Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study.

OBJECTIVES: To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN: A propensity score-matched retrospective study. SETTING: A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS: Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS: A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS: The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS: This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.

Preoperative cerebral and renal oxygen saturation and clinical outcomes in pediatric patients with congenital heart disease.

We examined the predictability of preoperative cerebral and renal rSO2 values for outcomes in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Patients who underwent pediatric cardiac surgery under CPB between September 2015 and September 2017 were enrolled in this study. Patients monitored with both cerebral and renal rSO2 at the beginning of surgery were included. The primary outcome was the prediction of outcomes after pediatric cardiac surgery. Outcome was defined as any of: (1) death within 30 days after surgery, or the need for (2) renal replacement therapy or (3) extracorporeal membrane oxygenation, (4) shorten mechanical ventilator-free day,(5) shorten ICU-free survival day. We included 59 patients: cyanotic n = 31; non-cyanotic n = 28. Among all patients, 15 (25%) had poor outcomes, including three deaths. The cerebral and renal rSO2 values were significantly lower in the cyanotic patients with poor outcomes compared to those without poor outcomes (cerebral: 59 ± 11 vs. 50 ± 5, p = 0.021; renal: 59 ± 15 vs. 51 ± 14, p = 0.015) but only the renal rSO2 value was significantly lower in the non-cyanotic patients (77 ± 10 vs. 61 ± 14, p = 0.011). The cut-off value (51%) of cerebral rSO2 were associated with risk of mechanical ventilator-free day and ICU-free survival day [ORs of 22.8 (95% CI 2.21-235.0, p = 0.0087) and 15.8 (95% CI 1.53-164.0, p = 0.0204), respectively] in the cyanotic patients. The cut-off value (66%) of cerebral rSO2 value was associated with risk of mechanical ventilator-free day [OR of 11.3 (95% CI 1.05-25.3, p = 0.0456)] and the cut-off value (66%) of renal rSO2 value was associated with risk of ICU-free survival day [ORs of 33.0 (95% CI 2.25-484.0, p = 0.0107)] in the noncyanotic patients. The preoperative low rSO2 values were associated with outcomes including 30-day mortality and might be reflective of the severity of cardiopulmonary function. Further studies are needed to confirm our results.

Experience with transesophageal echocardiography for mitral valve plasty in the remote stage after esophagectomy with gastric tube reconstruction via the retrosternal route.

A 69-year-old male patient with mitral valve prolapse was scheduled for mitral valve plasty. Sixteen years earlier, he had undergone right open thoracotomy for esophageal cancer with subtotal esophagectomy, cervicothoraco-abdominal three-region dissection, posterior mediastinal tube reconstruction, and cervical anastomosis. Postoperatively, the patient had a treatment- and recurrence-free course, and an upper gastrointestinal endoscopy performed 2 years prior revealed no abnormality. We scheduled a transesophageal echocardiography for mitral valve surgery. We attempted to insert the probe but felt resistance at the height of the mid-thoracic region, and the image quality was poor, so we abandoned the intraoperative diagnosis. The surgery was performed as planned, and when the probe was manipulated again at the time of cardiopulmonary withdrawal, the mitral valve could be observed. The mitral valve was judged to be sufficiently repaired, and the surgery was terminated. There were no complications associated with transesophageal echocardiography.