Evaluation of Activated Clotting Times With a Heparin Reversal Protocol Designed to Conserve Protamine During Drug Shortages: A Retrospective, Cohort Study.

OBJECTIVE: To retrospectively evaluate a protamine conservation approach to heparin reversal implemented during times of critical shortages. This approach was aimed at maintaining access to cardiac surgical services. SETTING: In-patient hospital setting. PARTICIPANTS: Eight hundred-one cardiac surgical patients>18 years old. INTERVENTIONS: Patients undergoing cardiac surgery who received >30,000 U of heparin were given a single fixed vial protamine dose of 250 mg or a standard 1 mg of protamine to 100 U of heparin ratio-based dose to reverse heparin. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was differences in post-reversal activated clotting times between the 2 groups. The secondary endpoint was differences in the number of protamine vials used between the 2 reversal strategies. The first activated clotting times values measured after initial protamine administration were not different between the Low Dose and Conventional Dose groups (122.3 s v 120.6 s, 1.47 s, 99% CI -1.47 to 4.94, p = 0.16). The total amount of protamine administered in the Low Dose group was less than that in the Conventional Dose group (-100.5 mg, 99% CI -110.0 to -91.0, p < 0.0001), as were the number of 250 mg vials used per case (-0.69, 99% CI -0.75 to -0.63, p < 0.0001). The mean initial protamine doses between groups were 250 mg and 352 mg, p < 0.0001. The mean protamine vials used were 1.33 v 2.02, p < 0.0001. When the calculations were based on 50 mg vials, the number of vials used per case in the Low Dose group was even less (-2.16, 99% CI -2.36 to -1.97, p < 0.0001).) CONCLUSIONS: Conservation measures regarding critical medications and supplies during times of shortages can maintain access to important services within a community.

The Year in Coagulation and Transfusion: Selected Highlights from 2022.

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

A Narrative Review of the 2020 Guidelines for Use of Transesophageal Echocardiography to Assist with Surgical Decision- Making by the Cardiac Anesthesiologist in the Operating Room.

Transesophageal echocardiography (TEE) has become an integral part in helping to diagnose, manage, and assess interventions in the cardiac operating room. Multiple guidelines have been created by the American Society of Echocardiography for performing a TEE examination for different cardiac pathologies. The operating room can provide unique challenges when performing a TEE examination, which include hemodynamic instability, time constraints, and use of general anesthesia. The Guideline for the use of TEE to assist in surgical decision- making in the operating room recently was published to provide a starting protocol for conducting a TEE examination for different cardiac surgeries and for using the information obtained to interpret and to communicate findings to the surgical team. This present narrative review focuses and expands upon the relevant portions for the cardiac anesthesiologist.

Coagulation and Transfusion Updates From 2021.

2021 and the COVID 19 pandemic have brought unprecedented blood shortages worldwide. These deficits have propelled national efforts to reduce blood usage, including limiting elective services and accelerating Patient Blood Management (PBM) initiatives. A host of research dedicated to blood usage and management within cardiac surgery has continued to emerge. The intent of this review is to highlight this past year's research pertaining to PBM and COVID-19-related coagulation changes.

Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians.

The use and evolution of oral anticoagulation therapies continue to advance for multiple reasons, including a growing segment of older patients with associated chronic prothrombotic illnesses including cardiovascular, pulmonary, hematologic and oncologic conditions. Correlated to this increased use of oral anticoagulants is bleeding complications associated with their use. Based on these trends, it is expected that perioperative physicians will be facing more and more of these patients requiring scheduled, urgent or emergent surgical procedures During May 2020, the American College of Cardiology updated its Expert Consensus Decision Pathway devoted to the approach of bleeding in patients on oral anticoagulants. This updated version emphasized the expanding role of the direct-acting oral anticoagulants in other conditions beyond nonvalvular atrial fibrillation, such as venous thromboembolism. Several details discussed within this most recent update are pertinent to perioperative physicians, who frequently deal with bleeding in the setting of anticoagulation. The purpose of this narrative review is to highlight and expand on these salient points because they relate to perioperative management.

A Narrative Review for Cardiac Anesthesiologists of the 2019 Expert Consensus on Operator and Institutional Recommendations for Transcatheter Mitral Valve Intervention.

