Selected 2023 Highlights in Congenital Cardiac Anesthesia.

This article reviews the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist published in 2023. After a search of the US National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2023. The authors of this article considered the following topics noteworthy to be included in this review: (1) advancements in percutaneous mechanical support in children with congenital heart disease, (2) children with pulmonary hypertension undergoing surgery for congenital heart disease, (3) dexmedetomidine in pediatric cardiac surgery, and (4) recommendations for pediatric heart surgery in the United States: Implications for pediatric cardiac anesthesia.

Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers.

OBJECTIVE: To assess the intraoperative use of 3-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, the authors created a survey aimed at evaluating the availability of equipment and the use of 3D TEE for specific surgical and interventional procedures and single-image modalities. The respondents were asked to identify the perceived impact on patient management and current limitations to its routine use. DESIGN: A multiple choice 25-question online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6, 2021, and closed on January 31, 2022. SETTING: An online survey. PARTICIPANTS: Registered EACTAIC members in 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 239 respondents from 44 different countries took part in the survey (27% of the total 903 EACTAIC members). Most respondents (59%) were TEE-certified by the National Board of Echocardiography, European Association of Cardiovascular Imaging (EACVI/EACTAIC), or had a national certificate. Of the respondents, 68% had no formal 3D TEE training. Eight percent of respondents had no 3D machines, whereas 40% had one for each operating room, and 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve surgery, and in more than 54% of cases for mitral and tricuspid clips, aortic valve, tricuspid valve, and aortic surgery. CONCLUSION: Current guidelines suggest integrating 3D TEE into all comprehensive examinations. The authors' survey reported that intraoperative 3D TEE was used in the majority of mitral valve surgery and only one-half of the other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel, and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

The Year in Review: Anesthesia for Congenital Heart Disease 2023.

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.

Year in Review 2023: Noteworthy Literature in Cardiac Anesthesiology.

Notable clinical research published in 2023 related to cardiac anesthesia included studies focused on resuscitation and pharmacology, regional anesthesia, technological advances, and novel gene therapies. We reviewed 241 articles to identify 25 noteworthy studies that represent the most significant research related to cardiac anesthesia from the past year. Overall, improvements in clinical practice have enabled decreased morbidity and mortality with a renewed focus on mechanical circulatory support and transplantation.

European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept.

The Pediatric Cardiac Anesthesia (PCA) fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is evaluated critically by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Heterogeneity Among Countries in the Subspecialty of Cardiovascular Anesthesia in Latin America: Survey Results.

OBJECTIVES: To evaluate demographics, workload, training, facilities, and equipment in cardiovascular anesthesia (CVA) in Latin America (LA). DESIGN: A descriptive cross-sectional study with data collected through a survey. SETTING: A multicenter, international web-based questionnaire that included 37 multiple-choice questions. PARTICIPANTS: Physicians and specialists in anesthesiology who regularly participated in cardiovascular surgeries and were members of the scientific societies of the Latin American Confederation of Anesthesiology. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 484 completed questionnaires were collected. A total of 97.8% of the respondents had a university degree in anesthesiology. Most did not receive formal training in CVA, and only 41.5% received formal training. Moreover, most of them were trained in their own country, and a smaller percentage were trained abroad. Half of the respondents reported receiving <12 months of training. A third part of the respondents had received training in transesophageal echocardiography. Only 5.8% of the respondents worked exclusively in CVA, and a high percentage dedicated <60% of their weekly work hours to this subspecialty. A total of 80.6% of the centers had <3 cardiac surgery operating rooms. Only one-third of the centers performed heart/lung transplantation, venoarterial extracorporeal membrane oxygenation, venovenous extracorporeal membrane oxygenation, and ventricular assist device implantation. CONCLUSIONS: A significant lack of training programs in anesthesiology practice and complex procedures in medical centers in LA are evident. Thus, basic accredited programs should be developed in medical centers in LA.

Cardiovascular anesthesia training: A single center survey among fellow doctors.

