to confirm these findings and to optimize TXA administration strategies in different patient populations.

Background: Effective postoperative pain control is essential for enhanced recovery after cardiac surgery, yet optimal multimodal strategies continue to evolve. The superficial parasternal intercostal plane (S-PIP) block has been proposed as a simple and safe technique for median sternotomy analgesia; however, current evidence remains fragmented, and its clinical impact is unclear.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials assessing the analgesic efficacy and safety of the S-PIP block in adult cardiac surgery. PubMed, Embase, CENTRAL, Web of Science, Scopus, ClinicalTrials.gov, and gray literature were searched through September 2025. Trials comparing S-PIP with standard or placebo analgesia were pooled using a random-effects model. The primary outcome was 24-hour opioid use (morphine milligram equivalents). Trial sequential analysis, meta-regression, and Grades of Recommendation, Assessment, Development, and Evaluation were applied to evaluate the robustness and certainty of evidence.

Results: Twenty-seven randomized controlled trials (1,760 patients) met the inclusion criteria. S-PIP block significantly reduced 24-hour opioid use compared with control (mean difference, -8.53 mg; 95% CI, -14.39 to -2.68), although the reduction was below the minimal clinically important difference and demonstrated substantial heterogeneity (I² = 98.1%). Trial sequential analysis confirmed statistical significance, but the required sample size was not achieved. The block also lowered early pain scores, reduced rescue analgesic use, and shortened extubation time and intensive care unit stay. No meaningful differences were observed in hospital stay, postoperative nausea and vomiting, or chronic postsurgical pain. The certainty of the evidence ranged from moderate to very low.

Conclusion: S-PIP provides modest early analgesic benefits after cardiac surgery. Further high-quality multicenter trials are required to clarify its overall clinical value.

Objectives: To evaluate the feasibility, safety, and early outcomes of a standardized operating room extubation (ORE) protocol implemented for elective cardiac surgery patients requiring cardiopulmonary bypass.

Design: A prospective observational cohort study with systematic protocol implementation and data collection.

Setting: A single academic medical center.

Participants: Six hundred twenty-eight patients undergoing elective cardiac surgery with cardiopulmonary bypass between November 2024 and June 2025.

Interventions: Implementation of a protocol requiring systematic consideration of ORE for all eligible patients, with 171 patients (27%) receiving ORE and 457 patients receiving conventional intensive care unit (ICU) extubation.

Measurements and main results: Primary outcomes included unadjusted ORE utilization rates, reintubation rates, 30-day mortality, ICU length of stay, and hospital length of stay. On average 28% of eligible cases were extubated each month. Patients selected for ORE were relatively young (median age 62 years) with a low comorbidity burden. All ORE patients survived for 30 days. Reintubation occurred in 5 patients (2.9%). Median ICU stay was shorter for ORE patients compared with the overall cohort (26 v 38 hours), while median hospital stay was similar between groups (5 days).

Conclusions: A standardized ORE protocol demonstrated feasibility and safety in selected cardiac surgery patients, with low reintubation rates, zero 30-day mortality, and reduced ICU length of stay. However, these encouraging outcomes likely reflect patient selection based on clinical judgment and cannot establish comparative efficacy relative to early ICU extubation. A multicenter randomized controlled trial is needed to determine efficacy and define optimal patient populations for ORE.

Objectives: To evaluate the relationship between intraoperative 3-dimensional (3D) planimetry-determined left ventricular outflow tract (LVOT) area and Doppler-derived peak gradients in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing septal myectomy and to determine whether 3D echocardiography can better differentiate true systolic anterior motion-related anatomic obstruction from other causes of elevated gradients.

Design: A retrospective, single-center, observational study.

Setting: A single tertiary university hospital performing septal myectomy for HOCM.

Participants: Thirty-six patients undergoing septal myectomy for symptomatic HOCM between February 2021 and December 2024.

Interventions: Real-time 3D echocardiography was performed during pre-bypass procedural planning. Dobutamine stress echocardiography was conducted both before and after cardiopulmonary bypass to reproduce peak gradients and assess LVOT-mitral valve interaction. Septal myectomy was performed per standard surgical protocol.

Measurements and main results: LVOT area was quantified using multiplanar reconstruction during stress echocardiography, and continuous-wave Doppler gradients were measured before and after myectomy. Preoperatively, stress augmentation resulted in a median 58.2% reduction in LVOT area at peak gradient levels previously associated with symptoms in the awake state. After myectomy, peak gradients decreased significantly (median, 11.5-24.0 mmHg; p < 0.001), with only a 16.9% reduction in LVOT area. A strong preoperative correlation was observed between LVOT area and peak gradient (r = -0.64, p < 0.001), which was weaker postoperatively (r = -0.30, p = 0.018). Postoperatively, 22% of patients showed elevated peak gradients without demonstrable LVOT obstruction.

Conclusions: Intraoperative 3D echocardiography enables precise, real-time quantification of LVOT obstruction in HOCM and enhances intraoperative assessment during septal myectomy. It may improve clinical decision making in patients with high intracavitary gradients by differentiating true LVOT obstruction from residual functional gradients.