Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting.

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

Robotic Cardiac Surgery Part I: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS).

The application and evolution of total endoscopic robotic cardiac surgery (TERCS) has become greater as institutions and surgeons become more comfortable with robotic technology. Over the years many improvements have been made to facilitate technically challenging cardiac procedures using robotics and increase overall survival and quality of life for these patients. However, a dedicated multidisciplinary approach led by a core group of clinicians is necessary for good patient experience and outcomes. In addition, good communication and performance improvement measures with attention to detailed perioperative management are essential to a successful robotic cardiac program.

Intravenous and Inhaled Milrinone in Adult Cardiac Surgery Patients: A Pairwise and Network Meta-Analysis.

OBJECTIVE: To summarize the evidence on the hemodynamic, echocardiographic, and clinical effects of inhaled and intravenous milrinone (iMil and IvMil) in adult cardiac surgery patients. DESIGN: Systematic review, pairwise and network meta-analysis. SETTING: Multi-institutional. PARTICIPANTS: Adult cardiac surgery patients. INTERVENTIONS: Comparison between iMil and IvMil versus other agents or placebo. MEASUREMENTS AND MAIN RESULTS: The primary endpoints were mean pulmonary artery pressure (MPAP) and peripheral vascular resistance (PVR). Secondary endpoints included the following: (1) mean arterial pressure, heart rate, and cardiac index (CI); (2) echocardiographic data; and (3) clinical outcomes. Random model, leave-one-out-analysis, and meta-regression were used. Thirty studies (6 iMil and 24 IvMil) were included for a total of 1,438 patients (194 iMil and 521 IvMil). IvMil was associated with a lower MPAP, lower PVR, and higher CI compared to placebo (standardized mean difference [SMD] = -0.22 [95% CI = -0.48 to 0.05], SMD = -0.49 [95% CI = -0.71 to -0.27], and SMD = 0.94 [95% CI = 0.51 to 1.37]). No difference in any outcome was found between iMil and placebo. At network meta-analysis, significantly lower PVR and shorter hospital length of stay were found for IvMil compared to iMil (SMD = -0.82 [95% CI = -1.53 to -0.10] and SMD = -0.50 [95% CI = -0.95 to -0.05], respectively). CONCLUSION: These results support the clinical use of IvMil in cardiac surgery patients. No evidence at present supports the adoption of iMil.

Influence of cryoprecipitate, Factor XIII, and fibrinogen concentrate on hyperfibrinolysis.

BACKGROUND: Hyperfibrinolysis is a potentially life-threatening condition associated with poor clot integrity and excessive bleeding. Although antifibrinolytics are an effective treatment, more liberal use of these drugs may lead to a prothrombotic risk, and an earlier and potentially safer treatment option would be desirable. Hyperfibrinolysis has been shown to be attenuated by in vitro supplementation of purified human Factor (F)XIII concentrate. Cryoprecipitate represents an alternative source of FXIII and the only approved source of concentrated FXIII in some countries. The aim of this study was to investigate whether cryoprecipitate, FXIII, and fibrinogen concentrate mitigate hyperfibrinolysis. STUDY DESIGN AND METHODS: Ten citrate blood specimens from healthy subjects were spiked with tissue plasminogen activator (t-PA) and subsequently supplemented with cryoprecipitate, FXIII, fibrinogen concentrate, and ɛ-aminocaproic acid (EACA). Thromboelastometry tests were performed at baseline, after t-PA, and after supplementation. Hyperfibrinolysis was assessed using the clot lysis index at 60 minutes (LI60; reciprocal of maximum lysis). RESULTS: The LI60 was significantly improved (fibrinolysis attenuated) after cryoprecipitate supplementation compared to t-PA alone and compared to FXIII and fibrinogen concentrate. Hyperfibrinolysis was only fully reversed using EACA. In addition, cryoprecipitate demonstrated the least variability in the attenuation of hyperfibrinolysis among 10 healthy subjects, compared to FXIII and fibrinogen concentrate. CONCLUSION: This is the first study to show that cryoprecipitate is able to significantly mitigate hyperfibrinolysis in an in vitro model. Further investigations are warranted to determine whether cryoprecipitate may have a previously unrecognized benefit and should be administered earlier in resuscitation protocols.

Trial Of Pathogen-reduced Cryoprecipitate vs. Cryoprecipitated AHF to Lower Operative Transfusions (TOP-CLOT): study protocol for a single center, prospective, cluster randomized trial.