Despite the proliferation of research on anesthesiology training at all stages of medical education, there is relatively little published literature surveying the perspectives and concerns of anesthesiologists regarding cardiovascular anesthesia training. Therefore, we conducted a survey to investigate the attitudes, barriers, expectations, stress experiences, satisfaction, and future aspirations of anesthesiologists trained at a tertiary cardiovascular specialty hospital in China. A questionnaire survey was conducted among 260 anesthesiologists who received cardiovascular anesthesia training at departments of anesthesiology in a tertiary cardiovascular specialty hospital in China. After the study protocol was approved, electronic questionnaires were distributed to the target group through the online survey software "Wen Juan Xing." Respondents were asked to complete an anonymous questionnaire on their smartphones through WeChat, with the restriction of one response per device enabled. Of the 260 trainees, 240 (98%) completed the questionnaire. The majority of the trainees were 31 years of age or above. A large majority had approximately 10 years of clinical anesthesia practice, and nearly one-third had never undertaken cardiovascular specialty anesthesia practice before. The most common reasons for attending the refresher training were the need to learn basic specialty theory and improve clinical skills. The barriers were mainly time constraints or staff shortages in the department. Sixty-one (93.8%) trainees described the experience as "stressful or highly stressful" and identified poor teacher interaction as the highest-ranking stressor. Anesthesiologists were most dissatisfied with job rewards, with a satisfaction rate of only 15%. Anesthesiologists are highly stressed during the refresher training. Poor teacher interaction and low job rewards were identified as the highest-ranking stressors during cardiovascular anesthesia training. Training providers need to pay more attention to these stressors to enhance the quality of cardiovascular anesthesia training.

Association Between the Use of Midazolam During Cardiac Anesthesia and the Incidence of Postoperative Delirium: A Retrospective Cohort Study Using a Nationwide Database.

OBJECTIVE: To evaluate the association between the intraoperative administration of midazolam and the incidence of postoperative delirium in patients undergoing cardiac surgery. DESIGN: Retrospective observational cohort study. SETTING: The Japanese Diagnosis Procedure Combination database. PARTICIPANTS: Patients aged 65 years and older who underwent cardiovascular surgery (excluding transcatheter surgeries, multiple surgeries per admission, and preoperative delirium) between April 1, 2015, and October 31, 2019. MEASUREMENTS AND MAIN RESULTS: Patients who received midazolam (midazolam group) were compared with those who did not receive midazolam (no midazolam group). The primary outcome was the incidence of postoperative delirium. The secondary outcomes were the incidence of postoperative nausea and vomiting, mortality, and duration of intensive care unit stay and hospitalization. Propensity scores were estimated using logistic regression based on the covariates. The outcomes were compared using stabilized inverse probability of treatment-weighting analyses. Among the 16,185 patients analyzed, 10,633 (65.7%) received midazolam. No significant differences were observed in the incidences of postoperative delirium (odds ratio [OR] 0.95; 95% CI 0.87-1.03; p = 0.21) and hospital mortality (OR 0.92; 95% CI 0.76-1.11; p = 0.39) between the groups; however, the midazolam group had slightly longer durations of intensive care unit stay (3.5 [3.5-3.6] v 3.3 [3.3-3.4] days, p < 0.001) and hospitalization (31.5 [31.1-31.9] v 29.4 [28.8-29.9] days, p < 0.001), and slightly lower incidences of postoperative nausea and vomiting (OR 0.92; 95% CI 0.85-0.99; p = 0.03). The sensitivity analyses supported these results. CONCLUSIONS: Intraoperative administration of midazolam may not induce postoperative delirium in patients undergoing cardiac surgery.

Pediatric Cardiac Anesthesia Training and Staffing in the National Health Service.

