European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Antegrade and Retrograde Cerebral Perfusion During Acute Type A Aortic Dissection Repair in 290 Patients.

AIM: Hypothermia and selective brain perfusion is used for brain protection during an acute type A aortic dissection (ATAAD) correction. We compared the outcomes between antegrade and retrograde cerebral perfusion techniques after ATAAD surgery. METHOD: Between January 1995 and August 2017, 290 patients underwent ATAAD repair under deep hypothermic circulatory arrest/retrograde cerebral perfusion (DHCA/RCP) in 173 patients and moderate hypothermic circulatory arrest/antegrade cerebral perfusion (MHCA/ACP) in 117 patients. Outcomes of interest were: 30-day mortality, new-onset postoperative neurological complications, and length of intensive care unit (ICU) and in-hospital stays. RESULTS: No differences were observed between the preoperative details of both groups (p>0.05). Thirty-day (30-day) mortality did not differ between groups (RCP vs ACP, 22% vs 21.4%; p=0.90). New-onset postoperative permanent neurological dysfunctions and coma was similar in two group in 6.9% versus 10.3% of patients and 3.8% versus 6.8% patients of patients, respectively (p=0.69). The incidence of 30-day mortality and new postoperative neurological complications were similar in the RCP and ACP groups (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.39-2.83 [p=0.91] and OR, 1.7; 95% CI, 0.87-3.23 [p=0.11], respectively). There was no difference between length of stay in the ICU and overall stay in hospital between the RCP and ACP groups (p=0.31 and p=0.14, respectively). No difference in survival rate was observed between the RCP and ACP groups (hazard ratio, 1.2; 95% CI, 0.76-2.01 [p=0.39]). CONCLUSIONS: Thirty-day (30-day) mortality rate, new-onset postoperative neurological dysfunctions, ICU stay, and in-hospital stay did not differ between the MHCA/ACP and DHCA/RCP groups after ATAAD correction. Although the rates of 30-day mortality and postoperative neurological complications were high after ATAAD repair, ACP had no advantages over the RCP technique.

Perspectives on the Fellowship Training in Cardiac, Thoracic, and Vascular Anesthesia and Critical Care in Europe From Program Directors and Educational Leads Around Europe.

This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (São Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided.

European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition.

This special article summarizes the design and certification process of the European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia (CTVA) Fellowship Program. The CTVA fellowship training includes a two-year curriculum at an EACTA-accredited educational facility. Before fellows are accepted into the program, they must meet a number of requirements, including evidence of a valid license to practice medicine, a specialist degree examination in anesthesiology, and appropriate language skills as required in the host centers. The CVTA Fellowship Program has 2 sequential and complementary levels of training-both with a modular structure that allows for individual planning and also takes into account the differing national healthcare needs and requirements of the 36 countries represented in EACTA. The basic training period focuses on the anesthetic management of patients undergoing cardiac, thoracic, and vascular surgery and related procedures. The advanced training period is intended to deepen and to extend the clinical and nontechnical skills that fellows have acquired during the basic training. The goal of the EACTA fellowship is to produce highly trained and competent perioperative physicians who are able to care for patients undergoing cardiac, thoracic, and vascular anesthesia.

Long-Term Results after Modified Bentall Operation in 200 Patients.

BACKGROUND: Composite graft replacement of the aortic root is the treatment of choice for an array of aortic root pathologies, such as annuloaortic ectasia, Marfan syndrome and acute or chronic aortic dissection type A. In this retrospective study of the authors' aortic surgery database, an exploration was made of factors related to early and long-term morbidity and mortality of patients who underwent this procedure. METHODS: Between 2000 and 2009, a total of 200 consecutive patients (male:female ratio 4:1; mean age 56.2 ± 11.66 years) underwent the modified Bentall operation at the authors' institution, with a composite graft (mechanical valve) being used to correct aortic root pathology. All preoperative, perioperative and postoperative data, as well as long-term follow up data, were retrieved from the authors' aortic surgery database. RESULTS: Preoperative characteristics of the patients included elective and emergency operations (83.1% and 15.9%, respectively). Intraoperative and 30-day mortalities were 2% and 3.5%, respectively, while the rate of postoperative cerebrovascular events was 1.5%. Long-term survival at a mean follow up of 110 months for the elective and emergency groups was 88.6% and 71.9%, respectively (p = 0.007). Moreover, during the same period new cerebrovascular events were observed in 5.8% of cases. Predictive factors for late survival were type of surgery (elective versus emergency; p = 0.023), conduit size (≤23 mm versus >23 mm; p = 0.053) , age >65 years (p = 0.001), intensive care unit stay (days; p <0.001) and postoperative creatinine level (p = 0.002). Survival rates at one, three, five and 10 years postoperatively were 93.5%, 92.5%, 91.5% and 85.9%, respectively. CONCLUSIONS: Patients who underwent the modified Bentall operation presented with minimal major adverse effects and demonstrated a good long-term survival.