BACKGROUND: Intraoperative hemorrhage in cardiac surgery increases risk of morbidity and mortality. Low pre-operative and perioperative levels of fibrinogen, a key clotting factor, are associated with severity of hemorrhage and increased transfusion of blood components. The ability to supplement fibrinogen during hemorrhagic resuscitation is delayed 45-60 min because cryoprecipitated antihemophilic factor (cryo AHF) is stored frozen, due to a short post-thaw shelf life. Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex, IFC) can be kept thawed, at room temperature, for up to 5 days, making it possible to be immediately available for hemorrhaging patients. This trial will investigate if earlier correction of acquired hypofibrinogenemia with IFC in hemorrhaging cardiac surgery patients reduces the total number of perioperatively transfused allogeneic blood products (red blood cells, plasma, and platelets) as compared to cryo AHF. METHODS: This is a single center, prospective, cluster randomized trial with an adaptive design. Acquired hypofibrinogenemia will be assessed by rotational thromboelastometry (ROTEM) and the threshold for cryo AHF/IFC transfusion defined as FIBTEM A10 ≤ 10 mm in bleeding patients. IFC/cryo AHF will be randomized by 1-month blocks. Cardiac surgery patients will be enrolled in the study if they have an eligible procedure and at least one dose of a cryo AHF/IFC product (approximately 2 g fibrinogen) is transfused. Data from the electronic health record, including the blood bank and lab information systems, will be prospectively collected from the health system's data warehouse. DISCUSSION: This trial aims to provide evidence of the clinical efficacy of utilizing readily available thawed IFC during acute bleeding in the cardiac surgery setting compared to traditional cryo AHF. TRIAL REGISTRATION: ClinicalTrials.gov NCT05711524. Feb 3, 2023.

Safety and Efficacy of a Novel Approach to Pulmonary Vein Isolation Using Prolonged Apneic Oxygenation.

BACKGROUND: Improved ablation catheter-tissue contact results in more effective ablation lesions. Respiratory motion causes catheter instability, which impacts durable pulmonary vein isolation (PVI). OBJECTIVES: This study sought to evaluate the safety and efficacy of a novel ablation strategy involving prolonged periods of apneic oxygenation during PVI. METHODS: We conducted a multicenter, prospective controlled study of 128 patients (mean age 63 ± 11 years; 37% women) with paroxysmal atrial fibrillation undergoing PVI. Patients underwent PVI under general anesthesia using serial 4-minute runs of apneic oxygenation (apnea group; n = 64) or using standard ventilation settings (control group; n = 64). Procedural data, arterial blood gas samples, catheter position coordinates, and ablation lesion characteristics were collected. RESULTS: Baseline characteristics between the 2 groups were similar. Catheter stability was significantly improved in the apnea group, as reflected by a decreased mean catheter displacement (1.55 ± 0.97 mm vs 2.25 ± 1.13 mm; P < 0.001) and contact force SD (4.9 ± 1.1 g vs 5.2 ± 1.5 g; P = 0.046). The percentage of lesions with a mean catheter displacement >2 mm was significantly lower in the apnea group (22% vs 44%; P < 0.001). Compared with the control group, the total ablation time to achieve PVI was reduced in the apnea group (18.8 ± 6.9 minutes vs 23.4 ± 7.8 minutes; P = 0.001). There were similar rates of first-pass PVI, acute PV reconnections and dormant PV reconnections between the two groups. CONCLUSIONS: A novel strategy of performing complete PVI during apneic oxygenation results in improved catheter stability and decreased ablation times without adverse events. (Radiofrequency Ablation of Atrial Fibrillation Under Apnea; NCT04170894).

High-dose versus low-dose opioid anesthesia in adult cardiac surgery: A meta-analysis.

STUDY OBJECTIVE: We performed a systematic comparison of high-dose and low-dose opioid anesthesia in cardiac surgery. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING: Operating room. PATIENTS: 1400 adult patients undergoing cardiac surgery using general anesthesia. INTERVENTIONS: All RCTs comparing the effects of various doses of intravenous opioids (morphine, fentanyl, sufentanil, and remifentanil) during adult cardiac surgery using general anesthesia published until May 2018 (full-text English articles reporting data from human subjects) were included. MEASUREMENTS: Primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were ventilation time, use of vasopressors, perioperative myocardial infarction, perioperative stroke, and hospital LOS. MAIN RESULTS: Eighteen articles were included (1400 patients). There was no difference in ICU LOS between studies using high or low dose of opioids (both short-acting and long-acting) (standard mean difference [SMD]-0.02, 95%CI: -0.15-0.11, P = 0.74). Similarly, there was no difference in secondary outcomes of ventilation time (SMD-0.27, 95%CI: -0.63-0.09, P = 0.14), use of vasopressors (OR 0.61, 95%CI: 0.29-1.30, P = 0.20), myocardial infarction (risk difference 0.00, 95% CI: -0.02-0.03, P = 0.70), stroke (RD 0.00, 95% CI: -0.01-0.01, P = 0.92) and hospital LOS (SMD 0.03, 95% CI: -0.26-0.33, P = 0.84). At meta-regression, there was no effect of age, gender, or type of opioid on the difference between groups. CONCLUSIONS: Our data suggest that low-dose opioids, both short acting and long acting, are safe and effective to use in adult cardiac surgery patients, independent of the clinical characteristics of the patients and the type of opioid used. In view of the current opioid epidemic, low-dose opioid anesthesia should be considered for cardiac surgery patients.