BACKGROUND: Considerable importance is attached to the process of training, appointing and retaining highly specialized pediatric anesthetists, such as those with a congenital heart disease practice. AIMS: For the 10-year period from April 2012 to March 2022, we wished to establish changes in the absolute number of consultant pediatric cardiac anesthetic posts in NHS Level 1 Centres, turnover in such posts, and what training appointees had received. METHODS: An email survey was sent to the Centre Representative from the Congenital Cardiac Anesthesia Network in each of the eleven NHS Level 1 Pediatric Congenital Heart Disease Centre. Further follow up was completed in order to confirm accuracy of responses. We defined a pediatric cardiac anesthetist as a consultant with a clinical practice including provision of anesthetic management for children undergoing cardiac surgery incorporating the use of cardiopulmonary bypass. RESULTS: The response rate to our survey was 100%. Over the study period the number of consultants increased from 69 to 81, though three posts were unfilled as at March 2022. There were 55 departures and 65 appointees. Five consultants moved between NHS Units. 52 consultants received formal fellowship training and 13 switched into pediatric cardiac anesthesia from an existing general pediatric anesthetic post, with a period of supplementary training within their institution. Appointees reported extensive additional training variably including fellowships in general pediatric anesthesia, adult cardiac anesthesia and pediatric intensive care, both within and outside the United Kingdom. CONCLUSIONS: There has been both an expansion in the number of posts, as well as considerable turnover in consultant posts in the last 10 years. Training standards which support and guide individuals as they develop a practice in this highly specialized field should reflect different routes into the speciality and could be established with the support and advice of the Congenital Cardiac Anesthesia Network.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation.

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

Cardiac Anesthesia Intraoperative Interpretation Accuracy of Transesophageal Echocardiograms: A Review of the Current Literature and Meta-Analysis.

Background: In the United States, echocardiography is an essential component of the care of many cardiac patients. Recently, increased attention has been given to the accuracy of interpretation of cardiac-based procedures in different specialties, amongst them the field of cardiac anesthesiology and primary echocardiographers for transesophageal echocardiogram (TEE). The purpose of this study was to assess the TEE skills of cardiac anesthesiologists in comparison to primary echocardiographers, either radiologists or cardiologists. In this systematic review, we evaluated available current literature to identify if cardiac anesthesiologists interpret TEE procedures at an identical level to that of primary echocardiographers. Methods: A PRISMA systematic review was utilized from PubMed from the years 1952-2022. A broad keyword search of "Cardiology Anesthesiology Echocardiogram" and "Echocardiography Anesthesiology" to identify the literature was used. From reviewing 1798 articles, there were a total of 9 studies included in our systematic review, 3 of which yielded quantitative data and 6 of which yielded qualitative data. The mean accuracy from each of these three qualitative studies was calculated and used to represent the overall accuracy of cardiac anesthesiologists. Results: Through identified studies, a total of 8197 TEEs were interpreted by cardiac anesthesiologists with a concordance rate of 84% to the interpretations of primary echocardiographers. Cardiac anesthesiologists had a concordance rate of 83% when compared to radiologists. On the other hand, cardiac anesthesiologists and cardiologists had a concordance rate of 87% in one study and 79% in another study. Conclusion: Based on these studies, cardiac anesthesiologists are shown to interpret TEEs similarly to that of primary echocardiographers. At this time, there is no gold standard to evaluate the accuracy of TEE readings. One way to address this is to individually assess the TEE interpretation of anesthesiologists and primary echocardiographers with a double-blind study.

Selected 2022 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study.

OBJECTIVES: The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery. DESIGN: A retrospective observational study. SETTING: A single large teaching hospital. PARTICIPANTS: A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data. INTERVENTIONS: Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications. MEASUREMENTS AND MAIN RESULTS: The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups. CONCLUSIONS: Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

Effects of Thoracic Paravertebral Block on Postoperative Analgesia in Infants and Small Children undergoing Ultra-Fast Track Cardiac Anesthesia: A Randomized Controlled Trial.

