Seminars in Cardiothoracic and Vascular Anesthesia最新文献

The research findings relevant for Cardiac Anesthesiology studies published in 2024 involved key innovations in devices and gene therapy in addition to the expansion of transcatheter techniques for valve repair or replacement. We reviewed 447 relevant articles and selected 21 as the most noteworthy studies published in 2024. Themes that emerged from our review include the etiology and prevention of delirium or outcomes after mechanical circulatory support. Robust clinical outcome data now supports the use of microaxial flow devices for mechanical circulatory support for cardiogenic shock due to acute myocardial infarction. Pharmacology development presents colchicine as anti-inflammatory medication to prevent atrial fibrillation or intravenous amino acids for kidney protection after cardiopulmonary bypass. Technological advances include implantable wireless pacing-defibrillator devices, pulmonary artery pressure monitoring in heart failure patients, extracorporeal blood purification for preventing acute kidney injury and hypothermic oxygenated perfusion of the donor heart in heart transplantation. Transcatheter interventions on mitral or aortic valve were gaining advances over surgical procedures. Novel paradigms included treatments with gene therapy for cardiac amyloidosis or refractory angina and the emerging risk of microplastic exposure in cardiovascular events.

This article reviews noteworthy additions to the literature for the management of critically ill cardiothoracic surgical patients published in 2024. We reviewed 8100 articles to identify 10 publications that provided new or updated information across a diverse range of topics including extracorporeal membrane oxygenation (ECMO), sepsis and shock, and acute hypoxemic respiratory failure (AHRF). Additional topics within these publications included prophylaxis guidelines and evidence for prevention of common complications in the intensive care unit, such as bleeding, thrombosis, and acute kidney injury (AKI).

Noteworthy in Cardiothoracic Surgery 2024 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery this past year. Specifically, this year saw the release of many in-depth reports comparing the long-term outcomes of transcatheter aortic valve replacement (TAVR) vs surgical approaches for aortic valve replacement, data which is expected to move the transcatheter pendulum. In particular, this included a national analysis of trends reporting the rapid increase of post-TAVR surgical aortic valve replacement (SAVR). This year's literature also reported ground-breaking milestones related robotics in cardiothoracic surgery, with publication of the first multicenter series of robotic aortic valve replacements, the first entirely robotic double lung and heart transplants, as well as the first combined robotic aortic valve replacement and coronary artery bypass grafting. Specific to lung cancer, data continues to emerge regarding the de-escalation of magnitude of surgical resection from lobectomy to sublobar when able, and in the benefit of immunotherapy in the neoadjuvant treatment of non-small cell lung cancer. Frequent in the literature this year were concerns about toxicity, surgical challenges after therapy, and potential increases in perioperative complications following neoadjuvant chemoimmunotherapy, with calls for surgeons to crucially assess these effects on surgical outcomes to help refine patient selection criteria. Finally, 2024 saw many advancements in intraoperative tumor localization focused on enhancing precision, minimizing invasiveness, and improving surgical outcomes, including robotic-assisted bronchoscopy, electromagnetic navigation bronchoscopy (ENB), and encouraging data regarding intraoperative molecular imaging.

Human metapneumovirus (hMPV), a ubiquitous RNA virus of the Pneumoviridae family, has been associated with respiratory tract infections for decades in various age groups and populations. Though most of the infections, especially in children, are mild and self-limited, severe infections ranging from bronchiolitis or asthma exacerbation to severe pneumonia and acute respiratory distress syndrome (ARDS) have occasionally been reported. Among patients who require hospitalization for severe infections, treatment is supportive as no current antivirals or vaccines are effective or recommended. The following is a 45-year-old Caucasian man who developed severe ARDS complicating hMPV infection, and despite maximal medical support, he developed refractory life-threatening hypoxemia that required rescue therapy with veno-venous extracorporeal membrane oxygenation (V-V ECMO). After several days of ECMO support, the patient eventually recovered and was discharged home. This case highlights the importance of recognizing hMPV as an occasional culprit for severe respiratory infections, discusses the new global definition of ARDS, and delineates the updated recommended management, including the early application of V-V ECMO as a rescue therapy in severe cases with refractory, life-threatening respiratory failure.