Aortic Homografts in Surgical Management of Prosthetic Valve Endocarditis: A Case Series from Greece.

BACKGROUND Infective endocarditis (IE) is a severe, life-threatening, and relatively common complication after valve replacement operations, with incidence rates varying between 1.8% and 5.8%, with an in-hospital mortality rate of up to 20%. Common microorganisms are (listed by decreasing incidence) Streptococci, Staphylococcus aureus, Enterococci, bacteria of the HACEK group, and fungi. Treatment of IE is complex, typically involving prolonged courses of antibiotics. However, in cases of aortic prosthetic valve endocarditis, root abscess formation with involvement of the aorto-mitral skeleton is not uncommon and complex surgical intervention is required. One of the notable advancements in surgical management is the use of homografts for aortic root endocarditis. CASE REPORT We report the first case series of 8 patients successfully operated on for prosthetic valve endocarditis with extensive aortic root abscess formation in Greece at Onassis Cardiac Surgery Center with the use of aortic homograft. All cases were redo surgeries and had good outcomes. Interestingly, one of the cases had extensive aortic root involvement with abscess formation extending to the aorto-mitral fibrous skeleton, requiring aortic root replacement with homograft, aorto-mitral skeleton reconstruction with bovine pericardium and mitral valve replacement with a mechanical prosthesis. Two other patients required concomitant coronary bypass grafting of the right coronary artery with reversed saphenous vein grafts. CONCLUSIONS Aortic root replacement with aortic homograft is the preferred choice for prosthetic valve endocarditis with aortic root abscess formation. Despite the technical complexity needed for implantation, this option offers a second chance for survival in patients with this challenging condition.

Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial.

Introduction: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery is challenging, mainly due to the potential risk of right ventricular failure (RVF). Levosimendan is a calcium-sensitizing agent that has primarily been used in the treatment of decompensated heart failure. However, recently levosimendan has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension and PH associated with left heart disease. The aim of this study was to investigate the potential utility of the preemptive administration of levosimendan in cardiac surgical patients with preexisting PH and to compare its effectiveness with milrinone, which represents an already established therapeutic option in the management of PH during cardiac surgery. Materials and Methods: In this study, 40 adult cardiac surgical patients with PH were randomly assigned to receive either levosimendan intravenously or milrinone via inhalation in a double-blind fashion prior to a cardiopulmonary bypass (CPB). Hemodynamic and echocardiographic parameters were recorded and evaluated before and after the administration of the drugs. Results and Conclusions: The results of this study demonstrated that both levosimendan and milrinone administered before CPB in cardiac surgical patients with PH may offer protective benefits, reducing pulmonary artery pressure and preventing the exacerbation of PH and RVF. Pulmonary vasodilation attributed to levosimendan is of longer duration and greater magnitude compared to pulmonary vasodilation afforded by milrinone.

Comparison of continuous flow centrifugal left ventricular assist devices as a bridge to transplant strategy in a low organ donation environment: Single center experience.

BACKGROUND: In advanced heart failure patients, heart transplantation is currently the most effective treatment. However, in a low-organ environment, it is usually necessary to proceed in long-term mechanical circulatory support through left ventricular assist device (LVAD) implantation as bridge-to-transplantation METHODS: The study included all patients with advanced heart failure who underwent continuous flow LVAD implantation as a bridge to transplant strategy in our centre (n = 68). Following LVAD implantation and for the period that patients were on LVAD support, pump thrombosis, strokes, gastrointestinal bleeding and right heart failure occurrence rates were recorded. Outcomes were compared between patients implanted with HeartMate 3 (HM3) and HeartWare (hVAD) LVADs as well as between patients who did reach heart transplantation (HTx group) and those who did not (noHTx group). RESULTS: 35 out of 68 patients underwent heart transplantation at a mean time of 691 ± 457 days. 41 patients received a HeartWare hVAD and 27 a HeartMate 3 (HM3) device. HM3 patients had significantly better survival (p = 0.010) and lower complication rates (p = 0.025). Additionally, the noHTx group had significantly higher complication rates compared to the HTx group (p = 0.00041). The five-year estimated Kaplan-Meier survival rates following heart transplantation was 77%. CONCLUSIONS: Patients with advanced heart failure gain substantial benefit from left ventricular assist devices awaiting heart transplantation. In a low organ donation environment, the need for reliable left ventricular assist devices can further improve the outcomes through the reduction of complications provided by current devices.

Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the hemodynamic effects of inhaled nitric oxide (NO) plus aerosolized iloprost in patients with pulmonary hypertension/right ventricular dysfunction after cardiac surgery. DESIGN: A retrospective study. SETTING: A single center. PARTICIPANTS: Eight consecutive patients with valve disease and postextracorporeal circulation (ECC) pulmonary hypertension/right ventricular dysfunction. INTERVENTION: The continuous inhalation of nitric oxide (10 ppm) and iloprost, 10 µg, in repeated doses. MEASUREMENTS AND MAIN RESULTS: The hemodynamic profile was obtained before inhalation, during the administration of inhaled NO alone (prior and after iloprost), and after the first 2 doses of iloprost. Tricuspid annular velocity and tricuspid annular plane systolic excursion were estimated at baseline and before and after adding iloprost. At the end of the protocol, there were significant decreases in pulmonary vascular resistance (p < 0.001), the mean pulmonary arterial pressure (p < 0.001), and the mean pulmonary artery pressure/mean arterial pressure ratio (p = 0.006). Both tricuspid annular velocity (p < 0.001) and tricuspid annular plane systolic excursion (p < 0.001) increased. The cardiac index (p < 0.001) and venous blood oxygen saturation (p = 0.001) increased throughout the evaluation period. Each iloprost dose was associated with further decreases in pulmonary vascular resistances/pressure. By comparing data at the beginning of inhaled NO with those after the second dose of iloprost, the authors noticed decreases in pulmonary vascular resistances (p = 0.004) and the mean pulmonary artery pressure (p = 0.017) and rises in tricuspid annular velocity (p < 0.001) and tricuspid annular systolic plane systolic excursion (p < 0.001). CONCLUSIONS: Inhaled NO and iloprost significantly reduced pulmonary hypertension and contributed to the improvement in right ventricular function. Inhaled NO and iloprost have additive effects on pulmonary vasculature.

Intraoperative mydriasis in left ventricular assist device patients. Do eyes never lie?

We report two cases of transient intraoperative mydriasis in left ventricular assist device (LVAD) patients with no profound underlining neurological pathology. Both cases concern females on LVAD for more than 30 months, due to dilated cardiomyopathy, as a bridge to transplant. A possible pathophysiology mechanism is suggested. As LVAD patients' life expectancy increases, more and more physiological alterations due to laminar flow will be revealed and must be taken into consideration for the better care of this patient group.

Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters.

INTRODUCTION: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS: In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 µg/kg or 12 µg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS: A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 µg/kg. Additionally, administration of LS at a dose of 12 µg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION: LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.

Management of adult patients with perioperative pulmonary hypertension: technical aspects and therapeutic options.

Pulmonary hypertension (PH) is an independent risk factor for increased mortality in patients undergoing heart surgery. Existing chronic PH may be exacerbated by acute post-bypass PH, and this can lead to acute right ventricular failure. The prevention and treatment of right ventricular failure in cardiac surgery is based on three principles: optimize right ventricular preload, improve right ventricular contractility, minimize right ventricular afterload. The last of these may involve specific measures such as the inhalation of nitric oxide (NO) or of the stable prostacyclin analogue iloprost. The advantage of these inhalable substances is their pulmonary selectivity, and the subsequent reduction in systemic side effects. In order to avoid disastrous results in high-risk cardiac surgical patients, intra- and post-operative monitoring with pressure lines, a qualified team that pays attention to details, and an aggressive and early treatment in the operating room with inhaled iloprost and/or NO is necessary. The philosophy of 'wait and see' should be abandoned in favour of 'be suspicious and act early'. In a prospective randomized trial, the efficacies of inhaled iloprost and of inhaled NO in the therapy of PH immediately following weaning from cardiopulmonary bypass in cardiac surgical patients were compared. Iloprost proved to be significantly more effective with respect to mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac output than inhaled NO.

Predictors of Outcomes after Correction of Acute Type A Aortic Dissection under Moderate Hypothermic Circulatory Arrest and Antegrade Cerebral Perfusion.