OBJECTIVES: To assess whether a preoperative bilateral thoracic paravertebral block (TPVB) would improve postoperative analgesia in infants and small children undergoing open cardiac surgery in the protocol of an ultra-fast track cardiac anesthesia (UFTCA). DESIGN: A single-center, prospective, randomized, controlled study. SETTING: At a tertiary children's medical center. PARTICIPANTS: A total of 180 children undergoing cardiac surgery, aged 1 month to 3 years. INTERVENTIONS: Patients are allocated randomly to TPVB and parent- and/or nurse-controlled intravenous analgesia (PNCA) group (Group T) or PNCA group (Group P). MEASUREMENTS AND MAIN RESULTS: The primary outcome is the postoperative pain scores. The secondary outcome are intraoperative consumption of sufentanil, time to extubation, using of neostigmine, cumulative total and invalid PCA attempts in 24 and 48 hours after surgery, hospitalization characteristics, perioperative blood glucose, postoperative arterial oxygen partial pressure, arterial carbon dioxide partial pressure (PaCO2) and brain natriuretic peptide (BNP). The postoperative pain scores within 24 hours, intraoperative consumption of sufentanil, total, and invalid PCA attempts in 24 and 48 hours, perioperative blood glucose and BNP on the seventh day in Group T were all significantly lower than those in Group P (p < 0.001). The time to extubation, the use of neostigmine, and PaCO2 on the sixth hour, postoperatively, were significantly smaller in Group T than those in Group P (p < 0.05). There were no significant differences in the hospitalizations between the 2 groups. CONCLUSIONS: A combination of bilateral single dose TPVB and PNCA pain management is superior to a PNCA pain management alone in infants and small children undergoing open cardiac surgery and contributes to a rapid recovery with preferable perioperative outcomes in the protocol of UFTCA.

Anesthetic Preferences for Cardiac Anesthesia: A Survey of the Society of Cardiovascular Anesthesiologists.

BACKGROUND: Volatile anesthetics have been historically preferred for cardiac anesthesia, but the evidence for their superiority to intravenous agents is mixed. We conducted a survey to better understand the current state of practice and the rationale behind provider preferences for anesthesia for cardiac surgery with cardiopulmonary bypass. We hypothesized that anesthetic preference would vary considerably among surveyed providers without a clear majority, as would the rationale behind those preferences. METHODS: Email invitations were sent to members of the Society of Cardiovascular Anesthesiologists, who were asked to identify the anesthetics or sedatives they typically prefer to administer during induction, prebypass, bypass, postbypass, and postoperative periods and why they prefer those agents. Members' beliefs regarding the importance of anesthetics on postoperative outcomes were also assessed. RESULTS: Invitations were sent on 2 separate dates to 3328 and 3274 members, of whom 689 (21%) responded. The median (interquartile range [IQR]) respondent age was 45 (37-56) years, 79% were men, and 75% were fellowship trained. The most frequently chosen drug for induction was propofol (80%). Isoflurane was the most frequently selected primary agent for the prebypass (57%), bypass (62%), and postbypass periods (50%). Sevoflurane was the second most frequently selected (30%; 17%, and 24%, respectively). Propofol was the third most frequently selected agent for the bypass (14%) and postbypass periods (17%). Ease of use was the most frequently selected reason for administering isoflurane and sevoflurane for each period. During bypass, the second most frequently selected rationale for using isoflurane and sevoflurane was institutional practice. A total of 76% responded that the perfusionist typically delivers the bypass anesthetic. Ischemic preconditioning, organ protection, and postoperative cognitive function were infrequently selected as rationales for preferring the volatile anesthetics. Most respondents (73%) think that anesthetics have organ-protective properties, especially isoflurane (74%) and sevoflurane (59%), and 72% believed that anesthetic choice contributes to patient outcome. The median (IQR) agreement (0 = strongly disagree to 100 = strongly agree) was 72 (63-85) for the statement that "inhaled anesthetics are an optimal maintenance anesthetic for cardiac surgery." CONCLUSIONS: In a survey of cardiac anesthesiologists, a majority of respondents indicated that they prefer volatile anesthetics for maintenance of anesthesia, that anesthetic selection impacts patient outcomes, and that volatile anesthetics have organ-protective properties. The members' rationales for preferring these agents possibly reflect that practical considerations, such as ease of use, effectiveness, and institutional practice, also influence anesthetic selection during cardiac surgery in addition to considerations such as organ protection.

A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine.

Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.