Cardiothoracic Anesthesiology: Novel Milestone and Renewed Opportunities.

As a journal focused on cardiothoracic anesthesia and solid organ transplantation, readers of SCVA are undoubtedly enthralled by recent advances in our ever-evolving fields. This year has been particularly momentous in this regard, including Griffith et al. reporting the first cardiac xenotransplantation with a genetically modified pig heart in January 2022, an incredible triumph across the fields of clinical transplantation, biotechnology, and genetic engineering. A multitude of other relevant advancements have been made recently, and this issue of SCVA is affluent in such scientific progress; 6 original research manuscripts are published in this issue, along with a review article describing the value of cardiothoracic anesthesiologists in clinical outcomes after cardiac surgery and a variety of informative clinical challenges. Ariyo et al. present a brief review of value-added care by the cardiothoracic anesthesiologist (CTA). Implementation science is defined as the complex field focusing on planning, influencing, and evaluating the adoption (or barriers) of evidence-based practices. This includes principles of bundled implementation strategies, fidelity interventions, and critical drivers of change. The authors have highlighted certain cardiac surgery areas within the purview of cardiothoracic anesthesiologists to bring a change or make a difference. Not only do we need to understand more about the inflammatory effects of cardiopulmonary bypass, cognitive effects after cardiac surgery, transfusion, and coagulation, we need to understand and eradicate the barriers, if any, to improve the overall outcomes. While scientific guidelines are the outcomes of scientific studies, catering to and addressing the local needs associated with incorporating the guidelines is the goal for implementation sciences. Cardiothoracic anesthesiologists hold that unique position, as opined by the authors. Similarly, Osman et al. present their initial experience establishing a specialized center in Lebanon for CTEPH therapy. The authors must be congratulated on their successful endeavor as CTEPH surgery remains localized to only a few highly specialized centers, even in the United States. However, diligence must be exercised to differentiate initiation vs the center of excellence status. The designation often tends to be self-proclaimed due to the high-volume center. Ideally, it should be broader and must meet specific established criteria, including but not limited to volume, outcomes, research, and services. Cardiac surgery-associated acute kidney injury (AKI) continues to be a vexing problem. Quests for reversible or modifiable risk factors persist to this day. Over time, as our understanding of AKI has improved, the definitions have evolved too—from the RIFLE criteria to the AKIN criteria to the KDIGO criteria. Per the consensus statement of the Acute Dialysis Quality initiative (www.adqi.org), the definitions for AKI, acute kidney disease (AKD), and chronic kidney disease (CKD) are based on the time-bound persistence of renal dysfunction (Figure 1). An abrupt decrease in kidney function over 7 days or less is defined as AKI; if it persists but recovers within 90 days, it is defined as AKD, whereas if the dysfunction persists beyond 90 days, it is labeled as CKD. Acute kidney injury is further differentiated into 3 stages (Stages 1, 2, and 3), depending on the extent of “damage” and “loss of function” as described above (Figure 1). Acute kidney disease incorporates a reduced glomerular filtration rate (GFR) of <60 mL/minute/1.73 m, reduction in GFR of ≥ 35% of baseline, sCr > 50% of baseline, and albuminuria, hematuria, and pyuria. CKD is defined as the persistent state of reduced GFR (<60 mL/minute/1.73 m) with or without anuria beyond 90 days. Presentations and the temporal transitions between the different phases of renal dysfunction can follow multiple trajectories: early dysfunction with complete recovery, late dysfunction with late recovery, late onset of