Development and Publication of Clinical Practice Parameters, Reviews, and Meta-analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force.

The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes.

Marginal Improvement in Survival Post-Heart Transplantation in Patients With Prior Left Ventricular Assist Device: A Temporal Analysis of United Network of Organ Sharing Registry.

OBJECTIVE: An increasing number of patients undergoing heart transplantation are being bridged with left ventricular assist devices (LVADs). Bridge-to-transplantation (BTT) LVAD has improved wait list survival remarkably. Historically, post-heart transplantation survival in BTT-LVAD patients, however, has remained inferior to that of primary heart transplantation. The authors hypothesized that in the modern era, the difference between post-heart transplantation survival in BTT-LVAD versus primary heart transplantation should be reduced. The objective of the present study was to determine whether there has been a change in survival after heart transplantation in patients with prior LVAD. The present study's cohort was compared with a historical cohort using the United Network of Organ Sharing (UNOS) database from 1995 to 2004.5 DESIGN: Retrospective observational analysis of data from the United Network of Organ Sharing database. SETTINGS: Registry-based, observational, retrospective. PARTICIPANTS: Patients undergoing adult orthotopic heart transplantation, excluding redo transplantation and multiorgan transplantations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From the UNOS database, 22,065 patients who underwent heart transplantation between January 1, 2006, and December 31, 2016, were analyzed. Of these, 7,008 (31.76%) patients had prior LVAD (BTT-LVAD). Data analysis was performed with R software (Version 3.5.1) for Kaplan-Meier survival analysis and Cox proportional hazard ratio (HR) modeling to identify variables influencing survival. For patients with prior LVAD, the overall HR was 1.15 (95% confidence interval [CI] 1.07-1.24) for survival. An HR of 3.22 (95% CI 2.23-4.68) for death in patients who received extracorporeal membrane oxygenation post-transplantation and an HR of 0.72 (95% CI 0.58-0.90) for survival in patients whose procedures were performed in high-volume centers performing more than 35 transplantations per year were identified. CONCLUSION: Reduced survival in patients who received an LVAD before heart transplantation persists. However, there may have been a slight improvement in the HR for survival in the study cohort in the recent decade compared with the historical cohort from previous decades. It is intriguing that despite the paramount advances in both technology and clinical practice of LVAD, relatively minor survival benefit, if any, has occurred in post-heart transplantation for patients bridged with prior LVAD.

Perioperative Precision Medicine: Where Are We in 2020?

PURPOSE OF REVIEW: The present review examines how targeted approaches to care, based on individual variability in patient characteristics, could be applied in the perioperative setting. Such an approach would enhance individualized risk assessment and allow for targeted preventive and therapeutic decision-making in patients at increased risk for adverse perioperative events. RECENT FINDINGS: Prior and current studies highlight valuable lessons on how future investigations attempting to link specific patient-related characteristics or treatment modalities with outcomes and adverse drug responses might be designed in the perioperative setting. SUMMARY: Our review highlights the past, present, and future directions of perioperative precision medicine. Current evidence provides important lessons on how a specific patient and disease tailored approach can help perioperative physicians in delivering the most appropriate and safest perioperative care.

Hydroxocobalamin for the treatment of cardiac surgery-associated vasoplegia: a case series.

PURPOSE: Vasoplegia is a clinical syndrome marked by severe arteriolar vasodilatation, hypotension, and low systemic vascular resistance refractory to multiple vasopressor treatment. We report our experience with hydroxocobalamin (B12) infusion as a potential rescue adjunct for refractory vasoplegia during cardiopulmonary bypass (CPB). METHODS: We performed a retrospective chart review of 33 patients undergoing cardiac surgery between 1 January 2013 and 31 December 2015, who were given intravenous B12 for refractory hypotension during, or immediately following, CPB. We assessed mean arterial pressure (MAP) responses using semi-parametric group-based models (trajectory analysis). Vasopressor use was evaluated by norepinephrine-equivalent rates calculated five minutes prior, and up to 60 min following, B12 administration. RESULTS: Patients were mostly male (82%), had a mean (SD) age of 53 (13) yr, and median (IQR) EuroSCORE mortality index of 9 [4-40]. Four patterns of MAP responses to B12 were identified. In Group 1 ("poor responders") nine of 33 patients (27%) had the highest median [IQR] mortality risk (EuroSCORE 40 [4-52]), lowest mean pre-B12 MAP (50 mmHg), and minimal hemodynamic response in spite of continued vasopressor support. In contrast, Group 2 "responders" (8/33, 24%) showed a brisk MAP response (> 15 mmHg) to B12, sustained for > 60 min post-infusion, with 50% vasopressor reduction. Groups 3 and 4 had the lowest median mortality risk (EuroSCORE 8) and highest pre-B12 MAP (72 mmHg). Although Group 3 patients ("sustainers"; 9/33, 27%) showed a sustained MAP improvement, those in Group 4 ("rebounders"; 7/33, 21%) were characterized by hypertensive overshoot followed by a decrease in MAP. CONCLUSION: These data indicate considerable heterogeneity in patient response to B12, potentially dependent on both patient preoperative condition and non-standardized time of administration. B12 may provide a useful alternative therapy for refractory hypotension and vasoplegia, but controlled clinical trials to assess efficacy are needed.