INTRODUCTION: Hypothermic circulatory arrest is widely used for correction of acute type A aortic dissection pathology. We present our experience of 45 consecutive patients operated in our unit with bilateral antegrade cerebral perfusion and moderate hypothermic circulatory arrest. METHODS: Between January 2011 and April 2015, 45 consecutive patients were admitted for acute type A aortic dissection and operated emergently under moderate hypothermic circulatory arrest and bilateral antegrade cerebral perfusion. RESULTS: Mean age was 58±11.4 years old. Median circulatory arrest time was 41.5 (30-54) minutes while the 30-day mortality and postoperative permanent neurological deficits rates were 6.7% and 13.3%, respectively. Unadjusted analysis revealed that the factors associated with 30-day mortality were: preoperative hemodynamic instability (OR: 14.8, 95% CI: 2.41, 90.6, P=0.004); and postoperative requirement for open sternum management (OR: 5.0, 95% CI: 1.041, 24.02, P=0.044) while preoperative hemodynamic instability (OR: 8.8, 95% CI: 1.41, 54.9, P=0.02) and postoperative sepsis or multiple organ dysfunction (OR: 13.6, 95% CI: 2.1, 89.9, P=0.007) were correlated with neurological dysfunction. By multivariable logistic regression analysis, postoperative sepsis and multiple organ dysfunction independently predicted (OR: 15.9, 95% CI: 1.05, 96.4, P=0.045) the incidence of severe postoperative neurological complication. During median follow-up of 6 (2-12) months, the survival rate was 86.7%. CONCLUSION: Bilateral antegrade cerebral perfusion and direct carotid perfusion for cardiopulmonary bypass, in the surgical treatment for correction of acute aortic dissection type A, is a valuable technique with low 30-day mortality rate. However, postoperative severe neurological dysfunctions remain an issue that warrants further research.

Fracture guide wire during an elective percutaneous coronary intervention.

Dose the fractured guide wire should be removed during or after percutaneous coronary interventions? In case when the patients have unstable hemodynamic status the fractured guide wire should be removed with percutaneous or surgical method. Antiplatelet drug administration should be considered after procedure to prevention of the coronary artery thrombosis.

Unusual Location of a Cardiac Papillary Fibroelastoma.

Cardiac papillary fibroelastoma is a rare benign cardiac tumor that represents less than 10% of all cardiac tumors. Most papillary fibroelastomas are relatively small. Symptoms, if present, are due to flow obstruction or peripheral embolization. The most common sites of origin are aortic and mitral valve surfaces. We present successful surgical resection of a papillary fibroelastoma through the mitral valve which originated from the posterior papillary muscle of the left ventricle.

Outcomes after a left anterior descending artery endarterectomy in advanced coronary artery disease.

BACKGROUND: Coronary endarterectomy albeit infrequently utilized remains a pivotal treatment modality for advanced atherosclerotic heart disease. Benefits of coronary endarterectomy are explored in terms of better mid-term survival, freedom of major adverse cardiac and cerebrovascular events and improved left ventricular ejection fraction. METHODS: 50 patients with coronary artery disease including extensive diffuse LAD disease underwent a left anterior descending artery endarterectomy with coronary by-pass grafting and left internal mammary artery as conduit between 2006 and 2014. Prospective evaluation was performed on an outpatient basis with physical examination, echo recordings of ejection fraction and LAD flow reserve for 24 up to 60months. RESULTS: Study group was constituted by a male to female ratio 4:1 and mean age 62.4years old. Pre-operative characteristics included patients with age<60years old and gensini score>60 in 42.1% while patients with age>60years old had gensini score (21-60) in 63.4%. Furthermore, males were affected more severely by atherosclerosis than females. Postoperative anterior wall contractility of left ventricle was improved (56% pre-op vs. 66% post-op) and hypokinesis reduced (34% pre-op vs. 24% post-op). No deaths were recorded for a mean follow-up of 48months. Also, MACCE were recorded in 8% patients. Post-operative LAD flow reserve was normal in 66% and reduced in 33% of cases. Finally, gensini score preoperatively affects mid-term flow reserve postoperatively (p<0.05). CONCLUSION: Coronary endarterectomy presents a viable modality that preserves myocardial function and restores LAD flow in patients with diffuse atherosclerotic LAD. Also postoperative adverse effects were minimal while mid-term flow reserve was affected by preoperative factors.