Embracing Scrutiny: The Importance of Critical Evaluation and Transparency in Research.

In its 1952 second annual report, the fledgling National Science Foundation framed the process of technological innovation as a “sequence [consisting] of basic research, applied research, and development... each of the successive stages [depending] upon the preceding.” Medical advancement has proven no exception to this, and the relationship between basic science, applied research, and clinical development underpins the modern framework of evidencebased medicine. As much as we may bias toward thinking of this sequence as linear, it is imperative that we also look at innovation critically and publish studies that detail what doesn’t work. This issue of Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) is true to this ethos and encompasses the entirety of this arc. We present both positive and negative Original Research spanning basic science in thromboelastographic testing, applied research in arterial line ultrasound and video laryngoscopy training, as well as clinical development of lung isolation devices and opioid sparing cardiothoracic anesthetic techniques. Rounding this out is an excellent review of perioperative point of care ultrasound (POCUS) for hemodynamic assessment and 2 case reports describing ingenuity in the face of the unexpected. Finally, we present a retraction of a previously published study to correct the evidence-based medical record as well as reflect on the risks inherent in stepping away from the process of innovation framed by the National Science Foundation so many years ago. In the first Original Research article, Mathew et al report the results of the first pairwise meta-analysis of clinical outcomes for opioid-free anesthesia (OFA) vs opioid-based anesthesia (OBA) in patients undergoing cardiovascular and thoracic surgery. Including 919 patients across 8 studies, they found that OFA in cardiovascular surgery patients was associated with significantly reduced postoperative nausea and vomiting (PONV), inotrope need, and non-invasive ventilation while there was no observed difference in 24-hour pain scores, 48-hour morphine equivalent consumption, or length of hospital stay. Interestingly, these same trends were not observed in thoracic surgery patients, among whom there was no significant difference in any of the explored outcomes. In this first meta-analysis of OFA techniques specific to cardiothoracic surgical patients, the findings echo similar patterns of reduced PONV in the absence of increased pain scores across multiple surgical specialties. Taken together with literature demonstrating reductions in long-term opioid dependence and concurrent improvements in clinical outcomes and patient satisfaction with cardiac Enhanced Recovery After Surgery (ERAS), this study offers compelling support of OFA techniques within cardiothoracic-specific Enhanced Recovery After Surgery programs. While innovation is a constant driver of clinical care improvement and medical device development, not all novel techniques and technologies are universally superior. Our second Original Research article is a demonstration of this, evaluating the existing literature comparing the Rüsch EZ-BlockerTM to the more traditional left-sided double lumen tube (L-DLT) for lung isolation in thoracic surgery. In a systematic review and meta-analysis spanning 6 studies and 495 patients, Kumar and colleagues found that the L-DLT tube was faster to