Background: Pediatric cardiac transplant recipients undergo elective cardiac catheterization and endomyocardial biopsy (CC/EMB) for graft dysfunction surveillance often facilitated by general anesthesia (GA). GA and positive pressure ventilation (PPV) also depress cardiac function confounding the graft's functional assessment. We aimed to evaluate the frequency of cardiac function decline, going from the awake to the anesthetized state, and determine its association with anesthetic and patient-related factors.

Methods: Electronic medical records of pediatric heart transplant recipients undergoing CC/EMB under GA/PPV were retrospectively reviewed. Patients with awake normal cardiac function, assessed by same-day preoperative echocardiographic left ventricular shortening fraction (LVSF) ≥28% were included. A priori, groups were: (1) cardiac function decline (post- catheterization under GA, LVSF< 28%), and (2) no cardiac function decline. Univariate and logistic regression analysis accounting for repeated encounters per patient were performed.

Results: 225 eligible encounters occurred in 102 patients. Cardiac function declined in 17.3% (39/225) encounters, and in 25% (26/102) of patients. Logistic regression identified independent predictors as: older age (OR 1.4, 95% CI: 1.1-1.7, P = 0.002), angiotensin-converting enzyme inhibitor (ACEI) use (OR 2.5, 95% CI: 1.2-4.3, P = 0.018), and elevated right ventricular end diastolic pressure (RVEDP) (OR 2.4, 95% CI: 1.1-5.4, P = 0.039), with AUC 0.75. Older age and ACEI use (P = 0.001) and, older age and elevated RVEDP (P = 0.037) were correlated.

Conclusions: One in 4 patients demonstrated cardiac function decline from the awake to the anesthetized state, occurring most commonly in older children with elevated RVEDP using ACEI. Most cardiac function declines are unrelated to rejection.

Thoracic aorta pathologies, especially those of the ascending aorta and aortic arch, were traditionally approached via open surgical repair. This carries risk of ischemic end-organ damage and other complications. Endovascular repair of ascending aorta and aortic arch pathologies is becoming more successful and widespread, thereby posing numerous challenges to the anesthesiologist. This article reviews the anesthesia-pertinent pathophysiology, repair techniques, preoperative evaluation, intraoperative management, and postoperative care of patients presenting for endovascular repair of thoracic aorta pathologies.

Surgical repair of the proximal aorta is a complex endeavor, requiring cardiopulmonary bypass (CPB) and often the use of hypothermic circulatory arrest (HCA). In addition to the normal considerations for patients undergoing cardiopulmonary bypass, additional challenges include cerebral and end-organ protection during periods of circulatory arrest. This review aims to provide an up-to-date, evidence-based review on anesthetic management for proximal aortic repair.

Anesthetic management of open thoracoabdominal aneurysm (TAAA) repair poses a number of challenges for even the most experienced of cardiovascular anesthesiologists. This procedure encompasses a large number of unique anesthetic techniques, including one-lung ventilation, invasive hemodynamic monitoring, left-heart bypass, massive transfusion, selective renal and visceral perfusion, and central nervous system monitoring with CSF drainage. In this article, we aim to describe the anesthetic management for thoracoabdominal aortic aneurysm repair, including preoperative workup, intraoperative management, as well as postoperative concerns in the intensive care unit.

This case report describes the successful use of an intraoperative modified Valsalva maneuver to reverse atrial flutter in a pediatric patient with complex congenital heart disease undergoing systemic-to-pulmonary shunt surgery. The technique involved manipulating the Adjustable Pressure Limiting (APL) valve on the anesthesia machine to simulate the hemodynamic effects of the modified Valsalva maneuver, allowing for non-invasive management of supraventricular tachycardia without pharmacological intervention or electrical cardioversion. This intervention stabilized the patient's arrhythmia, maintaining hemodynamic stability throughout the procedure. The case highlights the potential of the maneuver as a safe, effective, and non-invasive alternative for arrhythmia management in pediatric cardiac surgeries, advocating for further research to validate this approach and possibly integrate it into standard practice for similar clinical scenarios.