Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Preoperative cardiorespiratory fitness, muscle strength, and frailty influence outcomes after cardiac surgery, but these modifiable physical factors are often not routinely incorporated into standardized risk assessments. This study examined the association between preoperative physical fitness and adverse postoperative outcomes across different elective cardiac surgery procedures. Logistic regression analyses were used to assess the association between preoperative cardiorespiratory fitness, muscle strength, functional mobility, frailty, and quality of life and delayed postoperative recovery of physical functioning (Modified Iowa Level of Assistance Scale), in-hospital complications, and postoperative atrial fibrillation in patients undergoing cardiac surgery via sternotomy, mini-thoracotomy, and transfemoral incision (transcatheter aortic valve implantation). Results showed that higher patient-reported preoperative cardiorespiratory fitness, functional mobility, frailty, and physical health-related quality of life were significantly associated with faster recovery of physical functioning and fewer postoperative complications in patients undergoing sternotomy. In patients undergoing mini-thoracotomy, preoperative cardiorespiratory fitness and functional mobility were significantly associated with in-hospital complications. No significant associations were found in patients undergoing transfemoral incision (transcatheter aortic valve implantation). Conclusively, preoperative physical fitness is associated with postoperative outcomes in patients undergoing sternotomy. These findings highlight the importance of incorporating physical fitness assessments into standard preoperative care to facilitate preoperative shared decision-making and optimize modifiable preoperative risk factors.

The left internal mammary artery (LIMA) is commonly selected as the graft of choice for coronary artery bypass procedures. Various pharmacological agents have been used to enhance LIMA blood flow. Left stellate ganglion block (LSGB) has been utilized to achieve sympathetic blockade, promote vasodilation in the upper extremities, and manage refractory angina. This randomized controlled clinical trial aimed to evaluate the effect of preoperative LSGB on LIMA blood flow in patients undergoing elective coronary artery bypass grafting (CABG). Seventy patients (aged 18-80 years, of both genders) scheduled for elective CABG were equally divided into two groups: the LSGB group and the control group. Patients in the intervention group received an ultrasound-guided LSGB using 8 mL of 0.25% bupivacaine. Both groups received topical nitroglycerin during LIMA harvesting. LIMA diameter was measured at baseline and again after an equal time interval before the induction of anaesthesia. Additionally, LIMA free flow after harvesting and mean graft flow were measured using a transit time flow metre (TTFM). LIMA free blood flow was significantly increased in the LSGB group (50.57 ± 5.79 mL/min) compared to the control group (46.86 ± 8.32 mL/min), with a P-value = 0.034. Similarly, the LIMA diameter was significantly greater in the LSGB group (2.38 ± 0.17 mm) than in the control group (2.31 ± 0.14 mm), with a P-value = 0.04, suggesting that preoperative LSGB significantly enhances LIMA blood flow and diameter in patients undergoing CABG.

. This single-center prospective observational study aimed to assess the correlation of net atrioventricular compliance (Cn) with pulmonary artery pressure in 26 adult patients with severe mitral stenosis (MS) undergoing surgical mitral valve replacement (MVR). Cn was estimated by doppler echocardiography, and pulmonary artery pressures measured by pulmonary artery catheter. Early outcomes including duration of intensive care unit (ICU) stay, mechanical ventilation duration, and vasoactive inotropic scores (VIS) were recorded. Cn showed moderate to strong negative correlation with systolic, diastolic, and mean pulmonary artery pressures at all time points. Receiver operating characteristic (ROC) curve analysis determined a cut-off of 2.31 to predict postoperative pulmonary artery systolic pressure. Cn with a cut-off value of 2.3 ml/mmHg serves as an indicator of persistent pulmonary hypertension following MVR surgery.

We present the case of a 73-year-old female with chemotherapy-induced cardiomyopathy, severe mitral regurgitation status post bioprosthetic mitral valve (MV) replacement one year prior, and atrial fibrillation, admitted for evaluation for left ventricular assist device (LVAD) implantation. While her preoperative transthoracic echocardiogram (TTE) did not reveal a discrete mass, it showed a mean mitral gradient of 7 mmHg; intraoperative transesophageal echocardiography (TEE) identified a 2 cm × 1.2 cm thrombus on the bioprosthetic MV. Given these findings, the surgical team decided to replace the mitral valve concurrently with LVAD implantation. Although this approach is not routine, the goal was to improve her quality of life and reduce postoperative complications. Post-procedure TEE showed an improved MV mean gradient of 3 mmHg with no evidence of paravalvular leak. The patient was subsequently discharged home in stable condition without any thromboembolic events. This case highlights the challenges of managing complex valvular pathology in patients undergoing LVAD placement.