US Food and Drug Administration approval of the edge-to-edge clip repair device (MitraClip; Abbott Laboratories, Abbott Park, IL) in 2013 led to wide adoption of the device for treatment of severe primary mitral regurgitation in patients unsuitable for surgery. Demonstration of favorable outcomes in the setting of secondary mitral regurgitation by the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial in 2019 provided an additional impetus to the transcatheter mitral interventional program. The role of the cardiac anesthesia service also is expanding to echocardiography services for these patients outside of the procedure room. Moreover, cardiac anesthesiologists serve on the multidisciplinary team that is involved in clinical decision-making pertaining to patient selection, optimization, and intervention. This document has direct implications for the cardiac anesthesiologist involved in the care of these patients because a broader understanding of pertinent issues is essential to function as an effective clinical member within the multidisciplinary team. As such, this narrative review serves to highlight the salient features of the "2019 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Mitral Valve Intervention: A Joint Report of the American Association for Thoracic Surgery, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons," focuses on issues pertinent to the cardiac anesthesiologist, and provides an outline for the clinical context and evolution of transcatheter mitral valve interventions.

Expert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist.

Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. To optimize care and improve access for patients with valvular heart disease the Expert Consensus Systems of Care Document by Nishimura et al.1 was recently published. The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report.

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.

ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Review of the 2017 Document for the Cardiac Anesthesiologist.

Chronic mitral regurgitation (MR) is the most prevalent valvular lesion in the adult US population. Appropriate patient selection for mitral intervention and selection of the appropriate interventional strategy and optimal periprocedural management rely on thorough clinical evaluation, accurate echocardiographic input, and in-depth understanding of chronic MR pathophysiology on the part of the cardiac anesthesiologist. The recently published Expert Consensus Decision Pathway on the management of MR was designed to provide tools to help the clinician with broad clinical decision-making, including patient referral, and the present review focuses and elaborates on the key aspects relevant to the cardiac anesthesiologist in the peri-interventional setting.

Predicting the Number of Edge-to-Edge Repair Devices Needed to Adequately Treat Mitral Regurgitation Using Transesophageal Echocardiography.

OBJECTIVES: Increased utilization and highly variable costs seen with percutaneous mitral valve edge-to-edge repair have made cost cutting strategies of significant interest. Mitral regurgitation etiology, the number of devices used, and experience all play a role in variability. Currently a paucity of data exists in predicting the number of devices. Any associations found between echocardiography parameters and the number of devices used could help with pre-procedure planning and device placement strategies, ultimately reducing variability and costs. DESIGN: In this retrospective analysis the authors evaluated the ability of established and novel three-dimensional (3D) mitral regurgitation measures, namely 3D vena contracta area and vena contracta length, to predict the number of devices used. Other factors evaluated include mitral valve area and ejection fraction. All factors were compared using the Mann Whitney rank sum tests. PARTICIPANTS: Patients over 18 years old undergoing the MitraClip procedure. SETTING: Catheterization Laboratory. MAIN RESULTS: No relationship was found between 3D parameters and the number of devices used, but mitral valve area was strongly associated with the use of multiple devices. CONCLUSION: The 3D parameters of interest were not associated with the use of multiple devices, but the mitral valve area was associated. Further studies are needed to determine if this relationship is predictive.

A Narrative Review for Perioperative Physicians of the 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants.

In 2017 the American College of Cardiology issued an Expert Consensus Decision Pathway dedicated specifically to the management of bleeding in patients on anticoagulants. The consensus document is both timely and important as indications for more novel anticoagulants expand rapidly. The document reviews in detail recommendations for interruption, management and re-initiation of anticoagulation in bleeding scenarios. Numerous points within the document are relevant to perioperative physicians managing patients on anticoagulation with either bleeding complications or undergoing surgical procedures. The intent of this narrative review is to highlight the salient points within the expert consensus for perioperative physicians.

An Unusual Suspect in a Case of Left Ventricular Aneurysm.

True left ventricular aneurysms are most frequently seen after acute transmural myocardial infarction. These aneurysms are distinct from apical left ventricular pseudoaneurysms, which can also be seen in ischemia, and have a different treatment course. A major dilemma for clinicians is using echocardiographic information to make this distinction. Coronary angiography aids in this distinction; however, in the case of normal coronaries alternate etiologies must be considered. The differential for a patient with a left ventricular aneurysm and normal coronaries or no prior cardiac surgery is broad and includes traumatic, infectious and infiltrative causes. In this e-challenge, we present an unusual cause of a left ventricular apical aneurysm in a patient with normal coronary arteries residing in the United States.

