How Would We Treat Our Own Heart Transplantation Surgery: A Perioperative Look.

Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room.

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors.

OBJECTIVES: To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery. DESIGN: A retrospective study. SETTING: At an academic university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery. INTERVENTIONS: SGLT2i use versus no SGLT2i use. MEASUREMENTS AND MAIN RESULTS: The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare. CONCLUSIONS: Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Supra-systemic pulmonary hypertension after complicated percutaneous mitral balloon valvuloplasty: a case report and review of literature.

BACKGROUND: The World Symposium of Pulmonary Hypertension in 2018, updated the definition of pulmonary hypertension (PH) as mean pulmonary artery pressures (PAP) > 20 mmHg. Pulmonary venous hypertension secondary to left-heart disease, constitutes the most common cause of PH, and the determination of a co-existent pre-capillary (primary) PH becomes paramount, particularly at the moment of evaluating and managing patients with heart failure. Pulmonary artery pressures above the systemic pressures define supra-systemic PH and generally leads to frank right ventricular failure and high mortality. CASE PRESENTATION: We present the perioperative management of a patient with rheumatic mitral valve disease, initially found to have severe PH due to pulmonary venous hypertension, who underwent percutaneous mitral balloon valvuloplasty complicated with mitral chordae rupture, severe mitral regurgitation and supra-systemic PH. Multiple medical therapies and an intra-aortic balloon pump were used as means of non-surgical management of this complication. CONCLUSIONS: This case report illustrates the perioperative implications of combined pre- and post-capillary PH and supra-systemic PH, as this has not been widely discussed in previous literature. A thorough literature review of the clinical characteristics of PH, methods to determine co-existent pre- and post-capillary PH components, as well as concomitant right ventricular failure is presented. Severe PH has known detrimental effects on the hemodynamic status of patients, which can ultimately lead to a decrease in effective cardiac output and poor tissue perfusion.

Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature.

BACKGROUND: Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature. METHODS: A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020. RESULTS: Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids. CONCLUSIONS: In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.

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.