Background: In cardiac surgery, protamine is used to reverse the effects of heparin after separation from cardiopulmonary bypass (CPB). Excess of protamine has been demonstrated to cause platelet dysfunction and coagulopathy. A protamin-to-heparin ratio of less than 1:1 is endorsed by the European guidelines. Pharmacokinetic models of heparin decay have been proposed to allow for individualised dosing rather than fixed ratios. The objective of this study is to compare three such models in a large cohort of simulated patients. Methods: The doses of protamine were calculated using the models proposed by Meesters et al., Miles et al., and in the PRODOSE trial. We employed data from the VitalDB database to calculate the doses of heparin and randomly generated time intervals in-between. We tested two scenarios: with an initial dose and heparin added to the priming solution, and where additional heparin was administered over the course of the CPB. Results: We simulated 1166 cases with a mean interval between heparin and protamine administration of 90 ± 22 minutes in the first and 140 ± 28 minutes in the second scenario. The PRODOSE formula produced the lowest protamine-to-heparin ratios, followed by Meesters' formula in the first scenario (0.68:1 vs 0.72:1, P < .001) and the Miles' formula in the second scenario (0.55:1 vs 0.62:1, P < .001). Conclusion: The doses calculated with pharmacokinetic models exhibited discrepancies of up to 13.6%. While confirmation of complete reversal with alternative methods is necessary, the models facilitate a more individualised dose selection than the fixed ratios proposed in the literature.

Background: Etomidate has minimal cardiovascular depressant effects at the cost of endogenous cortisol production suppression, whereas propofol has vasodilatory and myocardial depressant properties, which may be poorly tolerated in the cardiac surgical population. To offset the undesirable effects of propofol, ketamine can be co-administered to harness its cardiac stimulatory properties. Though etomidate is a more cardio-stable induction agent than propofol, its superiority over the combination of propofol and ketamine-colloquially known as "ketofol"-remains controversial. Methods: United States National Library of Medicine Database (MEDLINE) and Excerpta Medica Database (EMBASE) were searched for randomized controlled trials published since 2010 comparing etomidate and ketofol relative to propofol alone for induction of general anesthesia for coronary artery bypass grafting (CABG). Key data collected included post-induction nadir mean arterial pressure (MAP), heart rate, cardiac index, systemic vascular resistance (SVR), and serum cortisol levels at 24 hours postoperatively. Variables were compared by calculating a weighted mean difference (WMD) [95% confidence interval (CI)]. Results: This analysis included 15 studies (1125 patients). Anesthetic induction with etomidate was associated with a higher nadir MAP and SVR compared to ketofol during the peri-induction period by WMD 4.77 mmHg [95% CI 0.31, 9.23, P = 0.04] and 42.22 dynes/cm⁵ [95% CI 0.49-83.94, P = 0.05]. However, there was no difference in the frequency of needed boluses of vasopressors or fluids for peri-induction hypotension. Conclusions: Though etomidate appears to provide a superior hemodynamic profile compared to ketofol, both agents require similar degrees of clinical response to hypotension during the induction of CABG surgery patients.

Categorical variables are an integral part of clinical research. This article introduces their uses and most common analyses for clinicians seeking additional statistics exposure to more critically engage with literature and refine their own research endeavors. We describe and demonstrate the two most common tests of association for categorical variables: chi-square and Fisher's exact tests, along with their underlying logic, result interpretations, and relative strengths and weaknesses. We also introduce and explain two of the most common measurements of effect size in analyses of categorical outcomes: relative risk (RR) and odds ratio (OR).

Purpose: Acquired broncho-esophageal fistula (BEF) presents significant challenges in perioperative anesthesia management, especially when direct repair is not feasible. This case report highlights the anesthesia management strategies used during endoscopic submucosal dissection (ESD), an indirect repair method for BEF, focusing on airway preservation and minimizing intraoperative complications. Result: A 64-year-old male with BEF caused by small cell lung cancer underwent ESD. Anesthesia management focused on preserving spontaneous breathing and preventing air leaks through continuous endotracheal aspiration. A double-lumen tracheal tube was used to achieve selective lung ventilation, and recruitment maneuvers were performed postoperatively to improve lung function. The surgery was successfully completed without significant adverse effects, and postoperative follow-up showed improvement in the patient's condition. Conclusion: ESD represents a viable option for the indirect repair of BEF in patients unsuitable for direct surgical repair. Perioperative anesthetic strategies, such as spontaneous breathing preservation and continuous airway suction, may reduce complications. This case highlights the importance of a tailored, multidisciplinary approach in managing complex thoracic surgical cases.