Hypertrophic Cardiomyopathy and Left Ventricular Outflow Tract Obstruction: Expecting the Unexpected.

Hypertrophic cardiomyopathy is an increasingly recognized clinical disease that carries perioperative risk. Patients may or may not carry a preoperative diagnosis, but provocable left ventricular outflow tract gradients place them at risk for hemodynamic compromise under surgical conditions. Early recognition of obstructive patterns and rapid management alterations in the face of instability are imperative for the treatment of these patients. This review focuses on the diagnostic criteria, risk factors, and management strategies for the perioperative hypertrophic cardiomyopathy patient. Finally, novel diagnostic modalities are discussed.

Technology: Is There Sufficient Evidence to Change Practice in Point-of-Care Management of Coagulopathy?

Currently, hemostasis is one of the most widely researched topics in perioperative medicine. As investigators learn more about the complexity of coagulation, developing tests with the ability to rapidly monitor coagulation and guide targeted therapy is the key to optimizing hemostasis management. There is mounting evidence that algorithmic transfusion using point-of-care (POC) testing can reduce red cell and platelet transfusions and major bleeding after cardiac surgery. Integrating these tests during cardiac surgery and trauma management is especially important because these groups use the most blood products within a health system and the risks of transfusion are well documented. Currently, numerous POC tests are available for evaluating hemostasis. The purpose of this review is to provide a comprehensive evaluation of the current evidence surrounding the most common POC testing devices in practice for managing coagulation.

Comparison of Thrombelastography-Derived Fibrinogen Values at Rewarming and Following Cardiopulmonary Bypass in Cardiac Surgery Patients.

BACKGROUND: The inflated costs and documented deleterious effects of excess perioperative transfusion have led to the investigation of targeted coagulation factor replacement strategies. One particular coagulation factor of interest is factor I (fibrinogen). Hypofibrinogenemia is typically tested for using time-consuming standard laboratory assays. The thrombelastography (TEG)-based functional fibrinogen level (FLEV) provides an assessment of whole blood clot under platelet inhibition to report calculated fibrinogen levels in significantly less time. If FLEV values obtained on cardiopulmonary bypass (CPB) during rewarming are similar to values obtained immediately after the discontinuation of CPB, then rewarming values could be used for preemptive ordering of appropriate blood product therapy. METHODS: Fifty-one cardiac surgery patients were enrolled into this prospective nonrandomized study to compare rewarming fibrinogen values with postbypass values using TEG FLEV assays. Baseline, rewarming, and postbypass fibrinogen values were recorded for all patients using both standard laboratory assay (Clauss method) and FLEV. Mixed-effects regression models were used to examine the change in TEG FLEV values over time. Bland-Altman analysis was used to examine bias and the limits of agreement (LOA) between the standard laboratory assay and FLEVs. RESULTS: Forty-nine patients were included in the analysis. The mean FLEV value during rewarming was 333.9 mg/dL compared with 332.8 mg/dL after protamine, corresponding to an estimated difference of -1.1 mg/dL (95% confidence interval [CI], -25.8 to 23.6; P = 0.917). Rewarming values were available on average 47 minutes before postprotamine values. Bland-Altman analysis showed poor agreement between FLEV and standard assays: mean difference at baseline was 92.5 mg/dL (95% CI, 71.1 to 114.9), with a lower LOA of -56.5 mg/dL (95% CI, -94.4 to -18.6) and upper LOA of 242.4 mg/dL (95% CI, 204.5 to 280.3). The difference between assays increased after CPB and persisted after protamine administration. CONCLUSIONS: Our results revealed negligible change in FLEV values from the rewarming to postbypass periods, with a CI that does not include clinically meaningful differences. These findings suggest that rewarming samples could be utilized for ordering fibrinogen-specific therapies before discontinuation of CPB. Mean FLEV values were consistently higher than the reference standard at each time point. Moreover, bias was highly heterogeneous among samples, implying a large range of potential differences between assays for any 1 patient.